Are Our Entry Points Safe For Another (Ebola) Outbreak?
“There is nothing mysterious about what we need to do. The only real question is if we’ll do it fast enough.” — Tom Frieden. Former Director, U.S. Center for Disease Control
Patrick Sawyer: The first thing the immigration officers see at the Murtala Mohammed International Airport, is a dizzy man who is obviously under the weather. The 40-year old American-Liberian lawyer must have been on a long trip from Monrovia. So, they thought. The security officials at the air border, are up and about; but they do not pay much attention. It was a Sunday, the 20th day of July, 2014 — a stress-free day. They assume the fever was normal for a man of his age. Here is an ‘ambassador’ who has come all the way, to attend a conference in Calabar. They shrug their shoulders to the conclusion that he would sort himself out. What they do not know is that fourteen days before his arrival into Lagos, his elder sister had died of the same ‘fever’.
As these thoughts run through the minds of these officials, Mr. Sawyer collapses at the airport. His host -an ECOWAS protocol officer- drives him without much ado to First Consultant Hospital Obalende, Lagos. Here the puzzle begins –a team of medical experts are on their toes to help him get back on his feet. After several episodes of high fever, vomiting, stooling and bleeding, the man who had declared to the Liberian government on the 4th of July 2014, that he had been exposed to the Ebola Virus, would die four days after he got into Nigeria. The ECOWAS protocol official, Jatto Abdulqudir, 36 years of age, died on the 25th day of July 2014 — the day after Mr. Sawyer’s demise.
We would later learn also, that Mr. Sawyer was not a Liberian ambassador. He was a lawyer with the Liberian Ministry of Finance, who, doubting the competence of the health systems in his home country to treat his case, decided to have a ‘free’ entry into the giant of Africa.
In a country where ‘God-forbid’ and ‘It-is-not-our-portion’ are the layman’s preventive responses towards health abnormalities, Ebola Virus Disease became our portion for about 4 months. By the time Nigeria became Ebola-free by the declaration by the World Health Organization (WHO) on the 20th day of October 2014, she had recorded 20 confirmed cases, 8 of which were fatalities. Of these deaths, the most unforgettable remains that of Dr. Ameyo Stella Shade Adadevoh, the consultant endocrinologist with 20 years of experience, who took charge of Mr. Sawyer. She was dear to the nation and came from a reputable pedigree — having Sir Herbert Macaulay as her paternal great grandfather and Dr. Nnamdi Azikiwe as her maternal great uncle.
How did the Nigerian government squash the Ebola outbreak so easily? These were achieved by three major actions –the fast and thorough tracing of all potential contacts, an ongoing monitoring of all the contacts and a rapid isolation of potentially infectious contacts. The efforts of the Nigerian government alone would have yielded nothing without the palpable involvement of the Nigerian Centre for Disease Control (NCDC), in the establishment of incident management centres. Public health experts say that although this is a routine and regular approach, it was vigorous and rigorous.
About half-a-decade after one man sent shivers down the spines of roughly 190 million people, Nigerians seem to be living the normal life. The chaos and confusion that came with the Ebola scourge, have fizzled out. The attitudes of the government and her citizens towards epidemic outbreaks have evaporated. The hand washing stations are no more. The traditional media campaigns about the use of hand sanitizers have dwindled. Hand sanitizers no longer leave the market shelves with the speed they used to. The temperature checks at the various borders, public and private facilities, have been crucified, dead and buried. The people, especially those in the rural areas, have gone back to their normal methods of hygiene. The tweets, shares and regranns on massive health awareness and education by lay Nigerians are now replaced by screenshots of online clap-backs and savagery. These are the major signs of our fire-brigade attitude to almost all emergencies, including infectious disease outbreaks.
This rigorous and vigorous fire-brigade reaction of the government and her citizens, models that of a giant building, or skyscraper, bereft of fire safety equipment, yet experiencing electric sparks at several locations within it. There is a similarity in the outcomes of this kind of disease-fighting approach at our entry points. Although, the building has less chances of becoming completely destroyed if there is a positive rapid response from the fire service department, a part of it would never remain the same again. A room or two would be burnt, the valuables and other necessary documents could be destroyed, the back-up systems may be gutted by the inferno and one or two staff may die. In the same vein, the fire-fighting method for the Ebola Virus Disease, may have saved the entire nation, but it was by a narrow breath, because it took the self-martyrdom of some staff of First Consultant Hospital, as well as others.
Is Nigeria Prepared? The Details and the Consequences Are In The Data
The observations from this approach are technically summed up by a joint external evaluation of our health’s core capacities, which labels Nigeria as epidemically unprepared. According to Preventepidemics.org, the chances that Nigeria is ready for another infectious disease outbreak are 39 out of 100. An assessment of her ability to find, stop and prevent health threats has revealed very significant gaps. An outbreak today could cause numerous deaths and spread to neighbouring countries and the world. These gaps are due to the absence of financed plans and implementation for health security.
For a nation with an evidence of 39% readiness, five years after recording 40% of deaths from the Ebola scourge, there is a strong need to re-write the data; to change the narrative. The government and her citizens have roles to play. The once-bitten-twice-shy experience with the Ebola Virus Disease offers us very important and doable options that will override the rigorous and vigorous fire-brigade approach.
Addressing Cross Border Needs for Epidemic Preparedness
An Overview
How safe and strong are our points of entry? Were it not for the efforts of Dr. Adadevoh and her team, the Ebola mortality and morbidity rates would have heightened. With the 40% mortality rate achieved through a defensive approach, what would have been the fate of Nigerians, had Mr. Patrick Sawyer proceeded with his meeting by travelling 750km from Lagos to Calabar?
What would have been the outcome, also, if he had to travel through less busy airports? How about the numerous air or sea borders, not often used by Nigerians? Have we considered the high volume ground crossings at the Benin, Niger and Cameroun borders.
The story of Mr. Sawyer opens our eyes to the ease of access to-and-fro our borders. The strength of our points of entries is closely dependent on our preparedness to fight all forms and agents of communicable diseases. Preparedness is not done from a ‘when’ perspective, but with an ‘if’ attitude. It requires the vigilance of the government and her citizens, and a consistent attentiveness towards all form s of bio-terrorism.
A pandemic is a biological warfare and as such, the consequences of bio-terrorism will involve mass causalities. A 2016 report on creating a framework to counter infectious disease crises by The National Academy of Medicine accounts that a pandemic could kill as many people as a devastating war. A typical war setting comprises of many battles that both attackers and defenders would face –of hunger and deaths, financial crises, rise in the cost of living and accessing basic health needs. The list is simply endless if we imagine it for a pandemic that arrives our borders at a time when we are unready.
Public Health reports have identified key areas that would solve cross-border issues hampering epidemic preparedness. These approaches include: the need to collaborate on and exchange plans and protocols among agencies, developing contact protocols, maintaining a contact database, specific isolation and quarantine protocols for multi-state responses, creating a system for rapid and secure exchange of information, providing specific protocols for sharing human resources across borders, creating emergency credentials for physicians and healthcare workers, to mention but a few.
Joint Sector Collaboration and Training
Joint sector collaboration is not an option. An outbreak affects everyone, health and non-health professional. As a matter of concern, the Economic Impact of Ebola in Sub-Saharan Africa, as revealed by the 2015 World Bank Group, indicates that the impact of a major outbreak is not limited to the health sector. It goes further to elucidate that outbreaks affect multiple sectors economically due to trade losses from border closures, trade and travel bans, disrupted supply chains, decline in tourism, drop in foreign investment and cancellation of international events. The ministries in charge of health, defence and security, environment, agriculture are primarily involved in epidemic preparedness. Professionals whose places of primary assignments are at the various land, air or sea borders need to be aware of their roles in observing finding, assessing, stopping and preventing epidemic diseases.
Untrained staff are hazards to the lives of citizens in the environment. Since infectious diseases are often spread through contact, we can also imagine what the risk is like for immigration officers who flip through the passports and identity cards of travellers. These may not be possible if we refuse to see the impact of the negligence of one sector to another, and to the entire citizenry.
Health Equity, Universal Health Coverage Is Critical For Epidemic Control at the Borders
Disease outbreaks occur in the most vulnerable areas. As a centre of commercial activities experiencing the daily dynamics of migration, and with a booming population of about 21 million people, Lagos State was prone to the pandemic threat of Ebola. The impact of this disease was cut short by the availability of quality health systems and leverage of health tourism.
However, there is a need to consider if this would have been the case, had Mr. Sawyer come in from a route where good health facilities were inaccessible. These will open the eyes of every Nigerian on the dangers of health inequity. The systematic differences in the health status of different population groups have significant and social economic costs to both individuals and societies. The lower a population’s socioeconomic position, the higher their risk of poor health. Subsequently, this results in a higher risk of pandemic threat.
Health equity therefore is an important factor that propels the need for universal health coverage. It would have been an irreparable damage with huge economic burden if the proliferation of Ebola had begun in rural communities in Northern Nigeria where people gain access to-and-fro the country by foot; or in a camp with internally displaced persons. Areas with low access to health care and health security are still major threats to our global security. The key demand is for the Nigerian government to finance universal health coverage so that basic and quality health services available in every primary health centre in Nigeria.
The US Centre for Disease Control and Prevention reports that when a pathogen can travel from a remote village to major cities on all continents in 36 hours, the threat to national security is greater than ever. Universal health coverage is a great indicator of global health security. Epidemics have no respect for social class. As such, Nigerians who have access to luxury healthcare need to come to terms with the fact that an injury to one, especially one who has little or no access to good healthcare, is an injury to all.
Border Control Measures Will Reduce the Economic Burden of Epidemics
Epidemics affect economic activity at all levels –the micro (individual and household), meso (stablishment, village or city) and macro (national and international levels). As such, good surveillance and response systems to epidemics go well beyond the health benefits of limiting cases, deaths and disabilities from the disease.
Would it not cost more fighting an epidemic outbreak than it would cost preventing it?
In 2016, a survey carried out on the economic effects of Ebola in the Nigerian private sectors shows that the nation’s GDP was less by 186 million USD during the Ebola outbreak in 2014. Yet, 8 deaths were recorded out of 20 confirmed cases. This goes to support that even when the health impact of an outbreak is relatively limited, its economic consequences can quickly become magnified.
If we can establish that a pandemic can kill both a people and their economy more than a devastating war, why then are the resources committed to pandemic prevention and response a fraction of what we commit to security in Nigeria?
The NCDC’s National Action Plan for Health Security (NAPHS) details that preparedness for pandemics and health emergencies has a high return on investment, estimated at $2–7 for every $1 committed. Nigeria should go
beyond the health benefits of limiting cases, deaths and disabilities from the disease; or even spending money on security votes. It should involve financing health security, which is the sum total of sustainable investments made towards achieving healthy humans, animals and environment.
Charity Is Inadequate for Financing Health Security: A Budget Line for Disease Prevention and Border Control
Sequel to the Ebola Virus attack, the NCDC published a National Guideline on Infection Prevention and Control of Haemorrhagic Fever in 2017. This is just one of the numerous roles she has undertaken in finding, stopping and preventing infectious diseases, over the years. With the support of charitable individuals, donor agencies and international bodies, NCDC spends huge amounts of funds in confirming diagnoses, active case finding, taking clinical and environmental samples, analyzing and interpreting data as well as formulating and testing hypotheses about sources of exposure and modes of transmission. Parts of these funds are also spent on eliminating or reducing the source of infection and transmission, reducing or eliminating exposure and risk, case management and infection control. Contact tracing, analysis and dissemination of laboratory information, environmental control measures, behaviour modification, communication, social mobilization and mass prevention ; are other areas where these funds have been channeled.
The NCDC’s (NAPHS) is a comprehensive multi-sector work plan that seeks to strengthen the core capacities of the International Health Regulations (IHR) by adopting strategies, establishing priorities to close the gap identified with preventing, detecting and responding to public health threats. This health security can only be achieved if the current critical finance gaps are addressed so that issues concerning safe points of entry as well as the other technical areas are resolved.
With respect to forestalling the next Ebola attack, the NCDC has a well-defined plan for Viral Haemorrhagic Fever Preparedness and Response. Yet, plans need financing for implementation. The Nigerian government needs to reconsider its budgetary allocation system by giving the health sector adequate funds to prepare and forestall the any (Ebola) outbreaks. For a country whose budgetary allocation for security is much more than the health of its citizens, is it not proper to also include that victims of disease outbreaks are also threats to our security.
Although the current government takes some credit for signing the NCDC act, there are still lots of gaps begging to be filled. The key questions to ask therefore are:
— For how long would the giant of Africa depend on charity to organizations to solver her own health problems?
— When will the Nigerian government appropriate a budget for epidemic prevention?
— Specifically, when would there be a budgetary allocation be given to the NCDC to implement and fill in the gaps outlined by the NAPHS for epidemic prevention and control?
The re-emergence of the Ebola Virus would not come from Patrick Sawyer. The fire-brigade approach towards addressing the needs for epidemic preparedness would yield more fatalities, if our ports and ground crossings are not safe from Ebola virus and other contagions. To increase our chances of surviving and forestalling a pandemic threat from a figure as low as 39%, we have to see the need for joint sector collaboration and training, financing for universal health coverage, and equipping our border with necessary human and material resources. A constant evaluation of the economic burden of Ebola, and other communicable diseases should create the drive for the Nigerian government to allocate a budget line to the authorized body for prevention and control of diseases, NCDC, through financing the NAPHS plan for achieving health security in Nigeria. Since, no man would build a house and wait for burglars to attack before securing his locks and erecting his fences, it is best to remind every Nigerian that the time spent sharpening the axe and maintaining entry-point integrity may well be spared from swinging it in the a fire-brigade approach.
