By Charles Kumolu, Deputy Editor
Dr. Adaeze Oreh is a Senior Health Policy Adviser with Federal Ministry of Health and Fellow of the West African College of Physicians.
In this exclusive interview with Sunday Vanguard, she uses her experience as one of those involved in emergency preparedness during the 2013 – 2016 Ebola outbreak in West Africa to discuss Nigeria’s response to Coronavirus outbreak, stating that only a multi-sectorial approach would flatten the curve of infections in the country. She is also a Senior Fellow for Global Health with the Aspen Institute.
As someone who was among the team that successfully fought Ebola in Nigeria and West Africa, your experience counts at this time. What do you make of the ongoing battle against Coronavirus in Nigeria?
One of the things that have counted for us here in Nigeria given the global pandemic of COVID-19 is the fact that we had a nearly two-month “grace period”. This was a massive opportunity for us to take decisive action and prepare for what at the time appeared to be a rapidly spreading public health emergency.
In that time, Nigeria was able to build up the laboratory capacity to SARS-Cov-2, a new strain of the Coronavirus that had never been identified before December 2019. That was a very strategic step by the National Centre for Disease Control led by Dr. Chikwe Ihekweazu and the Federal Ministry of Health led by the Honourable Minister of Health Dr. Osagie Ehanire, because it meant that the first suspected case could be tested immediately after being reported to state authorities by the attending doctor and within 48 hours of his arrival in the country. At that time, there were only about two cases on the entire African continent – the first in Egypt and the second in Algeria. Imagine if we had no such testing capacity at the time.
Cases would have entered the country and we may have seen rapidly active community transmission of the virus with almost hundreds of cases by the time we were able to run our first test for the virus. This highlights the importance of investing in health security even before an outbreak occurs.
There is a quote that is especially relevant to the discourse on health security and epidemic preparedness and is derived from a late fourth-century writer, Vegetius who said, “In time of peace prepare for war”. Preparing for outbreaks like this is critically dependent on the strategies that are put in place before the onslaught occurs.
Do you think the model used in defeating Ebola can work this time?
During the Ebola response in Nigeria, substantial resources were deployed to ensure a robust response for case detection and the availability of personal protective equipment ,PPE, such as gowns, masks and gloves and critical care equipment across the country. There was enormous support from the organised private sector in ensuring this, quite similar to what we are observing in the present Coronavirus outbreak. However, recall that the Ebola outbreak then was limited and nearly exclusively to West Africa, except for a few exported cases to Europe and the United States of America. So, there wasn’t the enormous global pressure on PPE and critical care equipment that is currently being observed with nearly the entire world in the grips of this pandemic and pressed for supplies of PPE and life-saving equipment.
With factory shutdowns and restricted air travel, securing supplies of PPE and other equipment is certainly more challenging than during the Ebola outbreak. Securing international support and harnessing local opportunities for manufacturing hold enormous potential in the present national response against Coronavirus. In comparing models of response against Ebola and Coronavirus, we should remember that these are two different viruses with completely different characteristics regarding their ability to spread and the speed of that transmission.
While the Ebola virus infection required very close contact with blood or body fluids of infected persons, the coronavirus has no such limitations and can spread very rapidly by mere contact with infected droplets either by proximity to an infected person or by contact with droplet-contaminated surfaces.
Hence the focus on preventive measures such as physical distancing, cough hygiene, frequent handwashing with water and soap or the use of alcohol-based sanitizers and regular disinfection of surfaces in people’s immediate environments.
Thankfully, COVID-19 is not nearly as lethal an infectious disease as Ebola, but for those most vulnerable to severe and even critical illness it could be fatal, and so preventive measures that safeguard against spread of droplet-transmitted infections like Coronavirus are most crucial at this time to stop community transmission and reduce further spread of the virus in the country.
In specific terms, could you spell out the measures used in fighting Ebola that could be employed to flatten the curve of infections this time?
As I mentioned earlier, one specific measure that was successfully used in the fight against Ebola that could flatten the Coronavirus curve in Nigeria is the investment in health security at a time when there is no outbreak. Given that the outbreak is presently upon us, other proactive steps that could be taken include states in the federation aggressively ramping up their epidemics and outbreak responses by ensuring that they have emergency operations centres in place with clear chains of command and channels of communication.
I believe that as of last month, over 23 out of the 36 states had such emergency operations centres in place. It is critical that in every state, clinical practitioners are aware of how to report a suspected case to the notifiable authorities, there should be systems in place to enable appropriate testing of samples from suspected cases, and quarantine and isolation centres should be identified with referral and transportation systems in place that are clearly communicated to relevant professionals in the state. In addition, the provision of PPE in health facilities is critical is important. These steps are vital to any outbreak response and must be put in place even before any state records a single confirmed case.
What this does is to enhance the confidence of healthcare practitioners and by extension the public when it is known that systems are in place to manage infected cases and protect the health of frontline workers and the wider public.
It is also important at the national and state levels to communicate clearly and consistently to the public about suspected and confirmed cases while still being mindful of individual privacy and confidentiality. Gaps in communication encourage a lot of speculation and the unfounded circulation of baseless messages that not only lack merit but are designed to generate fear and panic. However, by strategically making information, especially on preventive measures available to the public consistently, concrete and evidence-based messages take ownership of the airwaves especially in this era of social media. Laboratory diagnosis capabilities are another vital aspect of the response.
When testing is decentralised to a large extent, then many more confirmed cases can then be isolated, thus limiting the possibility of massive spread among members of communities who were unaware that they were infected, because we know that even individuals who are infected but have absolutely no symptoms can still transmit the virus. State governments, therefore, need to work closely with the Federal Ministry of Health, National Centre for Disease Control and the Presidential Task Force on COVID-19 to enhance the testing capacity of their states for Coronavirus and get testing accessible to many more Nigerians.
So far in Nigeria, seven molecular laboratories for testing with plans for possibly another six more, thus ensuring lab testing capabilities in all six geopolitical zones. This is one of the critical success factors identified in Germany’s response to COVID-19 and one of the reasons proffered for one of the lowest death rates recorded since the outbreak of the pandemic. Political will is certainly a defining factor in the hopes of any successful outbreak response.
When it is lacking, it is difficult to galvanise a robust response because it requires substantial resources and collaboration across sectors that can only be driven by the support of government at the highest level and then down to sub-national levels. I am of the opinion that President Buhari has demonstrated this political will by signing into law the NCDC Establishment Act in 2018 and it is also manifestly clear that the NCDC has demonstrated its positive value in the current national response, and earned deserved commendation from the President.
This Act legally empowered the agency to prevent, detect and control infectious diseases of public health importance. Additionally, by constituting a Presidential Task-force for the Control of COVID-19 with representation from health, national security, disaster management, aviation, environment and education, the President has illustrated the fact that a health threat of this magnitude has far-reaching implications across sectors and would, therefore, require a multi-sectoral, broad-based and multipronged strategy to attack and win this battle.
Could you review some of the measures introduced so far in the country, identify gaps where they may exist and suggest how to scale up efforts?
The lockdown directives that have been issued in several states in the country have been primarily aimed at limiting the movements of persons across communities to create some physical distance that would inhibit the rampant spread of the Coronavirus from person to person. By creating this physical distance, the speed of transmission would in effect greatly reduce and lead to a flattening of the Coronavirus curve over time.
This is important, as the primary aim is to limit the spread such that at no time is the health system flooded or overwhelmed with a surging increase in symptomatic cases especially, those in severe or critical condition. Nigeria is a country where up to 75 percent of the population have one or more risk factors for non-communicable diseases such as hypertension and heart disease, diabetes, kidney disease, lung diseases and cancer.
If one pictures a scenario where due to a sudden upsurge in COVID-19 illnesses, other health cases in need of critical care such as patients with stroke, kidney failure, complications from diabetes and even cancer have no access to healthcare due to an overwhelmed system, then we can more easily visualise why emphasising prevention of rampant spread of the virus is crucial. Another advantage of the lockdown is the facilitation of contact tracing by NCDC who are currently following up on over 6,000 contacts of confirmed cases around the country, which isn’t good for a very active and mobile population. Contact tracing is an integral component of the overall strategy for controlling any outbreak and essentially means the identification and follow-up on persons who may have come in contact with an infected person. A robust system for contact tracing relies on an army of surveillance officers or “contact tracers” who interview each person who has been tested and confirmed positive with the Coronavirus.
Through painstaking and urgent detective work, the contact tracer then elicits who else might have been exposed to, or already acquired the virus from the infectious person. We need to bear in mind that several people can be infected from one individual who is Coronavirus positive, even by later entering a room and touching contaminated objects – and so even the most thorough contact tracing would not detect 100 percent of close contacts. Therefore, hand hygiene, disinfection of surfaces and other preventive measures must be simultaneously emphasised for everyone as a preventive mechanism.
When any close contact is traced, the individual is then isolated or quarantined depending on test outcomes to reduce further spread of the virus to others. With this in mind, and given the Nigerian environment, one can imagine how helpful lockdowns and flight restrictions could be to the process and success of contact tracing.
While lockdowns are not anticipated to continue indefinitely, without the support of members of the public with the preventive measures of staying at home and limiting their movements to the absolutely essential, the Coronavirus will continue spreading unhindered and the Nigerian caseload will stratospherically increase. Given our already fragile healthcare delivery system, this is a situation we should not enable under any condition, as it would be potentially catastrophic for millions of Nigerians.
That said, and ever mindful of the large proportion of the country’s population that belongs to the informal sector and who rely on daily income for their sustenance and survival, the Central Bank of Nigeria ,CBN, recently introduced a stimulus package for eligible households and small businesses who would be hardest hit by the adverse impact of the Coronavirus pandemic.
It is anticipated that this social safety net would help cushion some of the hardship and fears vulnerable Nigerians would be exposed to and which pose the greatest threat of compromise to lockdown and physical distancing directives.
They are not dissimilar to economic support structures put in place by countries such as the United Kingdom, Canada and the United States of America. However, there is a need for clear accountability and transparency in the remote disbursement of such potentially supportive packages to ensure equitable distribution and effectiveness and build confidence.
Africa presents a peculiar case in the battle against coronavirus given its poor healthcare indices. Given this, what kind of preventive controls do you think could be introduced bearing in mind the peculiarities of the African society?
In Africa, due to the time lag experienced between when cases around the world were at almost 100,000 and Africa had barely 30 cases in total, this disparity had many on the continent and even some international observers puzzled, raising questions as to whether there was some African genetic resistance to the virus.
Several on the continent held on to this idea, and so the concept of a Coronavirus outbreak here was a distant notion to many and therefore discouraged individual preparedness to some degree. I believe, however, that the slow increase in cases instead reflected the fact that the continent is not the business or tourism hub to the rest of the world as we would like to think, and this is what prevented huge numbers of infected cases entering the country when the international borders remained open.
That said, the message must be driven home to Africans that we are indeed as susceptible to the virus as the rest of the world and so, protecting our lives and those of our families and community members would be a function of the steps we take individually and collectively to mitigate the spread in our communities – physical distancing, the avoidance of public gatherings, frequent handwashing, cough hygiene and regular surface disinfection.
In some African communities where regular water and soap may be a challenge, locally effective measures to ensure hand hygiene such as the use of rainwater, ash and clay should be mentioned. Organisations like World Health Organisation ,WHO, and the United Nations Children’s Fund ,UNICEF have done this in certain African communities in the past. Of course, this should only be mentioned as a stopgap while efforts are made to enhance availability and access to safe water and soap which are most ideal even in the most remote communities.
Messaging on preventive measures must take the realities of geographical and socioeconomic disparities into consideration. Another challenge in African countries which of course includes Nigeria is the poor public transportation system where people are often packed and seated shoulder to shoulder.
Without measures put in place to effectively carry road transportation business owners and workers on board with directives on numbers per vehicle, such directives would never be adhered to and many lives would be needlessly or avoidably put at risk of infection daily.
Your article entitled: Epidemic of fear: Misinformation and Panic in Infectious Disease Outbreaks, is a useful guide in the battle against Covid-I9. Now, ignorance is one of the factors that could worsen the situation in Nigeria. How can this challenge be handled by the authorities?
Ignorance can be countered by clear and consistent communication of the nature of the outbreak, confirmed cases and locations, in addition to global updates on research on vaccines and effective treatments. Conveying information relating to the outbreak regularly is crucial in times of uncertainty and unquestionably during unprecedented disease outbreaks like that of COVID-19.
The NCDC, Federal Ministry of Health and the Presidential Taskforce for COVID-19 have been at the forefront of communications to the public with regular detailed updates. However, given that this is a risk to which one of the most densely populated countries is exposed, we see that the responsibility of communication cannot reside with government alone. Citizens and corporate entities have to take up the personal and collective responsibility with a sense of urgency in ensuring that they circulate preventive messages, and that the information they disseminate via their social networks is not only verifiable but also genuine and regular.
As I had written in the article ‘Epidemic of Fear’, challenges in healthcare delivery and indeed social structures over the years have led to a lot of mistrust of authority. And when you add a new disease outbreak with a heavy dose of uncertainty in the mix, one can see that even in higher-resource settings like the USA, and in parts of Europe, when systems are overwhelmed people tend to lash out at government. It is therefore vital that health communications are viewed as a vital part of the outbreak response and should be at the forefront of communications from every sector.
Leaving communications to the health and disease control bodies alone excludes communications to citizens on the impact of the outbreak on the economy, jobs, transportation and education for example. The Coronavirus pandemic has shown that a threat to health security is a threat to national and socioeconomic security. Communication must thus be also multi-sector driven – involving ministries of health, information and communication, international organisations like the World Health Organization, telecommunications, information technology and social media corporations – all utilising trained volunteers to deliver clear and coherent messages to the public.
This is also where influencers from entertainment, sports and myriad sectors should in collaboration with the relevant authorities lend their voices and support to drive preventive messages to the homes of Nigerians leveraging on the influence they wield and their power to mould public opinion.
Civil society should also be involved in the communications effort, harnessing their community-based networks and working with traditional, religious and community leaders to ensure that prevention messages are also delivered at the grassroots level. With such a comprehensive information strategy, there would be an avoidance of contradictions and confusion that can spiral into panic, chaos and the unmitigated spread of the virus, which could become a vicious cycle feeding itself.
From growing statistics in the country, do you foresee the situation spiraling out of control?
From the current statistics and given epidemiologic principles, we still have another 3-4 weeks to determine if we have reached the peak of infected cases in Nigeria. The situation can, however, spiral out of control under one condition and that is if we rest on our oars and decide that we have won the battle against COVID-19.
The fight against COVID-19 will be a long-drawn-out war because it will rely on a ceaseless vigilance and commitment to protecting the lives of our people through investing in health security systems designed and enabled to prevent, detect and control COVID-19. To ensure the resilience of these systems, it must be a comprehensive, collaborative and multi-sector driven effort.
If the outbreak of infectious diseases is inevitable, how can nations prepare for it to avoid large scale disruptions of human activities as being witnessed?
There should be no room for complacency, and the only way to prevent or mitigate future outbreaks is to invest in strong, resilient primary healthcare systems. Good outbreak control involves identifying and treating cases, preventing and controlling infections, tracking contacts and monitoring those infected as well as good laboratory testing, infection prevention and control practices in health facilities and community involvement.
Sadly, across Africa, less than 25 percent of recurrent health expenditures are directed at this kind of essential healthcare system. Without functional primary healthcare systems, these vital steps in controlling epidemics will hardly be effectively carried out. Surging conflict and insecurity on the continent have contemporaneously further eroded systems and yet heightened the need for such systems.
Outbreak prevention and control activities must be integrated into existing healthcare systems to improve the proximity of services to communities, thus ensuring that systems remain functional during outbreaks. As we learned from the 2014 – 2016 Ebola outbreak in West Africa, community involvement in infection prevention and control was vital to bringing the three-year crisis to an end. It is worth emphasising that the trust of the people cannot be built during times of conflict or heightened fear, and so national and state governments across Africa need to prioritise investments and resource allocation for robust outbreak detection and management systems in addition to efficient primary healthcare structures because it is at the community level that more than 80 percent of health conditions can be prevented or treated.
People are far less likely to distrust a system that consistently protects the lives and wellbeing of their families and communities.