When Liberian-American Patrick Sawyer collapsed at Lagos airport, he
brought Ebola into a potentially ideal place for the deadly virus to
spread, a vast, dirty, overcrowded city where tracing carriers and their
contacts is a major problem.
Sawyer's arrival last month from
Liberia, which along with Sierra Leone and Guinea lies at the centre of
an outbreak that has killed more than 1 000 people caught authorities in
the Nigerian commercial capital unprepared.
By the time they
realised where he was from or what illness he had, Sawyer had had
contact with dozens of people. Lagos has now had 10 cases of Ebola, an
illness spread by contact with the fluids of an infected person.
As
Africa's biggest economy, Nigeria has a better health system than the
other West African countries which are among the poorest in the world,
and Ebola doesn't spread through the air or water supply as with many
other epidemic diseases.
But health experts, who are trying to
overcome superstition and public ignorance about Ebola as well as the
disease itself, say there is now only a short opportunity to find and
lock down other infected people before the outbreak in the city of 21
million gets out of hand.
"Lagos is big, it's crowded. It would
make in many ways a perfect environment for the virus to spread", said
Nigerian epidemiologist Chikwe Ihekweazu, who runs website Nigeria
Health Watch and worked on Ebola in South Sudan a decade ago.
"In
the heart of Lagos, people live on top of each other, sharing bedrooms
and toilets. In densely populated communities infection control becomes
almost impossible to do well."
When Sawyer landed at Murtala
Mohammed airport on 20 July, none of the bystanders, airport staff or
healthworkers who rushed to help him understood the danger they were in.
No
one had the full body protection of mask, suit and gloves that are
essential to prevent contagion, so his ill advised journey gave the
worlds worst Ebola outbreak a foothold in Africa's most populous nation.
Sawyer died five days later, followed by one of the nurses who first
treated him.
"Unfortunately nobody knew the status of this person,
no one knew the kind of illness that he had, no one knew he was
coming", Lagos state health commissioner Jide Idris said. A health
official said he had also been sick on the plane.
The West African
regional body Ecowas announced on Wednesday that one of its staff who
travelled with Sawyer had also died from the fever, taking the toll to
three. The remaining infected patients, including a hospital doctor, are
receiving treatment.
Sawyer was taken to First Consultants Hospital where, Idris said, he was treated "like any ordinary patient".
Hospital
staff took blood samples, checked his temperature, treated his
symptoms, which by then included severe vomiting, diarrhoea and bleeding
- all signs of late-stage Ebola.
"In the course of doing this, a lot of those health workers got infected", said Idris.
It
took weeks to trace about 70 people who were primary contacts with
Sawyer, multiplying the possible avenues of contagion in the meantime.
Tom
Frieden, director of the US Centres for Disease Control and Prevention
(CDC) which is helping to fight the West African outbreak, said he was
"deeply, deeply concerned about the situation" in Lagos because of the
city's size.
"If you leave behind even a single burning ember,
it's like a forest fire. It flares back up", he told a US house
committee on foreign affairs last week.
‘One mad man’
Nigerians
are furious that Sawyer, whose sister had died of Ebola and who was
himself under surveillance, was able to hop on a plane and give the
virus a free ride to Nigeria.
"It is unfortunate that one mad man brought Ebola to us", President Goodluck Jonathan put it bluntly on Monday.
Sawyer,
who worked as public health manager at an iron ore mining project of
steelmaker Arcelor Mittal, caught the disease from his sister who died
in Monrovia of Ebola on 8 July.
Liberia's information minister
Lewis Brown told Reuters that Sawyer had travelled against medical
advice. Arcelo rMittal said there were no more cases among its employees
and contractors in the country "at this time".
The arrival of the
virus in Lagos has raised global attention to the biggest and most
complex outbreak so far of Ebola, which has no proven cure and was first
detected in 1976 in the forests of then Zaire, now Democratic Republic
of Congo.
In many ways, Africa's top oil producer is in a better
position than the other three affected countries. According to
consultancy DaMina Advisors, it has one doctor per 2 879 people,
compared with one per 86 275 in Liberia.
While public doctors are striking over pay, Nigeria has the money to mobilise enough health workers for now.
Recent progress in tracing Sawyer's contacts, though it got off to a slow start, gives some cause for hope, experts say.
Yet
because it is a city of migrants, Lagos is a potential springboard for
Ebola to spread across Nigeria. "There's a lot of mobility within the
country. If infected people end up taking taxis to their villages, then
we're in trouble", said Ihekweazu.
‘People are afraid’
Alarm
bells first went off when the hospital ran ID checks on Sawyer two days
after his arrival, and figured out belatedly that he was Liberian who
had come from Monrovia, Idris said.
They quickly isolated him and
tested him for Ebola. Yet even after that, nurses continued treating
Sawyer without protection, so "the chances of infection again went up".
Tracing Sawyer's contacts aboard the flight then took time because the airline produced a passenger list only after a week.
Three
weeks later, 177 primary and secondary contacts of Sawyer's have been
traced and all are under surveillance, federal health minister Onyebuchi
Chukwu said on Monday.
Chukwu also announced measures to contain
the disease, including training health care professionals in
surveillance of possible cases, putting port officials on red alert, and
a public awareness campaign in multiple languages.
In its
built-up metropolitan areas, Lagos has 20 000 people per square km, the
state government says, about the same as other overcrowded cities such
as Mumbai and Dhaka.
Sanitation is at least as bad as either of the other two, with most Lagosians urinating and defecating in the open.
Both
walls leading to the entrance to the now closed First Consultants
hospital have "Do Not Urinate Here" stencilled on them, though judging
by the smell no one pays much attention.
Against one, an old woman
sells a kaleidoscopic array of flip-flop sandals flowering out of a
rusty wheelbarrow. A child hawks plastic bags of pineapple slices next
to an open drain.
Almost every bit of this street in downtown
Obalende, a mishmash of rundown colonial buildings and tin roofed
shacks, has somebody walking, standing, sitting down or trading on it.
"We've
never had such a situation before, never had Ebola in a large, densely
populated area like Lagos", said John Vertefeuille, leader of the CDC's
response team for the city. The real problem "is identifying suspected
patients and making sure that we find every contact", he told Reuters.
"That's our priority."
Public education is another essential.
Boyai Sanusi, who runs a bag-making shop on a street opposite the
hospital, was shocked when he heard Ebola was on his doorstep, but
confesses he has no idea how it is spread. "People are afraid", he said.
"They don't know what to do."
David Heymann from the London
School of Hygiene and Tropical Medicine, an expert on the virus that
struck near Congo's Ebola River almost 40 years ago, said Nigeria needed
to overcome the problem.
"They should be making use of every
channel of communication in Lagos, every radio station in every ethnic
language should be talking about this, explaining the symptoms over and
over again", he told Reuters.
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