An Epidemic Upon a Pandemic: Why we need stronger cardiovascular health interventions in Nigeria in the context of COVID-19
As COVID-19 spreads rapidly across Nigeria, with over than 50,000 cases and over 1,000 deaths as of August 25th 2020 (a case fatality rate of 2%), it is colliding with a quieter, but equally devastating, epidemic: noncommunicable diseases (NCDs) including heart disease, cancer and diabetes.
NCDs account for an estimated 29% of all deaths in Nigeria, including 11% attributable to heart disease. Hypertension (high blood pressure), which causes cardiovascular disease, is common: 29% of adults over 20 years old are estimated to have it (20 million people in Nigeria), a number expected to rise to 31% (39 million people) by 2030. This makes Nigerians more vulnerable to COVID-19: here, as in other parts of the world, most patients who have died from COVID-19 have had underlying illnesses, mainly NCDs. Heart disease and diabetes in particular may be associated with more severe cases of COVID-19.
Globally, the disruption of continuity of care grows more severe as COVID-19 transmission increases. Left unchecked, these disruptions might result in more deaths from other diseases than from COVID-19 itself, as seen in previous epidemics such as the West African Ebola outbreak in 2013-2016.
Outpatient visits in public health care facilities fell from about 4 million monthly visits before the pandemic to 2 million by May, according to data from the National Health Management Information system. Health workers have been diverted from routine duties to provide COVID-19 care, and others have been sidelined by the scarcity of personal protective equipment. Clinics have closed or ceased offering non-emergency services, and stocks of medicines and diagnostics have dwindled due to disruptions in global supply chains.
It has never been more important to strengthen health services and policies to prevent and treat NCDs. Combatting avoidable sickness and death from NCDs starts with increased funding for NCD prevention, care, treatment, and rehabilitation services, which are underfunded compared to other health programs in the country. According to the World Health Organization, only three of 10 essential NCD medicines and two of six essential NCD technologies are widely available in Nigeria. Funding will allow health care workers to train in providing better service for people with NCDs throughout the pandemic—and beyond—and will help to ensure supplies of essential medications and basic equipment necessary for uninterrupted health care services delivery.
The health system can also make changes that make it safer for people with NCDs to continue to receive care during the pandemic. These include scaling up community delivery of medications, extending the duration of prescriptions, so that patients need to refill them less frequently, and ensuring facilities have adequate screening and triage staff and are set up to separate suspected cases of COVID-19 from others. My organization, Resolve to Save Lives, an initiative of Vital Strategies, has been working with the World Health Organization, the Federal Ministry of Health, and State Ministries of Health in Ogun and Kano to implement the Nigeria Hypertension Control Initiative (NCHI) which is the first ever coordinated approach to diagnosing and treating hypertension at the primary care level in Nigeria.
Leveraging technology, such as telemedicine and virtually delivered health care interventions, can reduce the need for physical meetings between health workers and patients, including those with NCDs who make frequent outpatient visits. Telemedicine has been deployed successfully in many countries grappling with COVID-19,1 and has already increased in Nigeria, as some health institutions, health management organizations and even state governments have embraced this technology; for instance, Lagos has rolled out the Eko Telehealth initiative. Other measures that need to be set up to ensure that services continue to be provided to Nigerians include improvement of continuity of care and acceleration of progress toward universal health coverage, integrating NCD care with primary health care, and task shifting to devolve responsibilities to lower cadres of health workers.
Even as we work to maintain lifesaving care for patients with chronic diseases during COVID-19, we must not lose sight of the factors that cause these conditions, which are largely preventable. Policies that support tobacco elimination and improved diet (including salt reduction and the elimination of trans fat) can improve the health of our entire population, reducing our risk from COVID-19 and mitigating the impact of comorbidity with infectious diseases (including COVID-19, HIV etc.) Evidence-based efforts aimed at preventing NCDs should be implemented at scale across the entire country.
The intersection of COVID-19 and NCDs creates a double threat to the health of Nigerians, but by taking concrete steps to both prevent NCDs and to maintain treatment for NCD patients during the pandemic, we will create a stronger health system and a healthier, more resilient population that is better prepared to handle outbreaks in the future.
Dr Emmanuel Agogo MBBS MtropMed MSc DRCOG FRCGP is currently the Country Representative of Resolve to Save Lives (an initiative of Vital Strategies). Emmanuel is a Consultant in family medicine and was a 2019 ELBI Fellow at the Johns Hopkins Center for Health Security. He is a health Systems strengthening & global health security subject matter expert.
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