The COVID-19 pandemic is undoubtedly a worldwide threat to public health. But in Nigeria, the shortage of Personal Protective Equipment (PPE) to support clinical rescue has especially hastened deaths of patients suffering from other diseases. Lives of non-coronavirus patients suffering from acute respiratory distress, pneumonia, and malaria with symptoms suggestive of Sars-Cov2 infection are wasting from health workers’ fears induced by PPE shortage. Rather than quick, life-saving clinical intervention, unprotected specialists delay action until COVID-19 test results are available to ascertain the level of risk presented. In this investigation spanning the University of Benin Teaching Hospital (UBTH), Benin, the University College Hospital (UCH), Ibadan and the Lagos University Teaching Hospital (LUTH), Lagos, TEMITAYO AYETOTO finds that severely-ill patients who would have otherwise been saved if health workers were confident of full protection end up dying or relapsing irredeemably. 

Worrying about muscles, nerves, bones, and connective tissues was the reality of Joshua Samson’s professional life as an orthopaedist before COVID-19 became a global threat. But when, in late January, the horrid waves of the coronavirus hit the United Kingdom where the Nigerian-born doctor practised, his priorities shifted to soldering frontline intervention efforts at the COVID-19 assessment unit of his hospital.

Amid a heightened contagion rate that tipped many into clinical emergencies, Samson encountered a patient with a history of Chronic Obstructive Pulmonary Disease (COPD). The lung disease that chronically interferes with normal breathing qualified the patient as a high-risk suspect of the virus, but that did not stand in the way of prompt rescue action. Fully garbed in the PPE, Samson swabbed him as was done for every walk-in patient, took his samples and began to administer COPD medications without waiting to see a COVID-19 test result first.

It was an emergency that saw a decreasing concentration of oxygen in the patient’s blood. The process, medically termed desaturation, is a sour recipe for the destruction of tiny air sacs of the lungs and could lead to a fatal outcome. Finding the condition disquieting, Samson rang a respiratory consultant who advised the patient be switched to a continuous positive airway pressure machine to aid breathing, in spite of the procedure being an aerosol generating one, capable of dispersing the virus if he happened to be positive.

In its interim guidelines for clinical management of COVID-19T, the Nigeria Centre for Disease Control (NCDC) considers the procedure a highly sensitive one that must be done under the protection of N95 respirator, face shield or goggles and apron at all times when interacting with patients.

“That notwithstanding, I was kitted with the appropriate PPE and made sure this gentleman made it. Sadly, his result came back positive but that did not make us abandon him. We had to escalate to intensive care unit, and he fought his way out in few days,” Samson explained.

“When finally he was discharged after a negative swab, you could see the joy in his face and the family was very happy. There are lots of cases. Even the ones that we think would not make it, we give them palliative care, keep them comfortable as much as possible and give them a dignifying death.”

3,259 miles away…no PPE, no rescue

About 3,259 miles away from the UK, in his country, Nigeria, Samson could only wish the fate of his patient for his dearly beloved father who suddenly found himself at the mercy of University of Benin Teaching Hospital (UBTH) for clinical rescue.

With a combination of lack of PPE and a jeopardizing loyalty to a killer-policy of ‘no test, no rescue’, the octogenarian’s chances of surviving were squandered. Apart from the triaging doctors who had access to basic protection, specialist doctors who could offer the nature of critical intervention Samson gave his patient, lacked the confidence to swing into action primarily due to the unavailability of protection. About a month earlier, 25 doctors at the teaching hospital had been infected with the virus, the Nigerian Medical Association (NMA) confirmed. This was why doctors’ fears leaped to the height of insisting on the unwritten rule of obtaining a negative COVID-19 test result before approving a sensitive procedure as ventilator aid for a gasping patient.

Obtaining test result typically gulps more than 96 hours countrywide — an offshoot of decades of government’s prioritisation of politically gratifying efforts like expending billions on fuel subsidy over investing in manufacturing capacity capable of responding to a pandemic need of medical kits and building health infrastructure such as high-capacity molecular laboratories that would have hastened the rate of testing and detection of the coronavirus in many remote regions in Nigeria. As of June 22, Nigeria had crossed another grim milestone after it reported its single biggest daily total of 745 confirmed cases on June 18.

In its initial struggle with the pandemic, Africa’s largest oil producer had only about 200 testing facilities to a population nearing 200 million. Even in pre-coronavirus era, the biggest labs in the country shipped patients’ samples requiring molecular diagnosis abroad, said Abassi Ene-Obong, chief of 54GENE, the health startup that raised $500, 000 from private partners to equip government-run labs with polymerase chain reaction (PCR) machines.

‘No ventilator if the swab comes out negative at UBTH’

Samson’s old man was evidently gasping. His saturation had sharply nosedived to the value of 58 even on 10 litres of oxygen. He had no respiratory drive and was essentially drowning in his own fluids.

It means dying. Healthy people require a saturation level above 94 to sustain their vital organs. But in his case, a ventilator strength was critical to force out the fluids. Throwing him in a tank of oxygen would not have made a difference. That was the main concern of the doctor who transferred him from a private facility where he had earlier been managed to UBTH — the only tertiary hospital where a ventilator aid was available in the entire city of Benin. Efforts to scout for private ventilator service were futile. At the news of resorting to UBTH, the old man got jittery. It never sat well with him. And unfortunately, his suspicion was right.

As Joshua Samson monitored events from his UK residence via phone calls, he asked that his younger brother Osas Samson let him speak with the doctor attending to their father. But the response was jarring: If the swab comes out negative, he gets a ventilator. But if positive, he does not.

“He said the team involved in doing that were only ventilating negative patients. Then what happens to patients who are positive? They are left to die?” Joshua wondered, regretting how his medical training and expertise could not serve the man who fathered him through life, simply because he was trapped in the web of an insensitive system.

Yet, there were idle ventilators in the ward, confirmed by a doctor who spoke to Samson. Joshua Uwaila, Public Relations Officer of the hospital, spoke of how the hospital had moved past trifle forms of incompetence, telling BusinessDay that two ventilators were dedicated to the isolation ward since the start of the pandemic.

He also confirmed that some ventilators were available outside the isolation ward. UBTH is one of the NCDC’s licensed centres for managing coronavirus cases.

Given the NCDC’s weakness at pacing up testing rates, and a critical shortage of PPE, suspected patients like Samson’s father are not just left to writhe in pains; more like kicking a man who is already down, they are equally burdened with a personal responsibility to stay alive in a ‘holding bay’ until a COVID-19 test result proves them negative.

In that holding bay, no severity of gasping can provoke clinical rescue action — simply because doctors are afraid to act without protection.

“That is a big gap in our healthcare system. Who takes care of patients awaiting test, who have likely Covid-19 symptoms? You should have doctors working with full PPE because these people are Covid-19 patients until proven otherwise. And you may even have a testing lab in that holding bay,” said a consultant surgeon at the frontline of Covid-19 in one of Nigeria’s tertiary hospitals who didn’t want to be mentioned in this report for fear of retribution.

“But here, we are overstretched. PPE are being prioritized for those working in the isolation ward. Yet, doctors at the frontline in the other wards, including emergencies, do not have adequate protection. The idea is that those who are treating confirmed coronavirus patients should wear N95, shields, gowns. But other doctors treating ordinary patients should just wear surgical masks and they will be fine. We all know that N95 is the most superior. We all know surgical mask is not as effective as N95 and yet politicians use it to address press conferences and senators wear them to plenary sessions.”

No PPE, delayed COVID-19 test result and death

Acute respiratory distress with desaturation is a clinical emergency all over the world, irrespective of the cause, says Francis Owoicha, a UK-based Nigerian doctor currently involved in the efforts to contain COVID-19.

“The coronavirus pandemic is just one cause; that should not lead to denial of treatment to anyone with acute shortness of breath even though they are suspect,” he says. “Intubate if they are desaturating even on Oxygen, with a ‘dirty ventilator’ if need be. While on treatment, a result comes out and then your management can change. The testing and admission criteria must be redefined and people who need intervention should be prioritized, rather than herding asymptomatic patients into isolation centers and publishing phantom recovery rates.”

For severely ill suspects such as the elder Samson, they were not merely to be isolated in the holding ward after collection of samples from the nose and the throat. The Centers for Disease Control and Prevention (CDC) in the US recommends that healthcare workers closely monitor vital signs, including pulse rate, blood pressure, respiratory rate, and temperature.

The doctors finally swabbed him on Sunday May 17, well over 48 hours elapsed without a result to show for the effort. This was at a time when the hospital had been licensed to conduct coronavirus testing within its facility. In-hospital testing kicked off May 11 — enough time to test-run and fix shortcomings if there were any. The turnaround was expected to be shorter compared to when the hospital had to take all samples some 87 kilometres north of Benin city to Irrua Specialist Teaching Hospital, where other samples arriving from nearby communities and states had to compete on a long queue.

By then, his family was panicky. Joshua kept tracking Osas to speak to a doctor. A typical diabetes case that was under control suddenly relapsed into sharp headache on May 14. The old man called in at the hospital and seem stabilized until few hours into the night when the pains returned, causing him to be managed as a case of migraine and slightly elevated sugar. By 2am the following day, gasping set in. Joshua asked for a chest x-ray which revealed pulmonary edema. The burden wasn’t for oxygen to shoulder. It was battle for a ventilator. Yet, to ascertain the level of risk in the absence of PPE, a coronavirus test stood in the way of ultimate clinical rescue in the golden hours of need. The gasping continued endlessly until the old man got tired of fighting alone. He died on Wednesday May 20, at the holding ward of the hospital.

But reacting to the grim fate of patients under the hospital’s negligence, Uwalia said: “That’s not the true representation of things. The management is conscious. We are conscious of the fact that beyond COVID-19, the cases we are managing are still there, like surgeries cannot continue to be put on hold. Women have to give birth.”

Days after the old man’s death, his COVID-19 test was yet to be released. It is not clear if the other members of the family were endangered.

At EKSUTH, no PPE, no rescue

In other hospitals, critically troubled patients were not even dignified with temporary admission because a holding bay did not exist. When Deborah Oluwadero was rushed to the accident and emergency department of the Ekiti State University Teaching Hospital (EKSUTH) as a diabetic emergency on April 21, she was stuck at a car park for roughly 73 minutes. Fearing she could be a COVID-19 case, healthcare workers did not go near her since they didn’t readily have PPE.

When finally admitted, the oxygen cylinder that was brought lasted no more than two minutes. At some point, one of the deceased’s sons filmed her gasping for breath — with no oxygen, of course. Ten minutes later, she died.

Yet, despite the unarguable evidence, including a video by John Oluwadero, Deborah’s last child, who escalated the situation on social media, an investigation ordered by Kayode Fayemi, Governor of Ekiti State, into the case claimed the alarm was false. It said there was no shortage of PPE or oxygen at EKSUTH and there was no delay in attending to the patient.

“Our health system is weak! It is a big shame on our health system for health workers in a tertiary hospital to not be provided with personal protective equipment (PPE) amidst this coronavirus pandemic,” John said in his first open letter to the state government.

EKSUTH is the same hospital where doctors who do not want to be mentioned have confided in BusinessDay how shortage of PPE has continued to cause casualties, especially in patients suffering from elevated diabetes or hypertension. Health workers, on the other hand, are buying their nose masks while doctors’ hazard allowance remains N5, 000.

“What can you do as a doctor in a week with probably four nose masks in a week, when you have hundreds of patients?” an EKSUTH emergency doctor asked. “There is no way you won’t buy your own protection kits if they are not protecting you, yet you’re told to work.”

Nine-month-old pregnancy lost at another Ekiti hospital due to PPE scarcity

Between April 29 and May 2, a 26-year-old woman could have died at the Federal Teaching Hospital, Ido-Ekiti, Ekiti State, due to the unavailability of PPE. But even as she survived, she lost her nine-month-old pregnancy.

The woman, admitted as a case of fetal distress on Wednesday April 29, also presented with fever, which may or may not have been COVID-19. She was supposed to immediately undergo an emergency CS which, of course, required healthcare workers to don the PPE.

However, due to the late provision of PPE, the CS was delayed for about five hours. By the time it was done, the baby had died in the uterus. Hospital sources told BusinessDay the baby would have survived had the CS been done immediately.

After losing her baby, the woman went into respiratory distress, but doctors were not seeing her because of the difficulty of getting the PPE, even though BusinessDay saw non-clinical hospital staff donning the N95 mask!

To get the PPE, the request had to be channelled through a typed — not handwritten — letter to the Chairman, Medical Advisory Committee (CMAC). This process took five hours on April 29! The Ekiti State COVID-19 Task Force was notified of the need to test the woman to ascertain her COVID-19 status, but they did not turn up until their hands were forced by social media outcry.

At UCH, buy PPE or face fatal delay

In different wards of the University College Hospital (UCH) Ibadan, patients were compelled to purchase PPE for doctors assigned to handle their condition or face a delay that could lead to death or deterioration, under an unwritten coronavirus policy.

It was what Oladejo Olayide experienced when UCH finally agreed to conduct a radiotherapy on his two-year-old daughter suffering from rhabdomyosarcoma — a common type of cancer in children.

Oladejo spent N16,000 out of pocket on two packs of theatre gown at N4600 each, a pack of examination gloves at 3500, and a pack of nose masks at N12,500 at Kunle Arà Pharmacy, opposite the hospital.

According to BusinessDay’s findings, it requires N25,000 or more to properly kit a doctor or nurse each day with PPE. These implies a hospital with 50 will need nothing less than N1.2 million to operate daily.

Some private hospitals have had to pause operations at some point due to the high cost of operation. In many government-run hospitals where operations have been restricted to essential services such as accidents, hypertension, diabetes and cancer emergencies, health workers in the emergency wards are not given the same standard of protection that workers in COVID-19 isolation centres enjoy based on the faulty assumption that they work with low-risk patients, whereas the method of determining which patient should be isolated is predicated largely on assumption or probability due to insufficiency of testing kits. Screening doctors work in the dark, creating a terrible loophole for coronavirus patients to slip into the wards not devoted to the treatment of COVID-19 patients.

As a result of these fears, doctors are not ready to risk their lives with their eyes open and would rather shift the burden of their safety to patients who must receive care at all cost.

The burden only injects more complications to the slew of problems facing non-coronavirus patients, as they doubly struggle to get clinical attention from a system that was already falling apart before the arrival of the virus. The situation is further worsened by the partial closure of operations in many hospitals, sending ailing conditions into relapse.

Goodness Olayide, for instance, was billed to begin the second batch of her radiotherapy treatment when the machine broke down and the hospital shut its facility under coronavirus fear. Her troubled father was advised to resume chemotherapy treatment at the largest government hospital in neighbouring Osun State — Obafemi Awolowo University Teaching Hospital (OAUTH), Ife, — where a paediatric oncologist managed her in the past one year.

But the doctor in Ife insisted the only option left was radiotherapy, which has its closest point in UCH, Ibadan. A temporary succour was then sought in a drug. But sadly, the pandemic strain on national and international medical supply chains blocked access to the drug.

By May 18, when UCH revived its radiotherapy machine and agreed to a once-a-week treatment for the young girl, the cancerous outgrowth had displaced her face, covering half of it. After the treatment, she lost her mobility.

“My baby was walking, jumping, and full of life as of May 18. On the day the second batch of radiotherapy was to take place, the anaesthesiologists (a doctor that administers drugs for insensitivity to pain) didn’t show up, so the treatment was cancelled. That was Friday. On Monday, the same thing happened,” Olayide told BusinessDay.

“They later managed to carry out the radiotherapy. But four days after she was discharged from the hospital, she was down. She could neither walk nor stand. She could not sit without support. I called UCH and they said the cancer cells could have spread terribly.”

Goodness continues to lie in the hospital’s children ward, with her family left with just hope.

At LUTH, No PPE, no treatment for octogenarian

In Nigeria’s fight against COVID-19, the Lagos University Teaching Hospital is a point of reference. On three different occasions, pregnant coronavirus patients have been delivered of their babies without onward transmission of the virus. Two of its five blocks have been earmarked as an isolation ward, thus further decimating the operating capacity of the poorly equipped and understaffed hospital.

But the world of non-coronavirus patients presenting clinical emergencies is grimly different.

After some series of dialysis, Ngozi Egenti, over 80, was rushed into the hospital in an ambulance on May 4 over kidney complications. Some of her symptoms were consistent with coronavirus signs. Her blood pressure was high. She was coughing and vomiting and had difficulty breathing. She was also being oxygenated in an ambulance parked opposite the accident and emergency department.

But the triaging doctor insisted nothing could be done until a swab test was obtained. “It will take a while. We are very busy,” he had said.

At 2:57 p.m., attendants in the COVID-19 team said the day’s business was over since 1 pm, until 8 am again the following day. Even if the test result was produced, beds spaces were not available in the usual fashion.

“If there is no space here, I’ll direct you to the private emergency to make enquiry,” the doctor said.

The spillover ward is the private emergency, but they had no room for any patient that afternoon on the excuse that they were fumigating. According to a consultant doctor at the hospital, such cases are rife and on the increase. He said the old lady would have been cared for if the specialists were equipped with PPE. The doctors in the emergency are left to grapple with their own protection as even the basic surgical masks and gloves were scarcely provided.

For him, “if you cannot test everybody, then you should protect all doctors”.

The pre-COVID-19 era at the hospital was already fraught with inadequacies. Barely 20 out of 65 patients seeking care daily got admitted to an accident & emergency (A&E) ward of less than 35 available bed spaces. The system relied on transferring, discharging or death to make bed spaces available. On a good day, a doctor could see about 13 patients. It’s a doctor to 20 patients on bad days, which are often the case.

Coronavirus has further reduced that attention, but people have not stopped coming down with other ailments nor have they stopped presenting their cases at hospitals as they regularly did.

“My main fear now is lack of testing, lack of manpower and lack of protection,” a source who pleaded not to be mentioned for fear of retribution told BusinessDay. “I also fear the complete collapse of the health sector. We are not far. Politics is still going on in the way we are responding to the pandemic.”

COVID-19 result makes no difference without PPE

At UCH, getting a quick swab test for patients was not a hassle but it made no difference for non-coronavirus patients presenting with highly sensitive conditions.

Although a 35-man team of doctors and nurses undertook daily monitoring at scheduled periods in six designated points, the queue of patients writhing in distress at the emergency department car park, for instance, was long, with clusters of relatives scampering to get doctors’ attention.

The doctors would not take them in due to lack of bed spaces in the ward. This killed even faster than the suspicion of the virus.

For example, on May 4, Isa Mumini stared without motion at the emergency department foyer from the back seat of a Lexus SUV till he took his last breath slipped. He was referred from Oluyoro Catholic Hospital Oke-Ofa — the largest private hospital in Ibadan, following the decline of his struggle with malaria and typhoid fever. His relatives thought the quick coronavirus test ran on him removed a major hurdle in the way of his rescue. They did not know that even with a bank of money, he stood no chance with a lean system of healthcare workers short of PPE and wards lacking beds.

The triage team led by one doctor Ojunaye sprinkled some salt of negligence in the recipe for Mumini’s death. The deceased’s brothers were still waiting for the internet connection to be stabilised at the pay port of the hospital when he died, at about 1: 50 p.m. He spent roughly four hours on the queue. Some of the things recommended for Mumini were hand gloves, sanitiser, and nose masks.

“We have been here since past 9am. The doctors asked about his health status and we presented the letter of referral from Oluyoro Hospital. They assessed him. Another doctor came to ask about his symptoms. He asked if he was coughing, had catarrh, had too high temperature level. After the oral test and an infrared thermometer screening, he was found negative for coronavirus. Since then, we have not set our eyes on those doctors again,” Taiwo Mumini told this reporter, who had earlier planted herself in the crowd of relatives to observe the unfolding events.

However, the moment cries of sorrow from the Muminis rang through the department, two triage doctors, including Ojunaye, appeared suddenly. The triage doctor seconding Ojunaye was primarily particular about exonerating his team.

“Am I the Federal Government?” he queried. It is not our fault. We asked you to buy those things because of coronavirus. You saw the amount of time you wasted trying to get them.”

In another shocking turn of events, Mumini’s death quickly paved the way for other patients who had queued for hours in private vehicles. A patient who had been sustained on oxygen from the referral hospital was given a pass to move to the emergency ward entrance and in barely 10 minutes, he was moved into the ward.

A deep-seated problem

Over the past decade, Nigeria’s health indicators have remained stagnant, as one in eight children die before their fifth birthday. Less than one in three have received all basic immunisations, with Nigeria accounting for the highest number of children in the world who remain unvaccinated against measles.

The health sector is plagued by an inadequate number of trained health workers in rural and remote locations. Government’s inability to commit more than 4 percent of total budget to health despite pledging 15 percent under the Abuja Declaration as well as delays in releases largely widen the gaps filled by international donors such as Gavi, the Vaccine Alliance, Global Financing Facility of the World Bank, UKAID, Global Fund and the CDC.

Average individual spending on health in Nigeria was just about $5 in 2018, according to the World Bank, whereas WHO estimates suggest at least $105 per person is needed to deliver a basic package of health yearly.

Out-of-pocket health expenditure in Nigeria was 75.6 percent of total health spending in 2016 – a system which punishes the have-nots and pushes families into poverty when illness strikes.

Even with the billions of donations to the Federal Government from international and private corporations as well as foreign allies, deadly loopholes remain generally unfixed.

The lack of prioritisation and disinvestment in the health sector nudged higher,

But perhaps more worrying is the halving of the statutory transfer of the 1 per cent Consolidated Revenue Fund (CRF). The Nigerian government has proposed N44.50 billion for the Basic Health Care Fund (BHCF) in the 2020 budget, but this does not appear to be in accordance with the National Health Act (2014). Which compels the government to allocate at least 1 per cent of the CRF, which should be about N81.55 billion, to health.

Mass testing and PPE provision for all healthcare workers

One of the foremost points echoed by health experts in addressing the PPE challenge is that the federal and state government enable mass testing across the country or provide protection for all health workers at all costs.

“If it were a scenario where the cases are still few, you can talk of managing surgical masks. But now, we are at a full-blown stage and we are not testing,” a source in LUTH confided in BusinessDay. “The logical thing is to give all doctors protection; if you arm them well, they will be more confident to work. Even the full adequate PPE does not mean you won’t come down with the virus, but at least it will reduce chances. Most doctors are buying their own PPE.”

But the government does not even need to listen to this LUTH doctor. Instead, it needs to listen to the cries of Chike Ihekweazu, the expert it picked to head the agency spearheading the war against this virus. Before now, both public and private Nigerian hospitals did not have a culture of including the PPE when drawing up their lists of regular purchases, the NCDC DG observed in May at one of the media briefings of the Presidential Task Force on COVID-19, with a warning that the attitude must change during and after this pandemic.

“The longer it takes for that change to come,” a doctor told BusinessDay, “the more lives we’ll lose during this pandemic.”

Note: Pictures of the minor in the story taken with the permission of parents.

This investigation was commissioned by the African Centre for Media & Information Literacy (AFRICMIL) as part of its whistleblowing initiative under its Corruption Anonymous project supported by the MacArthur Foundation. Published materials do not reflect the views of the MacArthur Foundation.