Chikwe Ihekweazu, Director-General, Nigeria Centre for Disease Control (NCDC)
When I walked out of the office and headed home at 10.30pm earlier this week, I left behind a few members of the NCDC team, still working on their computers. Some had only just resumed for the night shift. The test results for the day were still being compiled and confirmed with states. Since the onset of this pandemic, a typical day for me begins with phone calls as early as 6am and ends with meetings as late as 9pm. Our young agency has transformed to having staff working 24-7. The coronavirus pandemic has changed the world as we know it and like several other Nigerian institutions, medical professionals and frontline workers who are intimately involved in responding to the pandemic, we are putting in our best, despite all odds. As an agency, we have quickly adapted, working with partners and government at various levels to quickly control this outbreak. Our lives have changed, and we have all had to make the necessary adjustments to adapt to this “new normal”.
It seems like the distant past now, but the first confirmed case of coronavirus disease (COVID-19) in Nigeria was announced by the Honourable Minister of Health nearly six months ago, on the 27th of February. Less than a year later, Nigeria and indeed the world is in a very different place. What first began as a cluster of cases of an unknown illness affecting people thousands of kilometres away in Wuhan, China has morphed into a raging global pandemic that has infected just under 20 million people to date across all continents, leading to over 700,000 deaths, paralysing economies, changing our social life and transforming our world as we know it. In Nigeria, we have had to shut down schools, businesses, travel and introduced public health measures such as the wearing of masks, hand washing and physical distancing. Six months after the first case, I reflect on our response to the pandemic, changes happening in our health security architecture and what we must do to be better prepared for the next pandemic.
At the beginning of the pandemic, various models predicted a doomsday scenario for Nigeria and other African countries. This was linked to our weak health systems, high population density and informal economy. It is not clear that this will not be the case. But for now, Nigeria and other African countries have reported far fewer cases and deaths compared to other regions in the world. While this is not to be taken for granted and we continue to work hard to sustain and improve our response, we have to hope for the best, but prepare for the worst.
While it is often said that Nigerians are more reactive than proactive, yet, Nigeria was one of the first countries to recognise the risk posed by COVID-19. We started planning the response for COVID-19, very early, albeit with limited resources. A multi-sectoral National Coronavirus Preparedness Group was established by NCDC on the 7th of January 2020. This group included representatives from the Port Health Services of the Federal Ministry of Health, Office of the National Security Adviser, Federal Ministry of Agriculture and partners including World Health Organization (WHO), US Centers for Disease Control and Public Health England. In addition, the Honourable Minister of Health convened inter-Ministerial meetings with the Ministry of Information as well as the Ministry of Foreign Affairs to ensure collaboration across government. By the time the first case was confirmed, our preparedness group transitioned to an Emergency Operations Centre, while Mr. President instituted a Presidential Task Force on COVID-19 (PTF), for which the Secretary to the Government of the Federation, Mr Boss Mustapha has provided extraordinary leadership.
One of the areas where we have received the most criticism is with our laboratory infrastructure. To put this into perspective, we can compare a laboratory to a group of kitchens. The pots as equipment, ingredients as reagents, and the lab scientists as the cooks. If you have a great distribution of kitchens, pots, ingredients and cooks – it is easy to switch from cooking rice to cooking egusi soup. This is what South Africa and many other countries in the West could do. This is what we could not do in Nigeria– we simply did not have the appropriate or even enough kitchens, pots, ingredients and cooks to switch quickly.
Notwithstanding, we have worked very hard to make progress in our laboratory capacities in the last six months. We have gone from three testing laboratories to 61. We have strengthened our supply chain which was one of our biggest challenges at the beginning of the pandemic. One clear difference between the 2014 Ebola outbreak and COVID-19 is that our country now has the capacity to test and confirm the virus locally, without being dependent on other countries. This is coordinated at the centre by the NCDC National Reference Laboratory (NRL), a facility which was operationalised only in 2017. The NRL is now the single largest public health laboratory in Nigeria, with our team working 24-7 and providing services to all states in Nigeria.
Our human resources at NCDC and across the country has proven to be one of our greatest assets. In the last decade, Nigeria has faced several public health challenges. In 2014, Nigeria responded with relative success to an Ebola outbreak that affected four other West African countries. In 2017, we recorded the first cases of monkeypox, forty years after the last case was reported in the country and we have continued to learn from this. In the same year, the first yellow fever cases were reported, 21 years after the last case was found in the country. Over the last three years, there has been an increase in Lassa fever cases in the country. Almost every year, we record outbreaks of Lassa fever, cholera, meningitis, measles and yellow fever. All this has happened because our surveillance systems and diagnostic capacity for infectious diseases has improved. While responding to these outbreaks, colleagues involved in the response at the NCDC and the state epidemiology teams have learned many lessons and invested heavily in efforts to strengthen our health security. This has come to play in the last six months as we have responded to the COVID-19 outbreak. While this is an unprecedented outbreak, the experience from responding to previous outbreaks contributed to preparing us for this pandemic. I am incredibly proud of the work being done by colleagues at NCDC.
As a government parastatal, we are aware that we are accountable to our citizens and that we have to build and maintain the trust, that we have been imparted with. This is similar to many other countries around the world, where trust in government institutions has been a critical factor driving the response, and where politics may have influenced the public health response. In response to the outbreak in Nigeria, various containment measures were put in place, including the closure of international borders, restrictions on gatherings, school and workplace closures, stay-at-home orders, compulsory use of face masks and other public health measures. Unfortunately, the effectiveness of these containment measures has been affected by the need to sustain livelihoods in our largely informal economy and a persistent distrust in government institutions and as a result, the public health advisories.
It is difficult to gain public trust in a context of economic, social and security difficulties. Yet, at NCDC, we have remained focused on our mandate which is to protect the health of Nigerians. The reaction to COVID-19 in Nigeria has gone from fear to stigmatisation of infected people and to sometimes, denial. Together, with our partners, we have developed proactive and reactive communication strategies. The weekly press conferences with the Presidential Task Force provides an opportunity for me to engage directly with the media. In addition to this, we work very hard to respond to several daily media requests, developing key communication messages every week, utilising various media channels to reach all sections of our society.
It is easy to think of Nigeria as a country with uniform access to resources, forgetting the varying capacities and responsibilities across our states. The 36 states in Nigeria are at varying phases of this outbreak. There is established community transmission in some states, while other states are only at the beginning of this COVID-19 outbreak. This means that the intensity of the response will differ by state. We have deployed Rapid Response Teams (RRT) to all states in Nigeria. In Lagos, our RRTs have remained there since the first case was confirmed, with over 40 personnel still in the state. Through the World Bank, we have provided every state with a grant of 100 million naira each to implement their COVID-19 Incident Action Plans. While NCDC plays its normative role, every state should rise even higher to this challenge. We are only as strong as our weakest link and cannot afford to leave any state behind, as we respond to this outbreak.
There have been several changes since the first case of COVID-19 was confirmed in Nigeria. Cases of other infectious diseases are being missed. Every week, we publish a weekly epidemiological report with data showing increases in measles cases, sporadic cases of Lassa fever, monkeypox and cholera. We know that the COVID-19 outbreak will be with us for a while and we have learned to adapt our systems accordingly. Most health workers are fatigued, but we cannot stop pushing. We owe it to every Nigerian to build a system that ensures their health security.
At the Federal level, we have had strong political commitment and support as we respond to COVID-19. The Presidential Task Force has enabled collaboration and leadership at the highest level. Many states have begun to replicate this approach which has been even more critical as we move towards implementing a sustainable structure. The Nigeria Governors’ Forum has also played a key role in coordinating activities at the sub-national level and collaboration with the federal level. We have also had excellent support from national and global partners. Many partners have been embedded within the national and state Emergency Operations Centres (EOCs) to support the government’s response. Our President has let science guide decision making and has been open in accepting the recommendations of the Presidential Task Force.
We have learned various lessons from this pandemic. Critically, this pandemic has shown how critical health investment is to national security - a message we have championed for years. Our health system has been stretched and we have worked very hard to adapt. But we must prepare better for the next pandemic. We must have the laboratory, emergency preparedness and response structures that can adapt very quickly in the event of another pandemic. In the meantime, we will continue putting in our best – within and outside official working hours.
We keep pushing…