Between a strike and a virus

Samuel Usman endured two days of fever—made more tricky last when as Nigeria’s Ebola situation crested. By day three, he couldn’t take it anymore. “Do you know any doctor who can look at me?” he was asking. His definition of “any doctor” ruled out more than 52 teaching hospitals and an equal number of federal […]

Samuel Usman endured two days of fever—made more tricky last when as Nigeria’s Ebola situation crested. By day three, he couldn’t take it anymore.
“Do you know any doctor who can look at me?” he was asking.
His definition of “any doctor” ruled out more than 52 teaching hospitals and an equal number of federal medical centres Usman and millions of Nigerians visit for anything from fever to boils.
No hope there: doctors in those hospitals have been on strike since July 1, fulfilling a promise to the country, and daring the government to make good on its own promises.
Government hospitals, by now familiar to series of strikes by healthworkers, ran on the strength of nurses and every other healthworker present. Private hospitals took in patients discharged in the absence of doctors.
Other healthworkers hung around hospitals, diverting patients to private hospitals run by same striking doctors, in return for some extra pay, some nurses have alleged.
The strike hasn’t been as straightforward as planned.
A couple of long meetings and a couple of signed MOUs should have taken care of some 24 demands by doctors: in the event, a little media opportunity to cover lost grounds; both doctors and government make speeches about resolving to end the strike in the interest of the Nigerian public, and hospitals return to normalcy until the next strike comes calling.
It hardly went that way. None expected that Ebola virus disease, which broke out in Guinea in March—first time ever in West Africa—would come flying across four countries in the cells of Liberian Patrick Sawyer and land at Murtala Muhammad International Airport.
That was July 20—three weeks into the strike. The Ebola situation has left both government and doctors in a difficult position: doctors needing government to bow to pressure; government needing doctors to contain the virus.
In the aftermath came claims about government desperation to break the strike by proscribing the Nigerian Medical Association—a feat analysts say would have handed doctors a court victory thanks to protective labour laws.
Instead federal government blindsided doctors this week with amazing speed: it suspended its sponsorship of residency training programme for doctors.
It had taken days in which Ebola infected some 12 people and killed five, most of them healthworkers [even more died after bathing and drinking copious amounts of salt in water, as they were told on social media] for the government to reach its decision.
It complained it had “implemented more than 90 percent of its responsibilities as signed by both parties,” in the official document that carried the suspension.
“At the conclusion of each meeting, the NMA promised to call off the strike but would return another day to say that they could not.”
NMA admitted it couldn’t get 100% all its 24 demands and whittled them down to “minimum endpoints”—the least response it was ready to accept from government—on each demand it raised in an open letter to the Secretary to the Government of the Federation, published in newspapers on June 16.
It said only a government circular agreeing to its “minimum endpoints for restoration of sustainable sanity in patient care in Nigerian hospitals will end the strike.”
They include:
•       Position of DCMAC—deputy chairman of medical advisory committees—to remain in teaching hospitals and federal medical centres.
•       Opposition to use of the nomenclature “director” for anyone in hospitals other than a medical doctor, but insists non-medical workers can attain the height of their careers.
•       Desire to reserve the title “consultant” in a hospital setting for doctors handling patients and not applied to appointments of non-doctor consultants, insisting it “will be a source of confusion.”
•       Speedy passage of National Health Bill
•       Universal health coverage to all Nigerians, beyond the 30% target for 2015. They even suggest an extra one kobo per second on call costs to finance a community health insurance fund.
•       The office of surgeon-general of the federation appointed “with immediate effect, in accordance with [the President’s] pronouncement.”
•       Central Bank to withdraw a circular authorising Medical and Laboratory Science Council of Nigeria to approve licences for importation of in-vitro diagnostics (tools for lab tests), insisting that the council was duplicating the role of NAFDAC and causing obstacle to adequate development in healthcare.
•       At least N100,000 per month in hazard allowance for doctors, up from a present N5,000, citing dangers doctors are routinely exposed to.
•       Clinical duty allowances for honorary consultants be increased by 90% of consolidated medical salary scale.
•       Doctors allowed to skip pay grades as other health workers are allowed.
In the document suspending residency training, government insisted it paid doctors their july salaries—allowances for duty, teaching and hazard—believing its “magnanimity would appeal to reason for NMA to call off the strike.”
In the next breath, it called the strike “one of the most insensitive steps to be taken by any association or a labour union in the history of this country.”
And as far as Ebola is concerned, a presidential declaration of national public health emergency has united the entire country, said government, but it is “quite regrettable that the people who should take leadership role in the fight against Ebola disease are now the most unsupportive.”
“All efforts by Government to contain this disease are being frustrated by the continued industrial strike action of the NMA.”
Residency training is like eight years minimum of secondary school over again for doctors, once they go through medical school, housemanship and national youth service. That’s where they take up specialties and attain status of consultants.
Health minister Onyebuchi Chukwu has famously backed government-run residency training programme—and it’s always been on doctors’ demand at every turn with government.
In a concililatory meeting last September, NMA its former president Dr Osahon Enabulele listed funding for residency alongside national research funding.
This week they called the suspension a ruse to “break its ranks” on their strike, with the added blow of stopping the production of medical specialists.
The government circular was carefully worded to avoid the word “sack’ but doctors have interpreted suspended residency as the sack for 16,000 residents in government hospitals, redolent of the “infamous authoritarian dismissal of 774 doctors by the Babatunde Raji Fashola-led Lagos state government in 2012,” according to Enabulele.
NMA national officers committee demanded government to withdraw its circular and unconditionally reinstate the “so-called sacked resident doctors.”
It said government should show more commitment to improve the already poorly funded programme, improve healthcare with a view to discourage medical tourism abroad, and noted government stance “will further worsen the present industrial disharmony.”
The committee directed doctors not to accept any sack letter, sign any register in that regard or pick up any locum appointment—which hospital managements could use to replace full-time doctors.
“Any doctors who flouts this directive, does so at his/her own peril,” NMA told its members, at the same time directing doctors to “remain committed towards containing the Ebola outbreak.”
Days later, resident doctors themselves stormed the association’s headquarters in Abuja in protest with placards demanding the sack of health minister Chukwu.
“When you understand the role of resident doctors, you will understand that by this action the Nigerian government has closed down all federal hospitals and has closed down all medicals schools,” said Dr Chidozie Achonwa, vice chairman of the association in Abuja, and a past president of resident doctors’ association.
“By [this] news, government has said they don’t need specialists in the country again.”
A profile of Nigeria’s health workforce in 2012 showed deficit of more than 216,200 doctors, 190,150 nurses and 67,630 pharmacists—one of the highest shortages among middle-income countries.
“The question is: could this be their response to the strike or is it how they want to solve the crisis,” said Dr Jubril Abdullahi, president of National Association of Resident Doctors.
“For us [resident doctors] we are here to ask the leadership of the NMA for answers. We are here to ask if it is true that the federal government has stopped the residency program and effectively sacked 16,000 civil servants.”
NMA president, Dr Kayode Obembe, who resigned and later rescinded his resignation within hours over crisis rocking the association in the wake of its July 1 strike, insisted residency program was established by law and no government official had the power to suspend a program backed by law.
He called the suspension “the greatest assault that can be unleashed on our profession.”
Hippocratic Oath, which doctors swear to at the end of medical school, mandates that they “fight to maintain the structures and noble tradition of our profession,” Obembe said.
“In furtherance to that we had identified that structures of our profession were collapsing and if we didn’t act, it would be irredeemable.

“But along the line, we got the greatest shock of our lives when a letter was written to that those who are the bedrock of this profession that they have been summarily dismissed. Not only that, the residency training program was also suspended. The implication of this action is, serious, disastrous and calamitous.”
The implication is what happens to health care in a country without doctors, while other health workers carefully watch matters and gear up for their own strike.
Government called the protest hypocritical and insincere.
“There are doctors working right now. There are doctors working in the field. The consultants are there. There are other doctors who have subscribed to the emergency situation in this country,” said Linus Awute, federal health ministry’s permanent secretary.
“So, that demonstration, to me, is hypocritical because first of all, before you talk about somebody suspending you, you have to remember that you have suspended yourself for nearly two months now.”
He said doctors’ continued salary while on strike was “an insult to the entire Nigerian population … [and] an insult to those who are out there, looking for job.”
“This country doesn’t require any kind of distraction of that kind. Nobody needs this kind of distraction. A national emergency has been declared. There is a disease outbreak; there is insurgency, all of which want to pull this country down.
“And, I think the least we will expect from anybody is distraction. I am talking in my own position as the Permanent Secretary in the health sector that is taking responsibility in ensuring the disease outbreak is also contained. That is the point of view from where I am speaking,” he clarified.
The clarification hardly helps. With medical schools taking in an average of 2,550 doctors every year, it could take 84 years to train the 282,000 doctors needed for Nigeria present population, according to World Health Organisation recommendation of 2.3 per 1,000 population.
Current ratios indicate only one doctor for every 2,500 Nigerian. In effect, Usman shared his doctor with some 2,499 other Nigerians.
The ratio sharply focuses problems plaguing health: overworked doctors underpaid, driven out in search of better working conditions abroad. And patients like Usman paying the price.
He tested positive for malaria parasite, underwent a batch of other tests, including liver function, paid thousands for medical consult, drugs and lab tests—all at a private clinic.
Usman had a prescription note and drug invoice to show for his effort on the road to recovery. The health system of his country is hardly on the same road.