I still expect that Nigeria will succeed in snuffing out the outbreak of Ebola sparked by a seriously ill man who flew from Monrovia to Lagos. The Nigerian authorities have been doing it by the book: identifying and monitoring contacts, then isolating everyone who shows symptoms. This protocol has been used successfully in rural areas more than a dozen times over the past forty years. Nigeria has also taken other drastic steps to reduce risk, such as closing schools.
Update 10/2/14: It’s looking very good for Nigeria, although the definitive all-clear won’t come until October 12, after 42 days with no new cases. School is back in session and President Goodluck Jonathan gave a victory speech. [PBS 10/2/14] But it was a close-run thing, principally due to the pattern of quarantine violations described in this post. Nigeria — like everywhere else — will have to deal with a string of similar situations as infected people travel there from West Africa. The U.S. in particular would be wise to heed this story, since there has already been a quarantine violation in the Texas outbreak. [Dallas Business Journal 10/2/14]
My confidence has been shaken, however, by a pattern of quarantine violations which has repeatedly undercut Nigeria’s containment efforts. The culprit is not ignorance, superstition and mistrust, as in rural Guinea and in the urban slums of Monrovia. The problem in Nigeria has so far been arrogance and privilege. I now see that the wealthy and educated, if they are sufficiently arrogant and privileged, can undercut an Ebola prevention program as fatally as the irrationality of the poor.
- The story begins with Patrick Sawyer, a Liberian who had become a naturalized American citizen.[Daily Beast 2014-08-14] Leaving his wife and young children in Minnesota, he had returned to Liberia to take a high position in its Finance Ministry. When his sister fell ill with uncontrolled bleeding Sawyer took her to a hospital in Monrovia. Her symptoms were recognized and the hospital personnel tried to put her into an isolation ward. But Sawyer paid $500 to have her given a private room, where he personally undressed her. Ultimately about a dozen hospital staff — nurses, a doctor and an administrator — fell ill due to their exposure to Sawyer’s sister. [FrontPageAfrica 8/13/14] Update 10/2/14: The story of Sawyer and his sister and the hospital administrator turns out to be more complicated than first appeared, though the conclusions are the same. For details see EbolaStrategy: How Contagious is Ebola?
- After his sister died, on July 7, Sawyer was put under surveillance due to his exposure, and told not to leave Monrovia. After showing serious Ebola symptoms he nevertheless flew to Lagos on July 20, nominally to attend a conference. He vomited several times on the plane and collapsed on arrival in Lagos. He was helped into a taxi and taken to a hospital, where he initially denied being exposed to Ebola, and at one point pulled the IV’s from his arms. He infected around a dozen contacts, including doctors and nurses as well as the person who helped him into his taxi. He died on July 25.
- All of Sawyer’s contacts were put under surveillance, and those with symptoms were isolated. One of his nurses, however, violated restrictions and fled to her home in Enugu State. She had no symptoms when she fled, but showed symptoms in Enugu and was returned to Lagos by special ambulance to Lagos. Six contacts in Enugu were still under surveillance as of August 14.[Premium Times 2014-08-14]
- On August 26 the Nigerian Minister of Health declared that “Ebola has been curtailed.” [Premium Times 2014-08-28], but it turns out that a Nigerian diplomat who had met with Sawyer had escaped from an isolation ward in Lagos and fled to the oil center of Port Harcourt, where he was secretly been treated by a local doctor, Iyke Enemuo, in a local hotel. The diplomat survived but the doctor became infected, and died on August 22. Subsequently, WHO reported the troubling details [WHO 9/3/14]:
After onset of symptoms, on 11 August, and until 13 August, the physician continued to treat patients at his private clinic, and operated on at least two. On 13 August, his symptoms worsened; he stayed at home and was hospitalized on 16 August. Prior to hospitalization, the physician had numerous contacts with the community, as relatives and friends visited his home to celebrate the birth of a baby.
Once hospitalized, he again had numerous contacts with the community, as members of his church visited to perform a healing ritual said to involve the laying on of hands. During his 6 day period of hospitalization, he was attended by the majority of the hospital’s health care staff.
On 21 August, he was taken to an ultrasound clinic, where 2 physicians performed an abdominal scan. He died the next day.
The additional 2 confirmed cases are his wife, also a doctor, and a patient at the same hospital where he was treated. Additional staff at the hospital are undergoing tests.
Given these multiple high-risk exposure opportunities, the outbreak of Ebola virus disease in Port Harcourt has the potential to grow larger and spread faster than the one in Lagos.
Nigerian health workers and WHO epidemiologists are monitoring more than 200 contacts. Of these, around 60 are considered to have had high-risk or very high-risk exposure.
- Yesterday, we learned that the doctor’s wife has fallen ill, and his sister had fled to Abia State to avoid being quarantined. [Modern Ghana 2014-08-30] She was returned to quarantine in Port Harcourt, but of course now her contacts also need to be tracked.
Again and again people who were relatively well-off and presumably well-informed chose to break quarantine and place untold numbers of others at risk. Nigeria’s outbreak is spinning out of control not through ignorance and superstition but through the arrogance and recklessness of the privileged few. One still assumes that people will get a grip and start behaving themselves. But it may also be that the culture of wealthy privilege is so deeply ingrained in Nigeria that this will continue until the virus gets into a slum — or the ungovernable north — and Nigeria follows the disastrous trajectory of Liberia.