Musa Abubakar used to dig two or three graves a day at the main cemetery in the northern Nigerian city of Kano. Then overnight it became 40. “I have never witnessed mass deaths like this,” the 75-year-old said, his white kaftan muddied from his work at the Abbatuwa cemetery, where he has dug graves for 60 years. “From the first day of Ramadan to date, over 300 people have been buried.” A jump in Kano’s death toll by 600 in one week in April sent alarm bells ringing across Nigeria’s second largest city and beyond. Local government officials denied that a coronavirus outbreak was the cause and claimed the death toll reports had been exaggerated. But in Abbatuwa, the gravediggers were running out of space. Abubakar’s colleagues began burying on top of graves to make more room. Four fellow diggers, all over 50, have died in the past three weeks. Abubakar suspects they were killed by Covid-19. “The government has promised to provide gloves and face masks to us but we are yet to receive it,” he said. “We just depend on God.” After weeks of denials at the local level, last week a team of officials sent by Nigeria’s president, Muhammadu Buhari, said their initial investigations had established that the excess deaths were linked to Covid-19. The situation in Kano has heightened fears that health authorities across Africa will struggle to detect and control Covid-19. Confirmed Covid-19 cases in Nigeria have doubled in the last 10 days to 4,150, with 148 deaths. Low levels of testing across Africa’s most populous country have hamstrung health officials in states such as Kano. Just 22,000 tests have been administered among Nigeria’s population of more than 200 million. This, combined with a lack of protective clothing for medical staff, has led to many health services in the state closing all but their emergency care facilities. Across Kano, thousands of grieving residents are grappling with the consequences of both the spread of the virus and the deadly fragility of the state’s health services. Balabe Maikaba was a 54-year-old professor who taught mass communications at Kano’s Bayero University. His younger brother Tasi’u Maikaba said he took pride in his academic career and had a playful personality. When Balabe collapsed at home on 26 April, Tasi’u rushed to take him to one of the nearest hospitals but their choices were limited. “Most of the hospitals, especially the public hospitals, are afraid of accepting patients for fear of coronavirus,” he said. By the time Balabe was admitted to a private hospital, his blood pressure had soared and his condition was rapidly worsening. “His condition further deteriorated to the extent that he was struggling to breath. He was gasping for breath,” Tasi’u said. Doctors gave him oxygen but it was too late. “For a long time, his death will torment me in my mind,” he said, weeping. Balabe had a cough before he died but had not been tested for Covid-19. Like many of the deaths in Kano in recent weeks, it is unclear whether the virus was the direct cause. But even indirectly, the stark effects of the outbreak on the health system have been devastating. Lami Mohammad, 36, had battled lung disease a decade ago. He made modest wages from fixing electronics in Kano. “He was just thankful to be alive, all the time, always thankful,” his brother Abdullahi said. Two other families in his community in Fagge had buried loved ones days before Lami died. “We were just watching, fearing the situation but praying.” When he began coughing violently, none of the hospitals would admit him. Lami died while a doctor was travelling to his home “The pain is too much,” Abdullahi said. “I can’t say whether it is the virus or not but it is God’s will. I have to accept it.” Usman Bishir, a doctor at the Bayero University teaching hospital, said the lack of testing and protective equipment in Kano had forced health services to close. “We didn’t even have a testing centre when this began, we had to go to Abuja – about five hours from here – to test samples. It was taking three to four days to get results,” he said. “Medical professionals were vulnerable.” Kano now has three testing laboratories and is a significant focus for the Nigeria Centre for Disease Control. The state is under a two-week lockdown. “Kano is now doing 200 to 400 tests a day,” Bishir said. Testing capacity is growing but far too slowly. “It would be better if they do at least 5,000.” Medical staff in Kano have ramped up telephone consultations and remote treatment. Some healthcare centres with adequate equipment have reopened. A scarcity of personal protective equipment is slowly being addressed. Yet already the laboratories in Kano are overstretched. More than half of Nigeria’s states cannot test samples, leading to a backlog of cases. Tracing has been a challenge amid weak coordination between different agencies and levels of government. “This pandemic has exposed the challenges we faced in Kano,” Bishir said. “It will force us to change and invest in our services.”