In this concluding part of a story titled,   ‘A Walk Through the Valley of Ebola’, published on Thursday, folashade adebayo writes on the controversial issue of remuneration for health workers treating Ebola patients

 

Following the success story recorded in the containment of the Ebola Virus Disease in the country, a 250-health care worker contingent will Thursday (today) depart Nigeria for Liberia, Sierra Leone and Guinea under the African Union Support to Ebola Outbreak in West Africa mission. The team comprises medical doctors, nurses, hygienists and survivors of the EVD. The survivors are believed to be immune to the Zaire strain of the virus, a status achieved only after an individual has recovered from the illness.

 

But the survivors with a natural immunity to the Zaire variant are only a handful of the volunteers. According to a Consultant, Foetal Medicine and Genetics, Dr. Femi Oloyede, while the mission is laudable, the conditions in the Ebola-endemic countries will be different. Noting that the HCWs face a unique risk, he urges the African Union and the Federal Government to insure the HCWs against death and infections.

 

“They are now going into the battle field proper. It is like going into a lion’s den. I believe they must have been adequately trained. But beyond that, they need to be covered, insurance -wise, no matter the training. The risk of contracting the virus is higher now so, insurance should be paramount.

 

“It is now a different ball game entirely because they are going into areas where the risk of being infected is extremely high. Aside from specific and general safety practices, it is necessary that they get a life insurance cover,” he says.

 

The Vice-President of the Commonwealth Medical Association, Dr. Osahon Enabulele, shares a similar view. In a statement on Monday, Enabulele, the immediate past president of the Nigerian Medical Association, canvassed a life insurance policy as well as a quick re-integration of all volunteers upon their return from the affected countries.

 

“While we commend these efforts, we however wish to urge that all the necessary conditions (including pre-departure conditions) that will motivate and empower the volunteers should be provided. In particular, we urge the provision of a guaranteed Life Insurance Policy before their departure. We also urge the provision of an adequate welfare package, Personal Protective Equipment and other support medical facilities.’’

 

An email sent to the African Union Commission through its Deputy Director, Head of Communications and Information, at the African Union Commission, Wynne Musabayana, on Tuesday, requesting to know what life insurance policy was in place for the HCWs and where any health worker who gets infected would be evacuated to for treatment had yet to be responded to as of Wednesday night.

 

However, information obtained from the website of the International Institute for Security Studies revealed that the first batch of health care volunteers from Uganda, Rwanda, Nigeria, Ethiopia and the Democratic Republic of the Congo left for Liberia in September. The mission, it was learnt, was made possible by a coalition of African philanthropists and international agencies.

 

While the United States, European Union and China pledged $10m, $5m and $2m in that order for the humanitarian mission, Nigerian businessmen, Aliko Dangote and Tony Elumelu, also pledged $1m and $600,000 respectively.

 

From four initial Ebola treatment centres, the United States Department of Health on Tuesday also listed 35 other centres in the US.

 

HCWs face unique risks

In fact, the call for international safety standards for the departing HCWs is not misplaced. According to the Medecins Sans Frontieres, an international organisation, which has led HCWs from different countries to the front lines of the epidemic in Liberia and Sierra Leone, Ebola “is a highly infectious virus that can kill up to 90 per cent of the people who catch it, causing terror among infected communities.” A preliminary study by the WHO has also shown that the Zaire strain, considered the most deadly of the five Ebola subtypes, is responsible for the current outbreak.

 

Nigeria recorded seven deaths, including four HCWs who worked at the First Consultants Medical Centre, Lagos. But Liberia has been the worst hit with the WHO claiming that the virus has infected 228 persons and killed more than 100 health workers in the country. Mali, the latest African country to record EVD cases, is currently monitoring 43 contacts, 10 of who are HCWs.

 

Two of Ameyo Adadevoh, Amos Abaniwo, Evelyn Ukoh and Justina Ejelonu’s (health workers who died after treating the index case Patrick Sawyer) compatriots who died on the medical battle front included Dr. Sheikh Umar Khan, an infectious disease specialist with the Kenema Government Hospital, Freetown, Sierra Leone and Dr. Samuel Brisbane, a senior doctor with John F. Kennedy Memorial Medical Centre, Monrovia, Liberia.

 

Khan, 39, met his death alongside four other HCWs when they ran toward the danger of treating patients with little or no protective equipment. In the case of Brisbane, he reportedly contracted the virus after giving cardio-pulmonary resuscitation to an Ebola patient with his bare hands.

 

Yet, stakeholders say the chain of infection can only be broken with the involvement of adequate health care workers who will work to outpace the “wildfire” created by the virus. According to the World Bank President Jim Yong Kim, 5,000 health workers are needed to stop further spread of the disease.

 

But that has been a challenge with poor remuneration/hazard allowance, inadequate personal protective equipment, forced quarantine for workers returning to their respective countries and lack of an insurance coverage for many health workers of African origin.

 

Even at that, the provision of these requirements may not be enough to prevent transmission in HCWs. Like Adadevoh, Ejelonu, Abaniwo and Ukoh, some of the infected health workers in this latest episode, contracted the virus before knowing that the patient had the virus. Indeed, medics hold the view that once the virus established a foothold in one HCW in a health facility, a chain of re-infection was almost inevitable. The case of the medical workers who cared for Sawyer exemplifies this.

 

Oloyede says to reduce the risk of infection; volunteers need to maintain a high level of personal hygiene in and out of Ebola centres in the affected countries. He adds that a dose of suspicion for everybody they come in contact with as a suspected case of the EVD can also help in minimising exposure to the virus.

 

Yet, there are some victims of a less than airtight protection and insufficient knowledge of how the EVD behaves. The two Canadian scientists sent to investigate how long the virus lurks on hospital surfaces and doorknobs and determine how these avenues aid infection of the medical workers a typical evidence.

 

Again, removing the PPE is a delicate business and a possible means of infection, where stakeholders say a single mistake can nail any health worker. A Belgian scientist, who co-discovered the virus in 1976, Prof.Peter Piot, has on several occasions hit on the point. According to Piot, in a recent interview with the British Broadcasting Corporation, the virus enters the body through the eyes, nose, mouth or any open wound.

 

He adds, “A dangerous moment is when you undress. When you come out of the isolation unit, you take off your protective gear and you are full of sweat, and you take off your glasses and do like this (he rubbed his eye), and that would be the end.”

 

Controversy over insurance cover

Meanwhile, several meetings with some of the HCWs, who treated Ebola patients in Nigeria, show a simmering controversy surrounding the provision of life insurance cover for the health workers during the outbreak of the disease in the country.

 

While the Lagos State Government and the Federal Government promised to insure the workers, the Lagos State branch of the Nigerian Medical Association described the claims as tissues of lies. Other medical practitioners and HCWs who fought the EVD eye to eye have also debunked the claims.

 

Lillian Aladesanmi, a health worker at the Infectious Disease Hospital , Yaba, Lagos, who was initially slated to travel to Sierra Leone to assist in curtailing the outbreak in the country, claims the state government has abandoned the workers who risked their lives confronting the EVD. According to her, the state government not only abandoned the plan to insure the workers in case of fatality, it also owed them five days hazard allowance.

 

“It is all a lie. Nobody insured us, unless if it is possible to take insurance cover without one’s knowledge. They do not even know we exist anymore. As I am talking to you, the authorities owe us a five-day pay in September. We have not been paid October salary and this is December. We were initially part of those listed to go to Liberia. But I opted out when we were asked to pay for tests and passport with our money,” the HCW says.

 

Expressing regrets that, “we were used and dumped by the state government,” the medic insists that the mortalities would have been higher if nobody volunteered to care for the patients.

 

“This is a high -risk job. We were told it was a journey of no return. Many of us have lost our friends and accommodation. Even here (IDH), people avoided me. There were only a few of us (volunteers) when the patients came here in July. Volunteers came later when we conquered the risk and they noticed we were not infected,” she adds.

 

As far as another health care worker Yejide Ajayi is concerned, HCWs who sacrificed all to fight the EVD in the country deserve compensation. “They ought to have invited us for awards, commendation and compensation for the risks. The survivors received N2m each. Yet, those of us that assisted them, nobody is talking about us. Would they have survived if we did not volunteer? What if we had contracted the virus in the process?’’ she asks.

 

Another nurse, Kike Bandele has the same view. The HCW, who claims to have been motivated by adventure rather than money, says the payment of outstanding hazard allowances will bring some sort of closure to the fiery episode.

 

 

“We did most of the work. I was ready, I knew the risks involved because anything could have happened. But I like adventures, I love taking risks. I do not like being told stories; I have always loved to experience it myself because I find it thrilling. If they cannot compensate us, let them at least pay us the outstanding allowance.

 

“We worked very hard during the outbreak. The PPE was heavy and our goggles froze. As you breathe in and out, the heat freezes the goggles. Aside from the risks, the PPE is not comfortable at all, once you remove it, you will quickly rush to drink a drum of water. We could not even tell anybody that we were ill during the period. I was taking my anti-malaria, tablets quietly because if you reported that you were ill, you would be quarantined immediately,’’ the HCW says.

 

But the Lagos State Commissioner for Health, Dr. Jide Idris, insists that IDH volunteers were adequately insured. Idris notes, “They were all insured for both illness and death, especially the volunteers who worked at the IDH.”

 

The immediate former Minister of Health, Prof. Onyebuchi Chukwu, also confirms that the Lagos State Government made moves to insure the HCWs. Chukwu, who has since resigned to pursue his governorship ambition in Ebonyi State, says he was informed that the Lagos State Government had “completed the process.’’

 

“Only the Lagos State Government had completed the process. The Federal Government did not complete the process by the time I left office. Yes, I got information that the Lagos State Government had completed the process. I do not think anybody (health care worker) was infected while I was minister. I do not think any insurance policy was in place for the health workers who died (health workers at the First Consultants Medical Centre). A dead person does not need insurance,’’ he adds.

 

No life insurance policy yet –NMA

But for the Lagos State Chairman, NMA, Dr. Tope Ojo, the insurance claims by the authorities look like a tale by the moonlight. He declares, “As of today, there is no life insurance package for health workers in Nigeria. The government played around it during the outbreak. In fact, there was nothing in place for health workers. The bill is just lying there. There are universal safety precautions but many of our hospitals lack basic infrastructure, including potable water. The National Health Insurance Scheme is still covering just four per cent of the population and that is part of our agitation.”

 

The Head of Oncology and Radiology at the Lagos University Teaching Hospital, Prof. Aderemi Ajekigbe, however, agrees with Ojo. Urging the government to provide life insurance coverage for health workers, the Professor of Oncology says that medical workers need to be actively involved in efforts to make hospitals safer regardless whether their area of specialty involves contagious diseases or not.

 

“At present, there is no life insurance cover for health workers in Nigeria. What we need to do is to provide coverage for health workers, particularly doctors and nurses. They are the ones who actually face the danger. You do not know what the next patient has and by the time you know, danger would have been around the corner.

 

“I am an oncologist and cancer is not communicable. But this is what we should all have at the back of our minds because while cancer may not be communicable there are co-morbidities.

 

“Health care workers generally need to be more careful. They should wear gloves and mask at all times. Also, not everybody registered for the National Health Insurance Scheme; and even for those who registered, it is only beneficial when you are ill and not when you die,’’ he explains. The patient may have the co-morbidities that are contagious or infectious,’’ he adds.

 

In the absence of a comprehensive life insurance policy, Enabulele has advised HCWs in the country to protect themselves against infection while caring for patients.

 

“The issue of infection in the hospital is as old as man. Nobody wants to go into a crisis condition that will consume him or her. There is the need for appropriate nutrition and hygiene that will stave off infection or limit exposure to infective agents. Government also has to provide goggles for surgeons and those who are exposed to blood regularly.

 

“We expect that we must all imbibe the culture of universal safety. The NHIS is still going through some reforms and the coverage is still less than seven per cent. We need specific packages, built into the conditions of service and hold people accountable to it, not an amorphous provision that you cannot hold anyone accountable to,’’ he remarks.

 

Health workers exposed to blood, body fluids –Study

The high risk of occupational infection for Nigerian health workers has been a subject of study for researchers. In a 2012 study published on the website of the United States National Library of Medicine, four researchers – Ansa VO, Udoma EJ, Umoh MS and Anah MU – reported that the occupational risk of infection by the human immuno deficiency virus and hepatitis B virus is high among health workers in South-East Nigeria.

 

The scientists studied the work pattern of doctors, nurses, laboratory staff and cleaners in three tertiary institutions in the South East. They also observed the availability and use of protective equipment and materials in the various departments of the hospitals.

 

“Materials and equipment needed for protective and hygienic practices (adequate water supply, protective clothing and availability of disinfectants) were inadequate in all hospitals. Where available, they were not consistently used. Health workers in the three institutions were thus constantly exposed unnecessarily to blood and other body fluids, which might be potentially infectious as well as injury from used sharps.

 

“The risk of acquiring HIV and HBV infections by health workers in this region of Nigeria in the course of performing their duties is therefore still apparently high. Though distinct viruses, they share a similar mode of transmission and risk factors. Use of personal protective equipment and adoption of standard hygienic practices among health workers must be encouraged. Supply of protective materials and equipment should be greatly improved. It is recommended that reduction of occupational risks among health workers using this approach should form part of control strategies for both infections in the country,’’ say the researchers.

 

Beyond the provision of safety gadgets and the advocacy of its consistent use, stakeholders in the health sector are advocating a comprehensive life insurance cover, which they say, is the best practice around the world.

 

In the wake of the EVD outbreak, calls for this intervention reached a crescendo even as health workers at the IDH refused to attend to the Ebola patients. To recruit the human resources needed to attend to the patients in isolation units, visit suspected Ebola cases under quarantine and monitor primary and secondary contacts, the Lagos State Government had to call for volunteers from the public.

 

Subsequently, our correspondent learnt that the state government had to pay a daily hazard allowance of N30, 000 ($180), N40, 000 ($250) and N50, 000 ($300) to the attendants, nurses and doctors in that order. In addition, the Federal Government and the Lagos State Government promised that a comprehensive insurance coverage would be provided for the HCWs.

 

No safe haven

Highly contagious viruses such as Ebola pose a threat to health workers even in the laboratory. Unlike poliomyelitis and measles samples routinely cultured in many laboratories with bio-safety level 2, virologists work on haemorrhagic fever viruses with extra caution. For any of these viruses, Prof. Sunday Omilabu who diagnosed the first EVD case in Nigeria says safety starts from the gate.

 

According to the virologist, the EVD is so contagious that it has to be inactivated in the laboratory before the delicate screening process starts. That is also after virologists would have taken stringent precautions from the point of sample collection.

 

“The samples are in triple packages to ensure the safety of officials. Once they arrive, you disinfect the samples and the officials. You must have put on your PPE and then you remove the sample. Then you add hypo chloride to inactivate the virus and make it non-infectious before extracting its RNA (ribonucleic acid). We culture other less -infectious virus esbut BSL4 is required to multiply and culture Ebola. We do not venture into that,’’ he adds.

 

Omilabu explains that Ebola has followed an established pattern of other virulent infections. An instance is the death of an Italian medical doctor and microbiologist, Carlo Urbani, in 2003. Urbani, who died at the age of 46, was the first physician to identify the Severe Acute Respiratory Syndrome as a highly contagious disease in a patient.   Urbani, who was a top official of the MSF and an external consultant with the WHO, became infected and died of SARS while treating a patient.

 

Prior to his death, Urbani reportedly argued with his wife who questioned his choice of attending to patients with contagious infections at the risk of leaving his three young children fatherless. According to Wikipedia, he had replied, “If I can’t work in such situations, what am I here for? Answering e-mails, going to cocktail parties and pushing paper?’’

 

The SARS, according to the WHO, has caused 8,096 infections globally, 21 per cent of whom are said to be HCWs. The picture is scarier locally. In Hong Kong and Toronto, 62 per cent and 51 per cent of the infections were in HCWs respectively.

 

According to Omilabu, human error is also a constant factor that can cause infection for health workers. “There could be human error even within BSL4 facility. Accident can occur anytime, anywhere. There might be spillage of the sample on the container but that is why you have to take the first step of decontaminating the bottle and the messenger,” he adds.

 

With the gaps identified by experts in the health care system, it is clear that a cocktail of personal and institutional measures, a deficit, which the outbreak of the EVD, has magnified, can only guarantee the safety of the HCWs while in the process of saving lives.

 

BY FOLASHADE ADEBAYO