We are pleased to present, under our “Sneak Peek Series”, an excerpt from Chikwe Ihekweazu’s memoir, An Imperfect Storm, which is a riveting account told with the help of his wife, Vivianne about the heroic efforts of Chikwe and others like him in not just blunting the spread of COVID-19 but evolving a standard public health institution in Nigeria. This is a front-row seat account from a major player in the fight against the pandemic
The Inevitable
(February–April 2020)
Nigeria, as we learnt, was no stranger to outbreaks. Every single month, there was a cluster of infectious disease cases emerging in different parts of the country. But the COVID-19 pandemic was different. It was new, and it was spreading at an alarming rate.
Serendipity might seem like a romantic or idealistic concept, certainly not a term one might associate with a life and death scenario like the impending arrival of a rampaging virus, but in hindsight, it felt like everything that had led up to this point, all the twists and turns over the years, the challenges faced and overcome, the systems we had built from nothing and sustained, made it possible for us to face what was to come.
Our incident management systems and structures at NCDC Emergency Operations Centre had been functional since 2016. With the news from Wuhan, we quickly activated our emergency operation centre and appointed an incident manager to take charge. We hoped to do all we could to keep this virus out of Nigeria. As our understanding improved, we had to acknowledge that keeping the virus out of Nigeria would be impossible, so we rechannelled our focus towards preparedness. Information and guidelines were rapidly changing; preparing for the virus was like building a ship and sailing it at the same time. Our immediate goal was to develop and implement prevention and preparedness plans, while keeping close tabs on the situation unfolding in China and the rest of the world. It wasn’t just about protecting our own people. We had a responsibility to the global community to prevent the virus from spreading.
After our COVID-19 Preparedness Group developed a detailed plan, the problem of funds arose. We submitted our plans and budget to the Minister of Health, who was supposed to pass it on to the President. Days turned into weeks, yet nothing. I was worried that my Minister wasn’t giving this threat the attention it needed. I had a responsibility to protect the Nigerian people, and I had to find a way to surmount the bureaucracy of the government. So, I took a bold step and went straight to the Presidency. It wasn’t an easy move. I expected it would ruffle feathers, and I was right. It caused some tension that I was bypassing the usual channels, but sometimes, even in our beloved country Nigeria, one must put the needs of the people above bureaucratic red tape. Protocols, formalities, biases, personal grievances—all that does not matter when our collective survival is threatened. It turned out that the Presidency had been waiting for us and was actually dismayed that it had taken us so long to ask. I kept the reasons to myself.
At that point, NCDC didn’t have an outbreak response fund, except a limited revolving fund provided by Resolve to Save Lives—a non-governmental organisation founded by former US CDC Director, Tom Frieden—but it wasn’t designed for major events like the COVID-19 pandemic. I had been trying for years to set up a similar fund within NCDC, but it never gained traction with our leadership. Instead, we were forced to rely on begging for funds from our partners every time there was a crisis. I was incredibly frustrated and disappointed that our leaders had taken our resilience for granted, assuming that we would always be able to solicit funds in times of crisis. NCDC shouldn’t have been put in a position where its usefulness depends on its ability to raise funds from external partners in response to a crisis. It was like expecting the fire service to seek water vendors in search of water to be gifted when there was a fire.
Every other day in February, a new country reported its first case, increasing the global incidence. Part of our initial focus was strengthening screening measures at airports and developing guidance to enlighten passengers on the risks involved. While this was primarily the responsibility of Port Health Services—a unit in the Department of Public Health in the Federal Ministry of Health—they had even fewer resources than we did at NCDC and were unable to do this by themselves. NCDC funded the printing of leaflets and supported the staff of Port Health Services in deploying and collecting data from passengers. Our concern extended to case detection and transmission prevention. All prospects had to be considered.
We leveraged information gathered from WHO and other sources to develop public health messages aired on local media stations, despite our limited knowledge of the emerging virus. I mandated every member of NCDC team to remain informed, read up on the virus, follow up on news updates, and inform me of significant updates. In anticipation of a surge in demand, we sought out colleagues to support our work. I invited Dr Assad Hassan and Dr Kelly Eliman to join us on short-term contracts—excellent colleagues who could bring 100% focus to our initial response, as we needed that kind of commitment. Dr Assad was the State Epidemiologist for Kebbi State, while Dr Elimian was an academic from the University of Benin Teaching Hospital. Both had worked with us in the past and hit the ground running, immediately.
As the virus continued to spread, anxiety and scrutiny of returning travellers from China intensified. Even people of Chinese descent who hadn’t left Nigeria for years were stigmatised, and we had to deal with calls from concerned citizens who demanded immediate investigation of Chinese nationals for all sorts of reasons. NCDC Connect Centre would regularly receive calls from people informing us that they had just spotted an individual from China in their neighbourhood, requesting someone from NCDC to investigate. Sometimes people took the situation into their own hands and confronted their neighbours. It was a tough situation, but we did our best to educate and reassure people and discourage stigmatisation.
Looking back, one of the earliest gaps in the response in Nigeria and other countries was that surveillance was disproportionately focused on China. Given what I saw during my visit and the extraordinary measures that China was taking to limit the spread, I was somewhat less concerned about China at this stage. Nevertheless, we were quick to provide travel guidelines for passengers coming from China to Nigeria, maintaining surveillance and recommending isolation for 14 days. This measure was introduced as early as February 3. For other travellers, we simply advised them to adhere to recommended safety measures and report to designated hospitals if they felt ill. At that point, I began to really worry about the increasing number of cases in Europe, but was initially reassured because the cases reported in the UK—the biggest travel destination for Nigerians in Europe—were still apparently low. Reported cases in Europe were initially concentrated in the Lombardy region, an area in northern Italy. It was slowly becoming obvious that this new epidemic was spreading at an alarming rate, and we couldn’t afford to focus only on China.
Meanwhile, news reports from other countries showing images of people on ventilators and in hospital wards instilled fear in Nigerians. The average Nigerian could sense that the country’s poorly equipped and inefficient health system would struggle to cope with a potential influx of critically ill patients. At NCDC, however, we tried to remain calm while pushing on the areas that we had influence over. We focused our attention on the next stage of preparedness: testing capacity.
At this time, NCDC had a reasonable stockpile of personal protective equipment, given that the COVID-19 outbreak was occurring at a period we would normally be experiencing an upsurge in Lassa fever cases. But the supply chain for laboratory reagents was inefficient. We reached out to our traditional partners at WHO and the Africa CDC. I knew that global demand for their support would be very intense, so I also reached out to colleagues at the Robert Koch Institute (RKI), who agreed to immediately send reagents to test the first few cases. We split the first reagents between NCDC National Reference Laboratory (NRL) in Abuja and the University of Lagos laboratory, which was managed by Professor Omilabu, a long-standing collaborator of NCDC who played a key role in the detection of Nigeria’s first Ebola case in 2014. Finally, we could officially announce that we had the capacity to test and confirm cases here in Nigeria. This announcement significantly changed the perception of NCDC’s preparedness.
Throughout February 2020, there were multiple false alarms with reports of individuals showing symptoms of respiratory illness after returning from countries with ongoing transmission of COVID-19 cases. Initially, the only country in this category was China, but gradually, more countries were added to the list. NCDC chose a cut-off of people returning from countries with over a 1,000 cases as those that would receive extra checks at the airport on arrival into Nigeria. The call centre’s capacity was rapidly expanded, and colleagues in Port Health Services joined us to call passengers returning from these countries to check if they had any COVID-19 symptoms since their return.
One evening, I received a call about an Ethiopian Airlines flight enroute to Kano with a passenger who was coughing and had a high fever. The State Epidemiologist was notified, and colleagues went to the airport in personal protective gear to wait for the plane. The ill passenger wasn’t allowed to disembark, was stabilised on the aircraft, and flown back to the country of departure. Similar cases continued to pop up over the next few weeks, and each time I received a call from Professor Omilabu in Lagos, I thought: this is it. But it wasn’t. The anxiety associated with the anticipation of the inevitable was almost crippling.
In the meantime, NCDC continued to develop preparedness plans and build capacity locally; part of which meant my involvement in several discussions about the growing outbreak and response strategies. Together with 20 scientists from around the world, I was privileged to be a member of WHO’s Emergencies programme’s Scientific and Technical Advisory Group on Infectious Hazards. Through discussions in this group and with colleagues at WHO, I developed my analysis of the situation in Nigeria. I was also part of an informal group convened by Dr John Nkengasong, Director of Africa CDC, to support the coordination of prevention and response efforts across the continent. He made a tactical move, asking select countries to lead preparedness in specific areas; Senegal and South Africa led the development of laboratory capacity, while Nigeria led infection prevention and control. Courses were organised to train laboratory scientists and technicians on the diagnosis of the new virus, and in what had to be the shortest time ever from ideation to implementation, a team was sent to Senegal to participate in the training for the laboratory diagnosis of SARS-CoV-2.
Prior to the outbreak, NCDC had initiated the development of the first modern infectious disease ward in the country at the University of Abuja Teaching Hospital, Gwagwalada. We had spent years convincing stakeholders that this type of facility was needed, at least in the Federal Capital Territory. We had Lassa fever cases in mind when building the hospital facility and wanted to hedge against a future Ebola outbreak. It had male, female and children’s wards, and provision for its own operating theatre, laboratory, pharmacy, morgue, and all other facilities required to efficiently manage severe infectious disease cases, away from other patients.
The building was only halfway complete when the pandemic began, leaving us ill-prepared to manage a potential first case in Abuja. To address this, we worked with the Chief Medical Director of the hospital to convert a recently developed casualty ward into an interim COVID-19 facility. We managed to source beds and equipment, and even transported a generator from NCDC office to the hospital. We considered it more important to have a ward ready in Abuja than a generator in our office. The brutal race against time was in full swing.
In early April, we were invited to the National Assembly on one of several missions concerning the outbreak. There, the Chair of the Presidential Task Force, who was also the Secretary to the Government of the Federation, made a headline-grabbing statement:
“I can tell you for sure, I never knew that our entire healthcare infrastructure was in the state in which it is until I was appointed to do this work.”
Understandably, it led to an uproar when reported. How could a senior government official claim to be ignorant of the state of our healthcare infrastructure? It was plain as day to citizens and the government that the healthcare sector had just never received the attention it deserved and required. With the imminent arrival of an unknown virus, citizens began to place health and healthcare at the centre of the political agenda, scrutinising the country’s preparedness and response capacity. A salient point was made: sustained investment in public health infrastructure and emergency preparedness was no longer negotiable, albeit, too late for this pandemic. Nonetheless, NCDC worked creatively within its sphere of influence, strengthening screening measures, developing public health messages, and identifying potential cases to prevent further transmission. We established testing capacity in several labs, including NCDC National Reference Laboratory; the virology laboratory of the University of Lagos; the Nigerian Institute of Medical Research; and the Africa Centre for Genomics of Infectious Diseases. We were in the process of bringing on board 3 other laboratories, the Irrua Specialist Teaching Hospital, Federal Medical Centre, Owo, and Alex Ekwueme Federal Teaching Hospital, Abakaliki, to start testing suspected COVID-19 cases. Along with these measures, we developed guidelines for the notification of cases, case management, laboratory testing, and communication in anticipation of the inevitable first confirmed case. But there was another underlying factor that had potential to mar our preparedness plans. Lassa fever.
Lassa fever cases are recorded year-round in Nigeria, with the peak period usually between December and April. Many NCDC colleagues with significant outbreak response experience were already deployed to states for the Lassa fever response; our top 3 infectious disease treatment centres in Edo, Ebonyi, and Ondo were full of Lassa fever cases. State Epidemiologists were also occupied with investigating and responding to Lassa cases. In the same week that Nigeria’s first COVID-19 case was eventually reported, we had 109 confirmed Lassa fever cases with 8 deaths from 19 states.
The final feature of our delayed preparedness plans was a simulation exercise to practise our response to a potential case in Nigeria. Simulation exercises were a crucial part of our work at NCDC. In 2018, we collaborated with the West African Health Organisation to organise the largest-ever yellow fever simulation exercise in West Africa, which involved colleagues from the Republic of Benin. These exercises provide a chance to assess our capabilities, identify gaps, and generate additional evidence for increased attention and funding. They also offer the opportunity of collaboration with other government institutions in a near-real-life setting.
We planned for a simulation exercise to take place between February 27–28, supported by WHO Nigeria Country Office—Resolve to Save Lives, colleagues from the African Field Epidemiology Network (AFENET); the US CDC; World Bank, and Public Health England. We also typically invited other agencies such as the Nigeria Civil Aviation Authority (NCAA) and the Federal Airport Authority of Nigeria (FAAN) to join our simulation exercises.
It was at this point, in the middle of a simulation exercise, that the call came. The inevitable had happened; the novel coronavirus had made its way across our borders.
***An Imperfect Storm is out on August 8, 2024 from Masobe Books.
