Prof. Oyewale Tomori
. Domestic vaccine production derailed by policy somersaults of successive governments
. States, local governments must step-up, take ownership of diseases control and prevention in their domain
. Capacity building without capacity retention, fuels brain drain
Eminent Professor of Virology and infectious diseases expert, educationist and ex-Regional Virologist for the World Health Organisation Africa Region, Oyewale Tomori speaks exclusively with Africa Health Report, AHR, on a wide range of health issues, including the recent outbreak of diphtheria, brain drain, poor health system, among others. Louis Achi brings excerpt:
You are a key figure in the Nigeria’s health sector and internationally. Would you say our broad health sector situation meets your growth and development expectations?
No, it doesn’t. We should have done much better than we are doing now. There are two aspects of development we have not coordinated properly, and these are capacity building and capacity retention. So if you build and you don’t create an enabling environment for built capacity to function maximally and productively, they will go to where they can function. That is why we have the ‘Japa’ situation in Nigeria today.
Okay, the brain drain.
Exactly. A lot of people think that brain drain occurs only because people are looking for a better life. Yes, maybe, but there is also the fact that many are professionally unfulfilled. You train me to become a doctor or a lawyer and then the environment does not allow me to have fulfillment professionally.
Sometimes, professional fulfillment is more satisfying. There are a lot of people holding back in this country, not because they can’t find somewhere to drain to, but because whatever it is they are doing, they are professionally satisfied. So as a nation, we must always look at both aspects.
First, yes, you need money to survive. But at the same time, after you’ve trained someone to be a doctor and he has no hospital to go to or there is no drug in his hospital, or perhaps he has to carry out surgery with candlelight, he would notice that he is of little or no help. These people are trained to help people, and do good. But because they are not given the right resources needed to do the good, they are trained for, they cannot help the people and feel frustrated and professionally unsatisfied.
What is the use of an engineer sent to build a bridge and who is not provided with the materials he needs to build that bridge? Nigeria trains and builds capacity but fails to retain the resources because she does not create the enabling environment for the highly trained human resources to function and be fulfilled.
Since the lack of enabling environment is the key issue, do you foresee any change in this narrative as we look toward a new administration?
You see the story of Nigerian development and political leadership only allows you to hope and keep hoping. Countless times, our hope has been dashed. But at each change of government we pick up the pieces of hope and hope that if the old government used a stone to dash our hope, you hope that the new one will not use a sledgehammer to dash our broken hope. I know how many times our hope has been trampled upon in this country. So our history does not give us the confidence that what is left of our hope will not be buried by the new administration. Our politicians are wicked birds of different feathers flocking together. So, we always hope for our own perilous disappointment.
Recently, the Nigerian government confirmed the outbreak of diphtheria. The NCDC reported 38 deaths, and says it is monitoring situations in Lagos, Kano, Osun and Yobe states. What do you think is driving the resurgence in Nigeria given that world-wide, diphtheria has reduced in the past five decades?
We are reaping the result of our poor immunisation coverage. Over the years, our national vaccination coverage rates for most preventable diseases have never gone beyond 60 percent. Although the government coverage figures may hit 100 percent and sometimes above, accurate reviews often show otherwise. Perhaps, the joint WHO-UNICEF data provide a more accurate picture. So, according to these data over the last 10 years or more, our vaccination coverage figures for diphtheria, pertussis, tetanus (DPT) and Penta have remained at 60 per cent or below, annually.
So let me break it down for better understanding. Let us say, five years ago, of 100 children born, we vaccinated 60, leaving 40 children unvaccinated. If you maintain this poor level of coverage for the next year, you will add another 40 children to those unvaccinated last year. So, over the five year period, you are accumulating children who have not been vaccinated and boom…diphtheria or nay other vaccine preventable disease explodes with a bang, and you have an uncontrolled and uncontrollable outbreak in your hand.
Of course, while you are accumulating unvaccinated children, some of them will come down with the disease, but our surveillance is not sensitive enough to detect the small number of cases, and we assume we are doing fine. As they say, the absence of evidence is not evidence of absence. Now, the cases are occurring at the same time in the same location and in such large numbers, that even our blind and deaf surveillance system cannot miss. Now it is becoming obvious that there is a big problem. All those figures of numbers of cases and deaths may be the tip of the iceberg, and do not represent the reality.
If we upscale our vaccination coverage, can we contain it?
Of course. Go and check the children having this disease. You will find that many of them maybe five years and above or may not have received any vaccination at all…the so called zero-dose children. So, vaccination is the key. Let us vaccinate our children.
Other parts of the world are preventing the re-occurrence of diphtheria. They have adequately covered their children with appropriate vaccines with the right doses and at the right time. It is the failure of our immunisation program that is leading us to what we are getting now.
The COVID-19 pandemic exposed Nigeria’s low drive for domestic vaccine production, and this has national health security implications. What kind of intervention should government deploy to address this gap?
It is not that we have not been making attempts to produce vaccines locally. We were producing vaccines against human diseases locally in the 1950’s for smallpox, yellow fever, and others. But each time we have a change in government, that government changes the policy instead of building upon what we already have in place, we destroy what we have, with a promise to build a better facility. The failure of successive governments to continue the good programme of past administrations has led us back to where we were. A country that cares about the health security of its people will make the issue of local vaccine production a priority no matter which government is in place. .
You have been a player in the Lassa fever case management for many decades. What are we doing wrongly that we are still having this disease?
Let me make a correction. My involvement with Lassa fever has been in the surveillance and laboratory diagnosis area and not in case management. Lassa fever has been with us since 1969. That’s about 54 years ago and we are still behaving as if it is a new disease. This is because we have not learnt from past lessons. If we learnt any lesson at all, we have forgotten it. It is a disgrace and a disaster for Nigeria to be shouting every year about Lassa fever. We have been saying the same thing for the last 25 years or more.
We know the seasonality of Lassa fever, so we should be prepared. But we are, as usual, a country that only prepares when the battle has started. How can you start making ammunition at the warfront, when your enemy is firing at you? You think we have learnt from COVID-19? We haven’t. If another disease comes into this country tomorrow, we will be running helter-skelter like decapitated chicken.
Nigeria relies considerably on international partners and Western experts in coordinating disease control. Why is this so and what are we lacking?
We lack national self-respect and national pride. If we respect ourselves or if we have any national pride at all, we won’t be begging people for the things we already have. We have the resources – trained human workforce, experienced experts, and the financial capacity to find solutions to the diseases that plague us. But no, we would rather beg and whine for the crumbs of equity.
Remember I mentioned something about capacity building and capacity retention. Nigeria has enough talents to handle any situation, but we don’t give our human resources the encouragement and the environment to excel and function effectively. We are not preparing for the next disease. We live by the day. If there is a crisis now, we will rush into it and then forget it.
We seem happy when there is crisis, so we can break all the rules of accountability for self-interest to override and bury our national interest. Let’s be frank with each other. Some of the people in authority and their accomplices enjoy crises. This is why we are where we are today.
Let me ask you one question. How much of federal government money is in our National Center for Disease Control? Go find out how much. You probably will find that most of what they are spending in the national sphere and the NCDC is from foreign agencies and donors, including the Bill Gates Foundation, USAID, CDC, Global Fund, and a host of bilateral funders in Europe, the Americas and Asia. The issue is about our national health security, yet we are bringing outsiders to secure the health of our nation.
The error is not just at the Federal level; the States have abandoned their duties and just as the federal looks to external sources and donors, the States unashamedly depend on the federal government to solve their disease outbreak problems. The diseases start at the subnational level, not at the federal level. Most of the cases occur in the rural areas. We need to strengthen local government areas and the states so they can take responsibility for solving disease problems in their jurisdiction.
If States perform their duties and play their roles, our NCDC will not be running helter-skelter all over the place. In fact, they will do less of control and do more of coordination. We will only need the federal government to assist and coordinate. The central government should empower the states. If each state takes ownership of disease control and prevention activities in her domain, the support from the federal level will be minimal through the NCDC.
But when NCDC becomes the disease prevention and control police officers, it could be overwhelming, and that’s one reason for the current failure to adequately prepare our nation to prevent and control disease outbreaks. States and local governments must take responsibility for disease control and prevention in their respective states. They must be responsible for solving those initial problems.
Actually, a disease outbreak starts with one case. If nothing is done, just like with diphtheria, you hear of another one in the local government, then it spreads to state. If the state does nothing about it, the disease spreads to the other states of the country and where the country doesn’t do anything about it, it spreads to the world and that’s how COVID started. COVID-19 started in a community in Wuhan and then spread to the world. There are officers in the villages that will see that single case, who will report it and take the appropriate actions so that it doesn’t spread from one village to another, then to the town, then spread across the state, country, and then the world.
Do you think there is a linkage to the structure of our federalism with states’ apparent inability to handle certain critical health sector responsibilities?
You know everything is in the center in this country and I think someone said the center has not been able to hold for a very long time. We started this country not as these federal parts. We had regions. At the time, there were three regions. I grew up in what was the Western region. It was what made me to be what I am today. In my region then, we had free education, free healthcare, and so on. Then we broke all that down and now we have the federal that is running everything. The state has been incapacitated, and in turn has emasculated the local government.
Let each state own its resources and contribute to running the federal. That’s the way things can be handled, and that is what people should be handled. It worked very well for us in those days before independence and soon after. So why did we move into federalism, which appears not to be working well for our development. So, we need to go back to basics, to what worked well for us in the past.
