Almost sixty years after attaining independence, Nigeria does not have a coordinated emergency medical services (EMS) system. After a tour of some top public hospitals in the country, Associate Editor ADEKUNLE YUSUF in the part of this series reports that many Nigerians are losing their lives to injuries and illnesses that an urgent medical response would have saved
A haven for cheap deaths
AS grim as the pictures of probably avoidable deaths chronicled above appear to be, the reality in the country is worse by far. Due to the frequency of ghastly accidents, which have sent many to their untimely graves and left many fatally wounded, Nigerian roads have been dubbed as highways of death. According to data available from the Federal Road Safety Corps (FRSC) and the National Bureau of Statistics, Nigeria loses at least two souls to road crashes every four hours. Yearly, out of an estimated 11.654 million vehicles in the country, no fewer than 20,000 are involved in accidents.
From January 2013 to June 2018, records have it that the following lives were lost to road traffic accidents: 5,539 lives in 2013; 4,430 in 2014; 5,400 in 2015; 5,053 in 2016; 5,049 in 2017; 2,623 died from January to June 2018; while 126 lives were wasted on Nigerians roads between July and September 2018. In May 2017, the FRSC Corps Marshal, Boboye Oyeyemi, said during an event in Kaduna State that there were 33.7 deaths per 100,000 people in Nigeria every year. A summary of these staggering figures shows that a whopping 28,195 Nigerians were crushed in 68 months on Nigeria’s blood-sucking highways, an equivalent of 415 lives per month, 14 persons per day, and two lives every four hours – making Nigeria one of the countries with very high road fatalities in the world.
Though staggering, the above casualty figures were by no means exhaustive, as many accident cases hardly get to the notice of the FRSC, which appears to be the only federal agency that actively monitors activities on the country’s highways, performs rescue and evacuation functions and records casualty events. Although institutions such as the police and other para-military bodies also perform some semblance of services in emergency management activities in the country, experts lament there is no synergy between the agencies in a manner that can confer the requisite accuracy and integrity on the data being churned out on road accidents. While trauma care experts believe that the number of those that sustain life-threatening injuries is often far greater than those that lose their lives in road crashes, there is a conjecture that runs among medics that many among those that eventually end up in the mortuaries could probably have been saved or not died on the scene had there existed an efficient EMS system in the country.
In the second quarter of 2018, the NBS and FRSC road transport data reflected that 2,608 road crashes occurred in the country, blaming speed violation as the chief culprit (accounting for 50.65 per cent of the total road crashes in the period under review). However, while 1,331 Nigerians got killed in the road traffic crashes recorded, a total of 8,437 people sustained varying degrees of injuries. While 7,946 of the 8,437 Nigerians that got injured (representing 94 per cent of the figures) were adults, the remaining 491 (representing 6 per cent of the figure) were children. Broken down further, data showed that 6,415 male Nigerians, representing 76 per cent, got injured in road crashes in the period; while 2,022 female Nigerians, representing 24 per cent, were also injured.
Also, in the state-by-state casualty figures released for the second quarter of 2018 by NBS and FRSC, 64 Nigerians were injured while 12 got killed in road crashes in Abia State, posting a total casualty cases of 76; 634 injured and 66 killed in road accidents in the Federal Capital Territory (FCT); 103 injured and 13 died in Adamawa State; 31 injured and 12 killed in Akwa Ibom State; 107 injured and 17 died in Anambra State; 494 injured and 59 died in Bauchi State; 40 injured and 6 died in Bayelsa State; 186 injured and 22 died in Benue State; 72 injured and 20 killed in Borno State; 32 injured and 5 killed in Cross River State; 141 injured and 36 died in Delta State; 131 injured and 14 killed in Ebonyi State; 197 injured and 40 killed in Edo State; 44 injured and 3 killed in Ekiti State; 173 injured and 28 dead in Enugu State; 172 injured and 17 killed in Gombe State; 173 injured and 23 killed in Imo State; 145 injured and 74 dead in Jigawa State; 995 injured and 180 killed in Kaduna State.
Casualty figures from other states within the same period are: 384 injured and 47 killed in Kano State; 361 injured and 57 died in Katsina State; 82 injured and 5 died in Kebbi State; 301 injured and 51 died in Kogi State; 252 injured and 53 killed in Kwara State; 241 injured and 30 killed in Lagos State; 358 injured and 36 killed in Nasarawa State; 385 injured and 75 died in Niger State; 485 injured and 72 killed in Ogun State; 323 injured and 74 killed in Ondo State; 215 injured and 22 killed in Osun State; 308 injured and 66 killed in Oyo State; 225 injured and 6 died in Plateau State; 50 injured and 5 died in Rivers State; 153 injured and 22 died in Sokoto State; 76 injured and 9 died in Taraba State; 220 injured and 16 killed in Yobe State; while 156 were injured and 38 died in Zamfara State. Therefore, for the second quarter of 2018 alone (a period of just 3 months), there were 2,545 road traffic accidents nationwide, involving 18,320 people. Of this, 8,437 were injured and 1,331 died, leaving a casualty figure of 9,768 in just three months!
Besides the carnage on Nigerian roads, the country is witnessing a growing incidence and burden of non-communicable diseases and rising wave of gender-based violence, with the media awash with reports of gory endings of these issues. Hardly a day passes without reports of people being killed in their dozens in one part of the country or the other. In a recent report, the Nigeria Security Tracker (NST), a project of the Washington-based Council of Foreign Relations, said more than 25,794 people had encountered violent deaths in Nigeria since 2015. But many believe that mind-boggling figure is understated, as there are thousands of other Nigerians who are murdered or badly injured in remote villages, but whose accounts of misfortune do not grab the newspaper headlines.
The pervasive insecurity brought about by proliferation of illicit arms increasingly primes the country for rising violence and mass killings that now envelope the land. Last year, the Civil Society Legislative Advocacy Centre (CISLAC) said that Nigeria accounts for about 70 per cent of illegal small arms in West Africa, blaming porous borders that pave ways for free flow of arms in and out of Nigeria. Another recent research said out of 857 million small arms and light weapons in the world, 500 million are illegal with 100 million found in sub- Saharan Africa. Again, Nigeria is said to account for about 7.5 per cent of that, with experts stressing that this is what is fuelling the raging insurgency in the North-East, militancy in the Niger Delta, resurgence of the menace of herdsmen and the rising wave of violent crimes, including armed robbery, banditry, cultism and kidnappings in virtually all parts of the country that regularly throw up life-threatening injuries and illnesses that require prompt medical attention.
How to improve trauma care, emergency response services
At a recent conference in Lagos on trauma care and how Nigeria can get emergency medicine right like other countries of the world, medical experts agreed that trauma has become a global public health problem, with Nigeria recording over 4 million injuries and more than 200,000 deaths annually from road crashes – a major cause of traumatic injuries in the country. It was organised by Trauma Care International Foundation (TCIF), a non-governmental organisation (NGO) actively involved in mass health, safety education, medical advocacy campaigns, and voluntary blood donation initiatives in Nigeria. Its chairperson, Dr. Deola Philips, said there is an urgent need to begin mass health and safety education and advocacy campaigns, voluntary blood donation initiatives, hospital endowment, and MEDICAID programmes in the country. This, she explained, will increase the pool of skilled first responders in emergencies.
Trauma is said to be the leading cause of death in individuals less than 45 years of age worldwide, accounting for about 5 million deaths annually. The casualty figures and impact are lower in High- and Upper Middle-Income Countries (HUMICs) and generally much higher in Low- and Lower Middle-Income Countries (LLMICs), like Nigeria, where causative factors are many and response systems weak or non-existent. The affected age group in LLMICs is particularly significant, as victims in all the age groups are mostly aspiring and upwardly mobile family breadwinners, economically viable or still approaching the most productive years of their lives. The social impact of the loss of such figures is serious, because families, especially dependants of victims, are left more or less abruptly, without economic support.
From all public tertiary hospitals visited, experts disclosed that trauma accounts for a significant proportion of surgical admissions. Road traffic injury alone is currently the 9th global leading cause of death (2.2 per cent); and is expected to reach 5th position (3.6 per cent) by 2030. In Nigeria, incidence of trauma is rising at a frightening rate, with experts disclosing that it currently accounts for more than half of all surgical emergencies. Sadly, the greatest impact of injury is said to be more on the economically productive adults, especially males. On the way forward, experts say emergency medical care financing is one issue that needs to be tackled in a sustainable way. Because the National Health Insurance Scheme (NHIS) has captured less than 5 per cent in a country of about 200 million, it leaves access to healthcare to the vagaries of out-of-pocket payment for treatment of victims, leaving many a family bankrupt and hugely indebted. This fuels ‘pay before service’ policy in most public and private hospitals, even in emergency cases, since there exists no direct financing mechanism in place to ensure long-term sustainability.
On how to achieve better emergency response system in the country, UDUTH’s Dr. Bashir, who was trained in Europe, said the work in AEs will be less cumbersome and better outcomes achieved if there is an efficient national ambulance and paramedic system in place in the country. Right from accident scenes, he said paramedics who have the right training can evacuate and resuscitate victims and radio emergency wards so that “we can get prepared even before the ambulance arrives.” In the absence of EMS, he lamented that what AE specialists battle with daily are “victims that are just packed anyhow and dropped in the hospital without any prior notice.”
This, he said, often constitutes a huge problem by the time victims arrive, though his colleagues always try as much as possible to salvage the situation. “We have to establish a system of paramedics by making ambulance available at every point on our highways. We need to have ambulances that cover a specific area. I mean ambulances that are equipped; not just ambulances by name. Those who will be there will be paramedics who are trained so that they can start medication on transit and radio in through a dedicated line. Hospitals have their own lines and governments have their own, but there is no coordination. In Europe, paramedics are trained together with doctors on trauma and life-saving and if they radio in and describe a problem, you (in AE) will know what to do before they arrive,” he said.
The consensus among medical professionals is that EMS should be made to be an essential ingredient of overall healthcare system in the country because it saves lives by providing care immediately. When trauma happens, experts say EMS will guarantee and offer proper pre-hospital treatment and handling, which reduces incidence of secondary injury. For Nigeria to move its healthcare delivery to the next level, EMS services should be available and accessible in all emergencies, led by trained specialists and anchored on a sustainable template that integrates service delivery from the point of patient collection to the nearest hospital so that the ‘golden hour’ or ‘platinum ten minutes’ that define EMS all over the world can begin to have meaning in Nigeria.
According to the National President of the Nigerian Medical Association (NMA), Dr. Francis Faduyile, having an EMS that is both functional and responsive to the yearnings of Nigerians is doable, especially if those in public offices put on their thinking caps and walk their talk. “It is doable, and something that needs to be done. It will be great if we had such speed dial number,” he said. He said achieving it requires putting in place the right investment, infrastructure, human resources and technological template that accommodates all citizens and places primacy on human life.
However, he cautioned that having the software or speed dials (such as 911 in the US or 999 in the United Kingdom) or merely buying ambulances alone cannot achieve the dream. He fears that having the software (like in the more developed countries) in place is another pressure in a country that reels under a chaotic and grossly underfunded health sector, monumental infrastructural deficit and a system of government that does not seem to prioritise public welfare. The NMA boss, who hinted that emergency medical treatment is part anomalies the National Health Act seeks to address, also faulted the implementation of the law. “Unfortunately, in the operationalization, the Ministry of Health is trying to change the narrative and trying to use that fund (earmarked for emergency care such as gunshot victims that hitherto required police permit before accessing treatment) for the purchase of ambulances, which we have condemned in its entirety. However, the problem is not about policy but about implementation. The Ministry of Health needs to come back to the pragmatic way of addressing emergency medical treatment.
“The fund is primarily supposed to take care of the funds that are expended on cases of emergency that occurs in different hospitals. We expect that there should be a protocol to access the funds by those who claim they have seen emergency cases. Unfortunately, while they are supposed to streamline that process, what we learnt is that the Ministry of Health wants to use it to purchase ambulances; having ambulances does not have anything to do with emergency. Although it is an integral part of emergency treatment, it is not the ultimate. When you buy an ambulance, you think of who operates it, servicing, fueling etc. How can one place in the FCT be controlling all the states that are in the federation? Who knows how many ambulances they will provide for each of those states? So, that is not the right thing to do,” he said.
As for the way forward, Faduyile said the right thing to do is to streamline a protocol where practitioners who have treated emergency cases can access the fund for repayment for what has been expended on emergency treatment. “The Ministry of Health needs to walk the talk and not just talk without any direction. The question is: what do we need to get? Train people on EMS? The technology is not that expensive that the Nigerian government if it is truly interested in health, should not embark on.” As many people, especially those in their economic prime, continue to die needlessly as a result of injuries and ailments that can be managed, it is obvious Nigeria is in dire need of a functional EMS to halt the daily harvests of avoidable deaths.
This investigative report is supported by Ford Foundation and the International Centre for Investigative Reporting (ICIR)