Lagos State Commissioner for Health, Dr. Jide Idris, tells ‘NONYE BEN-NWANKWO and TUNDE AJAJA about the deadly Ebola Virus Disease and some other challenges facing the health system in Lagos State
The Ebola virus has been in some neighbouring countries for few months, how come we waited for it to get into Nigeria before we started preparing for it or did we think it wasn’t going to come near us?
We prepared but maybe not adequately, because we thought it would be contained over there. I know that when it started in those countries, we alerted our people by way of sensitising them on what the disease was all about, how it could be contacted and what they should do to prevent it. That was much of what we did. But as a way of standard emergency preparedness in the state, there were certain things that were in place already and nobody ever thought it would come the way it came because it has not happened here before. Perhaps we might say the preparation was not enough which is not unusual in this part of the world since we don’t know the nature of the virus. And then, how it came took everybody by surprise because nobody knew it was an Ebola case when Patrick Sawyer arrived in the country and the man did not disclose. That was why a lot of the people who tested positive were those people who had direct contact with him. It took one or two days before we realised that from the history taken, before he was then isolated. Before now, we had Laser fever, Severe Acute Respiratory Syndrome, Bird flu, which also raised some kind of panic but they turned out not to be as dangerous as when the alarm was raised.
Should we really be scared concerning this Ebola virus?
Well, in a way, yes, because the disease is very infectious and so for that reason alone, we should be scared. It is contagious. However, if you understand the nature of the disease and the simple precautionary measures that should be taken, we will be safe. It is only the health workers attending to the patients and family contacts that are mostly at risk because they are the people who come close to them. If we could take the basic precautionary measures, then the spread could be contained. Unfortunately, we are in an environment where ignorance prevails, rumours are around and people come with all sorts of stories and of course people feed on rumours, so, in most places where this has happened, rumour alone created a lot of panic and that is part of what we are facing. And the earlier we could contain such information, just to stop the spread, the better. If the proper things are properly done, we could reduce the spread a bit. If the health workers actually adopt the normal standard of care they should do, like wearing gloves, wearing face mask before touching anything, which are normal precautions, it will tend to reduce the spread.
Does it mean the affected health workers were not careful enough?
For every infectious disease, there are certain precautionary measures. We later found out from the hospital that the workers did not come out with the full truth initially, if not, probably the whole thing would have been contained in that place, it was later we found out that maybe out of fear, they hid some information from us, until the truth was revealed. For instance, some said they didn’t touch anything or anybody’s fluid, later from hindsight, they said some blood splashed on some.
Some people said we should even be grateful to Patrick Sawyer that it could have been worse if he had come through the land borders where there was no form of quarantine or basic check, do you agree?
In a way, that is right, because if he had landed elsewhere or gone to another hospital it could have been worse. Some of the people that came were his liaison officers who actually assisted him to the hospital. In fairness to the hospital, that first day, they didn’t know the nature of his disease. It was later they did some tests and realised that there was an inappropriate reaction to what they had done, they went back again and took history from his country, Liberia, where there is high suspicion of the virus, before they isolated him. If not, so many people would have even been in contact with him. So, in a way, yes, we are lucky that he didn’t go elsewhere in which case they probably would have tampered with the body and when he died they could have considered autopsy. The first thing was to deal with the body because in burying it, the chances of it spreading was equally high because the virus can spread much faster through the dead body and people may not know.
Beyond the airports, what has the government done to forestall the spread of the virus?
When it happened, the immediate thing was to deal with the body, then the next phase was to do contact tracing of all those people that he had come in contact with, and that was the standard thing. When it happened, there was a rapid response scheme and about five committees were formed. The contact tracing was very essential to get all the people he came in contact with. We have the surveillance team, case management team, public enlightenment, which is very essential and the fifth is the point of entry, which would deal with the seaports, airports and land borders. Those ports are basically the prerogative of the Federal Government and the President has said he is not shutting the borders, and the level of surveillance has been increased, they have sensitised the people and there are a lot of people involved now; immigration, customs, ministry of health, port health, etc, are all working together. What they do is to check the temperature of those coming from those areas, and once it is above the set limit, they put you aside for further investigations. Between then and now, a lot of things have been put in place, such as screening at the airports with emphasis on people coming from the affected countries, which are things that should have been put in place prior to now.
What are your constraints?
In contact tracing, because of the large population that we have and because of the fear of Ebola, everybody seems to be scared, nobody wants to assist, which is a major challenge. It is even more so for the treatment isolation ward. It is a major problem because a lot of people ran away, especially when the nurse died. We have been trying to persuade and re-sensitise them that it is not as bad as they see it. However, we can’t expect them to work there if they are not trained, so we have trainers and CDC experts who will train them on everything they need to know even before they start clinical management. If they are not trained, there are chances that they could catch the infection. We train them and that is why we are asking for volunteers because if those people in the isolation ward are not well managed, they will die. If we don’t do contact tracing, more people may get infected, so those are the challenges, we need more hands. One of the major problems that we are having now is the private practitioners; they don’t want to treat patients because once you say you have fever, they tell you to go away, which is wrong because if they continue to do that, this mainland hospital will be completely filled in no time. So we are trying to get them standard operating procedures to follow which we will pass on to them. If you don’t have a history of contact and you don’t have a history of travelling to those countries, the chances are that you don’t have Ebola. And the medical facilities that we shut down are not permanent, we only shut them down to decontaminate and reopen them later.
How did the state government take the salt and water therapy?
That was nonsense. I heard all sorts of things. Some pastors said they would do spiritual healing. Well, they can do the spiritual, but they should do what we recommend.
What has government put in place as benefits for the volunteers?
To address that, the governor said whatever it is they want, we should pay them including life insurance in case any of them dies as a result of the virus. So, we got them covered. We are already processing the insurance cover for some of our workers who started with them and the ministry of finance is already working on that. Luckily, now, I am told we have a few now who are volunteering, so, treatment has commenced fully there but we could still do with more staff. We are sensitising the Association of Private Medical Practitioners because how do we treat the people when practitioners are running away. Who would treat them, and what moral justification do we have to ask somebody from outside to come and help us when we cannot help ourselves. So, I think it’s more like persuasion now, and letting them know that it is not as terrible as people think if certain precautions are taken.
But we heard that the insurance benefit for health workers in Lagos State is N5, 000. Is that not too poor?
What they were talking about was hazard allowance being paid to normal hospital workers especially those who work in areas that can be called hazardous. It is the standard. It is being paid to all health workers and it is called hazard allowance, which is in addition to what they are being paid. That was what they felt was inadequate which I accept. In this kind of case, I won’t take N5,000. For Lagos State government workers, this insurance is aside from their normal insurance cover as a worker. This is a special one for this, just in case.
Is there any form of insurance for the matron that died or any compensation for her family?
Well, I can’t answer that because she came in at the very late hour when her situation was bad. Apparently, she was at home for a long time without people knowing. As of the time the special and designated ambulance went to call her, it had deteriorated and that was why she didn’t stay for too long in that place. This is the more reason we keep saying anybody who has the symptoms should come out for proper therapy. Well, we will consider that. It is only the people who will treat them that we are looking for now.
Is the death of the matron and the obvious spread not enough to scare people away, more so if they are not aware of the impending benefits for volunteers?
Well, you have a point there. Maybe if we give them incentives, probably they will come out. What we have concentrated on are people who will work to treat them because people who would look for those cases were not coming. I think you are right and that is something we will consider, as an incentive for people to come out. It’s worth exploring, I will discuss with my people.
We hear that even though the infection is not yet in Bayelsa State, they have well over 100 surveillance centres, and in Lagos we have less than three. Why?
I’m not too sure about that. They could have surveillance centres and not isolation centres because they are different. Luckily we already have Infections and Diseases Centre at the Mainland Hospital to cater for those with such infections like HIV/AIDS, measles, etc, and that is why we could use some of the facilities that are there. We are planning to set up in three other locations, which we have started in Ikorodu already. The problem is we have to be sure we don’t mix infected people with non-infected ones. The standard is that you don’t quarantine or isolate unless the person develops symptoms.
What about the overcrowded gatherings everywhere?
As part of the sensitisation, we have gone to the motor parks, market places, local governments, churches, met different stakeholders, and we will even visit schools when they resume. If they don’t understand how this virus spreads, when they have mass gatherings, there is a chance that they are increasing the spread. It’s a give and take issue. You can’t tell them to stop, because if they stop, they go to their houses and you may not even know what happens to them, so let them continue their normal lives but take precautions, and that is what the sensitisation exercise is meant to address. So, the best we can do is to enlighten the people because a lot of rumours are all over the place now and we need to counter them.
Can’t the virus be contracted through the congested commercial buses, BRTs and Molues?
You can only contract Ebola if you have contact with body secretions of an infected person just like sweat. But again, the person who has Ebola that is contagious cannot be in the bus, or play football with you. Rather, the person will be on the bed. If you look at the biology of the disease, they don’t become infectious until they start getting those symptoms and that is when the body fluids can be dangerous. Once they start vomiting, having diarrhoea, they become very infectious. So, that is why once there is fever, bring them out.
The President said public schools should delay resumption because of the virus, is the Lagos State government taking the same stand?
I don’t think so. I’m not too sure the state government will shut those schools. but we are lucky that our students are not in school now. Even though children are more vulnerable, we cannot disturb their programme because of that. But we are going to emphasise proper enlightenment which will focus on the school authorities, parents and the teachers on how to watch out for their children and themselves.
Can this disease be contained eventually?
Yes, it can, if the containment strategies to prevent the spread are well followed, because if you can locate it and prevent people from moving out of that locality, it can be done. That was what they did in Guinea but after a day it went wild because they had to lock out a whole community; no moving in or out until they sorted out who was who. Funny enough, I’m not sure if we have seen any secondary contact yet. It is possible it can be contained if everybody does what he or she is supposed to do. Instead of hiding, people should come out because it is when they hide that they tend to spread it in the community.
Truthfully, is Ebola case not a death sentence?
Ebola is not a death sentence because the mortality rate is between 40 and 90 per cent. If you are caught quickly enough and you are placed under proper supportive treatment, the chances are that you will live because what happens is the virus enters and multiplies; it starts breaking down blood vessels and leaking blood into various places. From there, the person can get shock, organ damage, etc. So, if you can properly manage those or prevent shock or anything that can damage the organ, and they are treated as soon as they are noticed, the chances are that you will live. That is why 10 to 60 per cent survive. The earlier people are brought for treatment, the more likely they will survive. Since there is no treatment or vaccine, it is basically supportive therapy. That is why the emphasis is to keep all the affected people properly treated. We have problems with that but those are the things that are being done at the treatment centre.
If Ebola is not a death sentence, how long can it be managed?
It depends on the immunity level of the patient and the kind of supportive therapy the person gets.
How long will the people under watch be there?
Well, 21 days, if they don’t develop symptoms. I have about 20 now who have completed the 21 days, so they are free, we will write them letters. Those ones did not come to the isolation ward. Those are the people that were being monitored at home. Once they have gone beyond 21 days which is the incubation period, and no disease, they are free to go.
The US government said we won’t have access to Ebola vaccine until 2015, why is government not funding research locally such that our medical experts and personnel can develop some solutions and exert our independence in such matters?
In those climes, it is the private sector that funds research, the government only stimulates or creates the platform or culture. Some universities, especially the top ones, fund research but a large chunk of that comes from the private sector. We don’t have that culture here. That is why Lagos State government created the research fund to stimulate something like that. It’s a perception and in this country, I’m sorry to say, we regard data as not important, unlike other countries where they see information as power. We had some research labs before but they seem to have deteriorated. I think it’s a reflection of the situation of the country. But I know some institutions now are gearing up and they don’t rely on government funding, they look for external funding. They write for research grants and these are the things we need to develop. Because the people who are going to fund you need to see transparency, competence and there must be value in the research you are doing. So, I think it has started picking up again. It used to be there but I don’t know why it stopped but it seems some people are trying to push it.
Is there an assurance that this virus is in no other place in Nigeria apart from Lagos?
I can assure you and that is why the minister called the National Council on health meeting. It is to test the level of preparedness of all state governments. Everybody is on the lookout now, set up their own structures and with our own experience, we shared with them and so no state should be caught unawares.
Is it not high time the state government did something concerning inadequate hospitals, like having at least one general hospital in every local government?
Yes, we agree, and that is the position of the government. But it is dependent on the resources available. We will love to do it, which is the policy of the government. If you recollect where we started from, some local governments did not have any hospital at all and they have now. So, as the resources are available, we build more. Beyond building hospitals, maintenance is an issue, staffing is an issue, which is even much more crucial, because if you build, people will work there, you will pay salaries, compensation, etc, and that is where the huge chunk of money is going. So, you can’t outspend your income and you can budget as much as possible but it has to be backed by revenue. But again, in other climes, a lot of these facilities are built by the private sector, as long as government can put down proper health insurance scheme to cover the people, and that is the way we are going. As it is now, in this environment, people want government to do everything. Though it is our responsibility, we will still try but we have to bring the private sector into this. It is another way of financing it because government cannot finance everything. No country can do that, no matter how rich you are. People want everything done free but it is not realistic. You can only do your best but the problem is setting down proper mechanism. Another thing is funding; until we increased our allocation to capital project and reduced recurrent expenditure, we could not refurbish some health facilities and build new hospitals. The other one is building more primary health care system so that majority of the minor cases can be dealt with over there, which will decongest the secondary health care facilities for them to face the real issues.
The general perception is that the members of staff of most public hospitals are usually very rude and hostile. Why is that?
One of the major problems we contend with is the attitude of staff, and I think it is something that developed over a long period of time. If you want to contain it, it’s like changing behaviour. It is not something you can do overnight, it is more like persuasion again, so, it is a major problem we have, there is no doubt about it. Staff attitude is bad and, I’m not giving excuses for them, but again it could be the pressure or the workload, but then if you say workload, who is doing what, so, that is measurement issue. The doctors will tell you that they are overworked, and if you ask, how much of work they have done that day, you will be surprised. It’s a major problem. What we do is organise seminars, persuade them. We will address the issues as they come. We understand and we have started addressing them.
What is the government doing about the issue of wrong diagnoses in both public and private hospitals?
It is not peculiar to this country, even in developed countries, they have medical errors. It’s a major problem in most countries, it could be worse here, I agree. We are doing some enlightenment and training because we need to get our people to be as current as possible in their various specialties, and that is why we have to send them on courses, register them for seminars and assess them properly over a period of time so that they know that they are doing the right thing. Again, we need to basically address the issue of quality, standard operating protocols, which are things that are not usually done here and these are things we are trying to set up here. It’s not easy. Over there, they monitor how they (health workers) treat cases. Here, it’s not the case. We have to address the issue of access and quality of health care. Access could be financial because a lot of people are poor and cannot afford to go to the hospital.
