Ebola: The battle of a continent

The head of Nigeria Centre for Disease Control and Prevention was in a meeting of physicians discussing what to do when Ebola comes into the country. Then Abdulsalam Nasidi got a message. It has landed, the SMS said. He told his colleagues in Yoruba: “O ti de.” That was the moment Liberian American Patrick Sawyer, […]

The head of Nigeria Centre for Disease Control and Prevention was in a meeting of physicians discussing what to do when Ebola comes into the country. Then Abdulsalam Nasidi got a message. It has landed, the SMS said. He told his colleagues in Yoruba: “O ti de.”

That was the moment Liberian American Patrick Sawyer, who’d been taken ill on arrival at Murtala Muhammad International Airport in Lagos, rushed to First Consultant Medical Centre in Obalende and put through a batch of tests, was confirmed to have Ebola Virus Disease.

Doctors had been treating his 39.7^oC fever as malaria, but his liver function test was bad, and they weren’t aware Sawyer had collapsed until an ECOWAS official next morning “brought us information that Patrick Sawyer collapsed at the airport,” said Dr Morris Ibeawuchi, one of Sawyer’s medical team, who caught the virus but survived.

“After that, she [lead doctor Stella Adadevoh] asked whether I got the information. That was how the whole thing started. From there, we instituted barrier-nursing technique.”

The disease had been knocking the socks off mostly rural populations in Liberia, Sierra Leone and Guinea since December 2013 in what became the first Ebola outbreak in West Africa.

The outbreak broke barriers. All previous outbreaks had been confined to single rural sites, never before in West Africa. This outbreak hit 60 sites in just six months, then slipped into Nigeria’s economic capital Lagos, then its oil capital Port Harcourt.

With both cities in the thrall of Ebola, experts estimate the outbreak could have stripped off some 60% of Nigeria’s economy.

Lagos, with some 21 million people, was Ebola’s first entry into urban population, sparking panic about how the virus could spread through a metropolis with a population more than that of Liberia, Guinea and Sierra Leone combined.

Sawyer’s death on July 22 sparked any actual Nigerian response to a disease that had already killed 660 in the three other countries. The death toll would later climb to more than 4,500 in October, mostly in the three most affected countries while the virus moved on to Spain and the US and a separate unrelated strain emerged in the Democratic Republic of Congo.

By January 2015, it would reach 20 206 cases—confirmed, probable and suspected—and more than 8,000 deaths.

The virulence of Ebola devastates families—the speed with which it kills victims as the virus migrates through the body, punching holes in blood vessels to cause its characteristic symptom; the shock with which families catch the virus from caring for their sick or burying a dead loved one.

No one knows why living patients transmit the virus less than a dead body, but experts have concluded the close cultural contact with bodies of dead relatives being prepared for burial is the reason Sierra Leone’s cases kept shooting up for 15 weeks straight.

Ebola’s virulence also devastates national health, economies and life. “Liberia is ground, Sierra Leone is in confusion, Guinea doesn’t know what to do,” Nasidi summarized. “Ebola so devastated these three countries that all other health services were grounded.”

Health systems in the region are shaky by Western standards but they took a buffeting.

Former health minister Onyebuchi Chukwu took exception to describing Nigeria’s health system as “weak”.

“However weak the health system, it is still there. In these other countries, it wasn’t working,” said Nasidi.

Panicked publics stayed away from hospitals known to have taken in even Ebola suspects—immunisation was impacted, along with maternal services, outpatient visits.

To control Ebola’s spread, governments slammed further restriction on movement, trade and transport, even closing borders. In turn, the measures bit down on internal and regional trade, transport, tourism.

The World Bank in October said Ebola was already having great impact: forgone output, higher deficits, rising prices, lower real household incomes, greater poverty.

“These economic impacts include the costs of healthcare and forgone productivity of those directly affected but, more importantly, they arise from the aversion behaviour of others in response to the disease,” the bank wrote.

Lost GDP in the three countries stood at some $359 million, and $7.4 billion for the entire region by end of 2014 alone. Projections for 2015 were even steeper. Nigeria didn’t close its borders, but closures aimed at breaking the chain of transmission amounted to an “economic blockade” that scaled back production and revenues for governments, according to Sierra Leonean President Ernest Bai Koroma.

Ebola didn’t spare agriculture. Disruptions in planting season diminished yields of staple crops like cassava and doubled prices in some places, according to the Food and Agriculture Organisation, amidst fears of likely inflation.

Mining alone constitutes 14% of Liberia’s economy and 17% of Sierra Leone’s. But mining firms scaled down operations as Ebola escalated, became afraid to enter areas considered high risk, suspended operations or sent foreign workers home. Guinea’s main mines, located outside areas with high risk of infection, were spared.

Ebola’s effect on tourism is linked to travel restrictions, which nations fear contribute to humanitarian crises by blocking crucial trade flows and pushing up food and medicine prices.

Dozens of airlines suspended flights into and out of affected countries. The African Union and ECOWAS stood against the bans, calling instead for proper screening at ports of entry. ECOWAS’s open-borders, no-visa regional integration suddenly looked like a bad idea, but the bloc insisted on stronger checks instead.

“Closing borders will not only undermine the very essence of economic union which is the free movement of persons and goods but could also deny them the financial resources to face the epidemic,” Kadre Quedraogo, president of ECOWAS Commission, told a high-level meeting of the Health Partners Coordinating Committee (HPPC)—the coordinating body for bilateral and multilateral partnerships in Nigeria.

Beyond the affected countries, countries untouched by Ebola also felt the virus’s fury. Corporate events were cancelled, international investors declined to visit and multinationals stayed on high alert.

A web developer paid to train some journalists in Lagos didn’t show up because he didn’t want visa for an “Ebola” country showing up on his passport and disrupting his future international travels.

Ebola had been ravaging Guinea since December 2013, but it wasn’t even identified as such, and no health emergency was declared until months later in March—time enough for the region to sit and take note.

“We were not well prepared for this type of epidemic which is not only a health issue but also an economic and security issue,” said Quedraogo.

“We lack the necessary human, financial resources and technical resources to face the situation hence the appeal for the assistance of partners in these areas.”

Nigeria’s health system wasn’t ready either, which is why many analysts believe Ebola landing in a place like Lagos is a stroke of good luck. Sure, eight people died, but even medical experts believe Ebola would have spread further if it had landed in any other state without the same level of logistic coordination as Lagos.

Sawyer’s transport to First Consultant would also bring him in contact with consultant Dr Adadevoh. She raised a red flag while attending to Sawyer, leading to positive confirmation of the index case.

That identification catalysed unprecedented action—tracing all who had been in contact with Sawyer—marking the difference between Nigeria and its neighbours.

The federal government took charge from Lagos state government, declared a public health emergency, set up an emergency operations centre housed at the Central Laboratory in Yaba.

Never mind doctors were on strike at the time; volunteers turned up to help trace contacts. Nearly 900 contacts were quarantined or put under surveillance. Surveillance means a healthworker comes around each day to check you up and monitor symptoms, if you are thought to have been exposed to Ebola.

With neither treatment nor cure for Ebola, 20 people who got sick were treated for symptoms, fluids replaced, infections controlled. Several experimental drugs failed to scale consideration by the Nigeria Research Ethics Committee for use in treatment. Twelve would later be discharged from hospital. Other contacts who didn’t show symptoms after a recommended 21-day observation were released from surveillance. Forty-two days after the last contact was released—and no new infection recorded—World Health Organisation declared Nigeria officially Ebola-free.

WHO representative in Nigeria, Dr Rui Gama Vaz, said the country held lessons for the rest of the world in how it managed to contain the virus: country leadership, timely allocation of resources, coordinating a single plan under a single lead, deploying the power of modern communication.

Other than a central command for everything Ebola, Nigeria fought a biological and information-management war. Official chain of command vested authority on the health minister, backed by the information minister, official social-media accounts, millions of public-information tweets, posts and SMS.

The October 20 declaration was remarkable, because Nigeria had no previous experience of Ebola, but Adadevoh and fellow healthcare workers paid the price, becoming heroes in national media.

“We were aware of what could come,” Bankole Cardoso, Dr Adadevoh’s 26-year-old only son, said in an interview after her eventual death.

“I’d had such a big loss [that] I was trying to close myself off from everything. So it was hard for me and then with time it became more and more apparent exactly what she had done.”

Dennis Akhaga’s pregnant wife Justina Echelonu Obioma, a nurse at First Consultant, was on her first day of work when she met Sawyer, he said. Akhaga later was taken ill after she died. “My being alive today, even though I lost someone, God knows why and has a reason for everything.”

Reason is what many searched to explain every perplexing thing in shadows and outside the news. Myths and conspiracy theories have spread even faster than the virus itself. Claim that a solution of salt in warm water drunk and bathed with at a fixed time before daybreak could cure or prevent Ebola was rampant. It was actually a prank among a group of university students and killed more people in Nigeria than Ebola ever did.

Conspiracy theories target science, pathogens and the West. Liberia’s paranoia was sparked by Dr Leonard Horowitz’s book Emerging Viruses – AIDS & Ebola, which said claims that the viruses emerged and jumped species from ape to man were “grossly unfounded”, while putting forth argument that the viruses were laboratory creations, accidentally or intentionally transmitted via tainted hepatitis and smallpox vaccines in the U.S. and Africa.

The Liberian Observer ran the stories like BREAKING: Formaldeyde in Water Allegedly Causing Ebola-like Symptom; Ebola, AIDS Manufactured by Western Pharmaceuticals, US DoD? and The Ebola Breakout Coincided with UN Vaccine Campaigns.

Conspiracy theories fuel rumours and denials, which in turn make treatment difficult when people affected refuse to surrender themselves for medical assistance.

Nigeria expediently nipped claims in the bud when it clamped down on prophets putting forth claims of being able to treat Ebola. Instead it set up a Treatment Research Group to investigate claims of everything thought to have some effect in scientific literature or by word of mouth—from bitter kola and nanosilver to HIV drugs and chloroquine, already approved drugs which could be repurposed for use against new diseases.

Among the drugs, chloroquine showed the most promise but is not a drug that will make much money for big pharmaceutical companies, experts have said.

Vaccines are a bigger consideration, but the start-stop pattern of outbreaks has not encouraged larger production and testing until now, when WHO proposes testing for a handful of vaccines by 2015.

Nigeria has opted into testing, as will other countries on the continent, pressured by a concern to have something with which to fight Ebola.

Because it will be back, as viral outbreaks typically do. Since containment, Nigeria switched from “response” mode to “preparedness” mode. In October, it set up a second national emergency operations centre in Abuja, and more than 500 volunteered to deploy to Liberia, Sierra Leone and Guinea to help fight Ebola.

In Rivers, the second state to be hit in Nigeria, a separate Ebola operations centre began to wind down as soon as the last contact was released from surveillance. In the build-up to handle Ebola, the state government forked over N1.198 billion; ambulances had to be remodelled so there’s no airflow between the driver’s cab and the back, according to Dick Iruenabiri, deputy incident manager at the Ebola emergency operations centre in Rivers State.

All that is gone: in the first drawdown, more than 200 operations staff were pulled. The laboratory for diagnosis was a mobile one donated by the European Union, and “now we have finished, they have taken the lab away,” said Iruenabiri.

No need to look abroad, he said. Port Harcourt’s index case came from a local, not international, flight.

“We need to keep EOCs open. If they wind down, if this comes again, we will need much more to restart.”

“People were very paranoid and in the last few weeks it has calmed down. I just hope with this news they don’t let their guard down,” Cardoso said.

A culture of handwashing, which sprang at the height of Ebola has begun to fade, and hand sanitiser bottles are going empty.

WHO has warned no country should get complacent until Ebola is defeated throughout the continent and the world.

The battle is over but not the war, said WHO, prompting concerns that viruses have no respect for national borders.

Fear of dying was critical to success against Ebola, and it is not time to lose that fear yet.