Keywords

COVID-19; Health inequalities; Social inequalities; Disparities

Introduction

The SARS-CoV-2 infection, first discovered in Wuhan, Hubei Province in China has evolved to a pandemic affecting almost all nations in the world. Nigeria, the most populated country in Africa, has not been spared in this scourge. Since the first case was identified in Lagos state [1]. There has been a progressive increase in the number of cases in the country [2]. At the time of writing, there were over fifty-eight thousand reported cases in the country, with cases in virtually all states of the federation.

Literature Review

The Nigerian situation, however, is characterized by challenging circumstances which could modify the impact of the pandemic on citizens and the country response. With a population of over 200 million people, there is a huge potential for spread and catastrophic outcomes. Nearly half of the population resides in rural areas where access to primary care facilities is limited. Under 5% of the entire population is enrolled into the National Health Insurance Scheme (NHIS) meant to ensure universal health access to the general population [3]. Enrolees are mainly engaged in the formal sector of employment, whereas majority of the workforce in the country are engaged in the informal sector [4,5]. Out-of-pocket expenditure for healthcare is therefore common among the uninsured, majority of whom are informally employed or unemployed and therefore poor. Although efforts are underway to improve the healthcare infrastructure, primary care facilities are underequipped to handle screening, diagnosis, and isolation of prospective cases of COVID-19. This represents inequality in healthcare access for the poor and vulnerable in the country.

Underlying non-communicable diseases such as Diabetes Mellitus (DM) and hypertension affect significant numbers of the Nigerian population. The pooled prevalence of DM in the Nigerian population was 5.77%, with nearly 12 million people having this disease. Urban dwelling and concomitant unhealthy dietary habits were the strongest risk factors for DM. Notably; older age groups had a 6.6% prevalence of DM from the study [6]. Prevalence of hypertension was shown to be up to 17.5% in North Central Nigeria with higher prevalence values in urban centres compared to rural areas [7]. To give these figures some perspective, Lagos and the Federal Capital Territory Abuja have the highest case numbers to date. The interplay of high population density of urban areas in these geopolitical regions, non-communicable disease, inadequate and improper use of masks may possibly account for the increased viral transmission, case numbers and mortality currently being seen. As documented in literature, non-communicable diseases such as hypertension and DM adversely affect the outcomes of patients with COVID-19 infections [8]. Although there was a seemingly protective effect of residing in rural areas when case detection began in Nigeria, this may soon be lost due to rapid community transmission. Indeed, there is a possible risk of faster spread in rural areas due to communal living practices. Poverty leaves lowincome earners and informal workers caught between two choices-staying indoors with limited activities to help flatten the curve or seeking their livelihood at the risk of contracting the virus. Although a larger proportion of the morbidity and mortality associated with COVID-19 in Nigeria is documented in urban areas, there is a possibility of higher mortality in rural areas as access to high quality urgent care is limited due to poverty and inequitable distribution of health resources.

Rapid contact tracing and case isolation are essential means of limiting community spread. Although contact tracing has largely been dependent on testing, it is believed to be insufficient in the country. At the time of writing, only 507,006 tests had been conducted in a population of 200 million people [9]. Testing centres are mostly domiciled in urban areas which arguably have higher case numbers. Public health-based digital contact tracing employed successfully elsewhere in the world is yet to be deployed in Nigeria therefore exposure to asymptomatic individuals is likely to go unchecked. This exposes the poorest to avoidable hazards in their endeavour for survival without any form of notification of contact.

Nearly 50 million Nigerians lack access to hygiene facilities and clean water services, which are crucial for handwashing as a preventative measure in the spread of COVID-19. Health disparities impact on the distribution of hygiene services and water among the poor population in Nigeria and have serious implications on the prevention of the pandemic [10].

Social distancing measures have since been implemented by all states in the federation. Although they follow recommended best practices, they seem impractical for majority of the Nigerian populace due to limitations in efficient transportation, supply chain and online purchasing systems [11]. Whereas developed countries have systems in place which allow a coordinated approach to minimize exposure of persons accessing essential services including food supplies and medical care, these were lacking for the general population in Nigeria at the beginning of the pandemic. Consequently, poorer families have experienced difficulties in obtaining food, while richer families were able to sustain themselves on existing supplies. Panic buying created artificial scarcity for products ranging from basic foodstuff to face masks, placing a higher burden of suffering on the poor. Programmes addressing Neglected Tropical Diseases (NTDs) slowed down considerably, with mass drug administration halted in the country [12]. The beneficiaries of these programs are largely in rural areas. As a result, it would not be surprising to find increasing cases of NTDs if the pandemic is prolonged. Although innovative use of television and radio services has been deployed in the country, access is limited for students from less privileged homes who may lack access to a television in their homes, power or money to obtain batteries for radio sets, or be outside the reach of the stations relaying such programs. Statistics regarding COVID-19 cases and deaths are still emerging in Nigeria, so it may be difficult to draw conclusions along socio-economic lines.

Possible solutions and research prospects

Although the pandemic has brought to light the wide inequality in healthcare access across the globe and particularly in Nigeria, there are potential benefits which could be harnessed. Local production of personal protective equipment, hand sanitizers and disinfection facilities have commenced around the country. Digital tracking measures for COVID-19 are being evaluated in Nigeria. However, these efforts will be useless if they are not accessible to the poorest and most vulnerable in Nigerian society, as the infection could resurge and spread from this population subset [13]. Leveraging on already existing systems being used in behaviour change communication and disease tracking for NTDs may be the best means to achieve rural community surveillance and control of COVID-19 in a unified approach to community care. Recommendations for the elderly, patients with lung, liver disease, and diabetes have been made by the Nigerian Centre for Disease Control (NCDC). These have been advocated by primary care providers working at the community level. Primary care physicians continually advocate social distancing, home-made mask use and limited attendance in ambulatory care settings as cost-effective measures to minimize nosocomial viral transmission. Community education delivered by primary care workers will help to increase protective habits and dispel false information regarding COVID-19 [14]. Researching the relationship between the socioeconomic characteristics and outcomes of COVID-19 patients should be championed as this may provide data to inform supportive care and disease prevention among high risk subgroups. Further research on the impact of the pandemic on childhood education may reveal inequalities which may need to be urgently addressed as the pandemic progresses. These are best championed by primary care providers who directly interact with patients in the community and have an intimate understanding of their impact on the lives of individuals and families.

Conclusion

Socio-economic and healthcare inequalities in Nigeria undoubtedly have impact on the spread of the COVID-19 pandemic in the country. The pandemic may also widen existing inequalities. Increasing awareness on inequalities in this period is critical to prevent a widening of disparities following a pandemic which has been catastrophic for innumerable families and communities.

References

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