COVID-19 has continued to ravage Nigerian society so we no longer look at the NCDC’s daily tally. We know it will have increased by several hundreds each day. We know that not enough testing is being done. We know that if Coro gets us, the only options are hell-to-pay or just dying. In a country with near-zero science, everyone knows that we will never know why those who survive the coronavirus survived it. So, it might as well be God, luck or one’s Ikenga. What has not been noted yet is how the coronavirus has ravaged the facade of the government of Nigeria and laid bare its scaffolding for all to see. What we see today is the skeleton of a thing, what is left behind after our several ostensible “reforms”. Nowhere is this more glaring than in public health.
The roots of Nigeria’s present public health infrastructure lie in the 1980’s, particularly in the period when Dr. Ransome-Kuti was Minister of Health. He tested and implemented the primary healthcare (PHC) model in Nigeria. The idea is of an inverted funnel. The emphasis is on preventive medicine, catching-infections-young as it were, at the eponymous primary healthcare centres. Cases that exceed the capacity of this bottom-of-the-funnel sieve could then be escalated to more specialist hospitals. The model solved a problem of the lack of structure in healthcare delivery in Nigeria. Looking back, we find beyond this the World Health Organization’s Alma Ata Declaration in 1978 which in so many words framed public health as a human rights issue, identifying the government of Nigeria’s responsibility to provide adequate administration of public health. In our implementation of this international strategy document, 80% child immunization was recorded under a new, comprehensive national health policy. Today, in our oldest healthcare centres, posters from this period, peeled and dirty like the system that created them, can still be seen. As at 2016, two years after the Ebola index case, only 20% of Nigeria’s estimated 30,000 primary healthcare centres were operational.
In a recent article where I discoursed the issue of healthcare in the northeast, I noted that the northeast and its Islamist insurgency has slipped off the radar of the government of Nigeria and “a health crisis with immense international cachet such as the COVID-19, should it break out in the formal camps, will give Boko Haram a propaganda coup that must not be allowed to happen.” In an earlier essay, I set out the structure of Boko Haram insurgency, how to identify it and how it radicalizes young people to join in its ranks. Luckily, we have not had any outbreak of Corona in the IDP camps as yet but neither have we done anything beyond deploying hard power to confront the insurgency. As a Nigerian, I am very happy to see videos of our gallant troops in high morale as they take on the insurgents, singing patriotic songs, and it gives me joy to see the young gunner at his turret returning deadly fire to the agents of crisis entrepreneurship as represented by Shekau and his gang. But. . . there is a “but”. These two seemingly unrelated strands—healthcare and ending the insurgency—are linked like twins sharing resources in a womb.
I have framed the Boko Haram crisis in terms of state stability because I believe it is not in fact merely about Mohammed Yusuf and Abubakar Shekau facing off against General Buratai and his predecessors. There is nothing unique about Boko Haram except in its 21st-century compliant cell-like structure and the government of Nigeria’s difficulties in adapting it’s response to this structure. We have had Maitatsine and his takfir-crazy pronouncements and violence, just as we have had ethno-religious crisis in central Nigeria and elsewhere where illegal SALWs were indiscriminately used. What Boko Haram is doing goes further, it puts into stark question the very legitimacy of the Nigerian state. This is where to locate the attempts to graft their sect unto the moribund Sokoto caliphate (1804 – 1903) and, more recently, buying into the late Abu Bakr al-Baghdadi’s Islamic State through various theological acrobatics. Boko Haram’s peacock display of terror—whether market bombings or kidnapping girls or murdering schoolboys—has the purpose of demonstrating this claim to all Nigerians, that it is in fact historical. Boko Haram’s use of terror is to say—if your government is legitimate and if your state is offering you a service, we would not even exist to destroy your bodies at will. Their very existence is a fundamental question. Legitimacy is a powerful concept rooted, perhaps, in the Roman idea of imperium being translated to modern nation-state structures such as a constitution. It used to be that merely winning elections and succeeding in post-election petitions guaranteed legitimacy. No longer.
Secondly, the Boko Haram insurgency is a labyrinth of mental health issues and while a hearts-and-minds strategy has been articulated, as government of Nigeria mandarins are excellent articulators, the individual context of this strategy, in operation, is assumptive. In a northeast, for example, where decades of biting poverty are indicated by the World Bank’s seemingly optimistic 25% of households having basic access to electricity, water and sanitation figures, Borno, Yobe and Adamawa particularly face an acute nutrition challenge (ReliefWeb). The link between nutrition and mental capacity is crucial and irrefutable. The multidimensional poverty and ensuing poor cognitive capabilities of the true victims of the insurgency, the people of the northeast, has been ongoing, for decades, prior to the arrival of Yusuf and Shekau. When the response to extrajudicial killings by soldiers in the early days of attempted containment of the insurgency was to join the insurgents; when regular people support the insurgents by offering funds or intelligence while being incapable of processing the inevitable brutalities of an eventual totalitarian theological state animated by thugs; when we hear of abducted girls refusing to leave “husbands” married to them in the camps in clear cases of a Stockholm-type syndrome; when local merchants, beyond the expected double-dealing, simply do not care who “wins” the insurgency, what we have is a mental health pandemic in plain sight. Unlike COVID19, this has been with us a long time, which might explain why we cannot see it. We did it ourselves. When we copy “winning the hearts-and-minds”, it will not paste in the northeast and in this country without an organic glue. I mean without seriously entering the psyche of people to understand the wounds inflicted there by the government of Nigeria’s neglect and the generational incompetence of the Nigerian elite – mandarin, expert and politician alike.
Conflict prevention is not a buzz phrase. Primary healthcare care is not a buzz phrase. Neither are “interagency cooperation”, “all-of-society approach”, “service delivery” or “reform”, amongst the many state-stability reinforcing and legitimacy reenergizing ideas rendered unto nonsense by rampant insincerity. What is happening in the northeast is a typical complex problem with wicked tendencies and the question is: how can we pre-empt and prevent future conflict when we just slalom our ways through and do not know we need to understand conflict? Ramping up our 30,000 primary healthcare centres in Nigeria would have prevented the Boko Haram conflict because these centres would have been the arrowheads of local-content nutrition campaigns as well as data collection and research. I spoke of skeletons and the bare bones of elite failure facing us, this is it. I believe the conflict in the northeast would have been prevented if Mohammed Yusuf and Abubakar Shekau had had good nutrition from birth, good education and basic quality social services and access to opportunity and exposure to the world. Yusuf and Shekau might have grown up to become Chartered Accountants or Quality Control officers. Instead, what we have is men who grew up with one purpose—to aggrandize to themselves deciding who is a true Muslim in the ways they want and who is not, which category could be killed, brutalized or enslaved. This is what Nigeria’s missing primary healthcare centres in the northeast did not prevent because they were either inoperative or did not exist.
Now, putting it all together. Public health must be seen as a national security issue on which the survival of the Nigerian state depends. Its failings are a scope, an indicator as with Boko Haram in the northeast, a wake-up call for what to expect with our youth-bulge demographic.
Amongst the several other things that must be done while our gallant troops are shooting at Shekau’s victims shooting at them is to sit down and examine the failures of the primary healthcare model in Nigeria in the specific areas of funding and administration, the building of capacity and community accountability. Why has the model, owned as it were by the local government levels within state governments even if federally-driven, failed? Beyond this, how can the thirty five-year old model be integrated with our hundred-odd research institutes in ways that see these institutes actually contribute to the policy implementation matrix as opposed to being cost centres in the clientist-minded “job creation” Nigerian pastime? How do we integrate our universities into primary healthcare, for real? Just about every state in Nigeria has a university or two, a college of something or the other or three, as well as private and donor-led research efforts that all seem decoupled from public health. Respondents to my inquiries have indicated that more money is allocated to public health in Nigeria than donor initiatives but you would not know this from the actual effects of these two types of spending. The key difference is accountability. In ensuring that money allocated and spent are accounted for qualitatively and quantitatively within a new strategy, just as donor agencies are scrupulously held to account by their governments, we can deliver primary health and nudge future Shekaus unto a socially productive and community beneficial path.
But all these, is this not what basic governance in the 21st century is about? I have often thought that the COVID-19 pandemic has finally forced the Nigerian elite to the reality they have to deliver governance and that they seem shocked by this realization. The missteps and shambling of Ministers Farouq and Ohanire are cases in point. So, how can we get the present government of Nigeria to learn how to govern and quickly start doing so, without importing aliens, before a synergy of catastrophes hits and drags us all to drown at sea? I have no idea. I’m just a columnist. I just ask questions.
Richard Ali was called to the Nigerian Bar in 2010 and has worked in private legal practice, consulted in a policy-shaping role at the Ministry of Interior (2015 to 2017) and has run a preventing and countering violent extremism (PCVE) programme. His expertise is in soft approaches to PCVE. He is an alumnus of the US National Defence University’s Africa