In Nigeria, health workers tackle stigma and misconceptions as they fight TB and COVID-19

By The Global Fund

November 13^th, 2020

Her flashy orange shirt displays a strange invitation: “Ask me on COUGH more than two weeks”.

Sewande Jekenu is a Community TB Worker from Akowonjo, a densely populated area in Alimosho Local Government Area of Lagos State, Nigeria. Every day, she walks up and down the streets to support and provide health care to patients, but also to inform people about the disease and detect potential TB missing cases. A cough that lasts more than two weeks – or even less, especially among high risk groups such as children or people living with HIV – could be due to tuberculosis and needs medical consultation.

In Nigeria, health workers tackle stigma and misconceptions as they fight TB and COVID-19

The COVID-19 pandemic has made Sewande’s work even more challenging. “Some people don’t want to work with us anymore, they just send us away. They say we are coming to isolate them,” says Sewande.

In Akowonjo, the fear of being quarantined and stamped with COVID-19 stigma seems to be more terrifying than getting the virus itself. The misconceptions between COVID-19 and TB – which can have some similar initial symptoms – are a new hurdle for health workers fighting TB.

“In the past, people would listen to us,” says Taiye Bakare, Sewande’s colleague. “If someone was coughing for two or three weeks, we would easily collect a sputum sample and then provide a free test and free treatment. But now people are very scared. They are not ready to give us their samples because they think we’ll be using them to test COVID-19. They don’t want to go into isolation.”

Sewande and Taiye believe more needs to be done to educate people on the difference between COVID-19 and TB and the importance of trusting community health workers. “They should do more on the radio, tell people they should cooperate with us.”

Nigeria is the largest economy and most populous country in Africa. It also has one of the highest rates of TB in the world – the highest in Africa – and the fifth-highest number of COVID-19 cases on the continent to date. All of Nigeria’s 36 states have reported COVID-19 cases with Lagos state accounting for 34% of these.

Last April, both Lagos and neighboring Ogun states went on a four-week lockdown in order to curtail the spread of COVID-19. The lockdown, which included restrictions on gatherings of people and transport stoppages, impeded visits to health care centers and disrupted medical supply chains, which is particularly concerning in a country with less than 1 doctor per 2,000 people. It also caused economic hardships, interrupted schools and universities and restricted religious gatherings.

But at the Alimosho General Hospital, 10 kilometers south of Akowonjo, there was no room for a timeout.

“We had to restructure the way we were running the clinic", explains Dr. Adejuwon Adewale, head of TB Directly Observed Therapy (DOTS) and antiretroviral therapy (ARV) at the hospital. “Instead of having two to three doctors in the building at the same time, we had to reduce to one, and organize the rotation of clients accordingly. We also had to go the extra mile in protecting ourselves with Personal Protective Equipment (PPE), knowing TB is said to be one of the underlying conditions that can predispose people to be more at risk of getting COVID-19.”

Access to PPE such as gloves, masks and goggles is vital to any country’s effective emergency response to the COVID-19 pandemic. Health workers on the COVID-19 frontlines are at risk of being infected or dying and passing the virus to their families if they don’t have PPE.

In addition to the challenges of accessing PPE, public transport services were severely disrupted or cancelled, generating extra costs for health workers.

Comfort Adebola, from the Ogun state, oversees TB Directly Observed Therapy (DOTS) at the Alimosho Hospital. DOTS is a specific strategy endorsed by the World Health Organization to improve adherence by observing and recording patients taking each dose. With commercial buses stopped, Comfort had to spend about 60,000 Naira (approximately $US155) to repair her car and drive the 90 kilometers to reach the hospital. Average monthly salary in Lagos is 350,000 Naira.

For the same reasons – lockdowns and higher transportation costs – TB patients also faced difficulties traveling to the hospital. Many did not even attempt to come to health facilities.

“Many TB patients fear they would come down here and leave with COVID-19,” explains Dr. Adejuwon Adewale. He says hospital staff called them to reassure them and let them know measures are in place at the hospital to protect them against the virus.

“We have no choice, we just have to make sure we move on with the work,” says Sulaman Victoria, a TB-DOTS provider working at Alimosho Hospital. “I call all my TB patients who are under treatment. If they are unable to come here because they live far and do not have enough money to pay a bus ticket, I ask the dispatch rider to take the drugs to them. And for patients who manage to come here to take their treatment but don’t have enough money to go back home, I sometimes take out of my pocket and just give it to them.”

Patrick Tunde Fawetan is one of these dispatch riders. Driving his purple motorcycle across Lagos and Ogun states, he picks up sputum samples and delivers medications to TB patients.

“During the lockdown, I was picking up 12 samples compared to only one or two before. Some places were very far from each other. It was tough times but people always tried to encourage us.”

Ernest Okonkwo Ugwueze, a retiree who has just recovered from TB thanks to the free treatment he received at Alimosho Hospital was thankful that his refills were dispatched to him at home during the lockdown. “When the lockdown started, they used a bike to bring the drugs to me so that I will not miss treatment. They called me, I met them at a bus stop, they gave me the drugs and I signed for them,” he says while showing his one-page health record.

As the sun is going down on Lagos, Sewande, Taiye, Sulaman, Patrick and the others return home to rest before another day of hard work.

Last year, 5.7 million people were treated for TB in countries where the Global Fund invests, including 120,000 in Nigeria. But COVID-19 threatens to reverse those hard-fought gains; a modelling study from the Stop TB Partnership earlier this year estimated that TB service disruption due to COVID-19 could lead to 525,000 additional TB deaths worldwide in 2020, compared to 2018.

The Global Fund is working with partners worldwide to urgently reverse as much of the losses as possible in diagnosis, treatment and prevention of TB to pre-COVID levels in 2021; accelerate TB diagnosis, treatment and prevention to reach the goal set at the UN High-Level Meeting on the Fight Against TB of finding and treating 40 million people by 2022; and prepare and remodel TB programming in the COVID-19 situation.