Lagos
THE GLOBAL EPIDEMIOLOGY COMMUNITY is relatively small and tight-knit. Even those who see each other as rivals are cordial and close; where other academics blow disagreements over theory out of proportion, those who spend their time in the field fighting ghastly diseases cannot help but see the good in their colleagues. The death of Sheik Umar Khan, his illness apparently so mismanaged by global health authorities, enraged those who had known Khan—and, importantly, those who had been urging the World Health Organization (WHO) to stop dragging its feet and declare an emergency months earlier.
But while so many in the medical community were pulling for Khan, another potential disaster, a cataclysm that would make the outbreak in Sierra Leone, Guinea, and Liberia look tiny by comparison, was threatening about a thousand miles away. On July 20, the same day Khan felt sick enough to ask colleagues to draw his blood, Patrick Sawyer arrived in Lagos, Nigeria.
Lagos is Africa’s largest city, the commercial capital of Africa’s largest country. It is home to more than 20 million people, some of whom live in slums with a population density of 50,000 people per square kilometer.1 Its population is highly mobile, both internally and externally. It is an international city in the way Freetown, Conakry, or Monrovia are not; Lagos’s Murtala Muhammed International Airport serves international destinations from London to Johannesburg, Istanbul to Madrid to Nairobi—and Atlanta, New York, and Houston. Nigeria’s oil and mining industries bring international businessmen from across the globe to Lagos, where they mingle with those who live in crowded slums. In other words, Lagos is not only the perfect petri dish for a virus that spreads from person to person through physical contact, it could also be the launching pad the Ebola virus needed to go from local epidemic to global pandemic.
“The last thing anyone in the world wants to hear is the two words ‘Ebola’ and ‘Lagos’ in the same sentence,” Jeffrey Hawkins, the U.S. consul general in Nigeria, said in 2014.2
All Lagos needed to become Ebola’s launching pad was an index case. And to many in Monrovia’s airport on the morning of July 20, Patrick Sawyer, a Liberian American lawyer scheduled to represent Liberia’s Ministry of Finance at a conference, looked suspiciously like that index case. Even before he boarded the plane, he looked obviously ill; footage from a surveillance camera showed him lying facedown in the terminal’s waiting area. He refused to shake an immigration officer’s hand, a sign he knew he was sick. On the flight to Lagos, he vomited. He vomited again in a private car on the way to a hospital, after Nigerian immigration officials diverted him at the airport in Lagos. Sawyer insisted he had malaria, or something similar; after all, he had not come into contact with any Ebola patients back home in Liberia. Malaria is not transmitted person-to-person, so several nurses did not bother to take precautions when checking him in.
At the hospital, however, Dr. Stella Ameyo Adadevoh suspected her patient was lying. After twenty-one years on staff, the veteran physician knew what she was seeing, and she knew Sawyer had something far worse than malaria.
She was right. Weeks before he traveled, Sawyer had cared for his sister, Princess Nyuennyue, who had arrived with her husband and her brother at Saint Joseph’s Catholic Hospital in Monrovia in early July; her husband told doctors at Saint Joseph’s that she was suffering a miscarriage. Sawyer had paid $500 to get his sister into a private room; while the medical staff worried the woman might have Ebola, Sawyer helped her change clothes.3
Princess Nyuennyue died on July 7 or 8. Sawyer, who worked as a consultant to the mining company ArcelorMittal, told his employers the next day that he had had contact with his sister. The company reported the contact to the Ministry of Health, which ordered Sawyer not to travel until he was no longer an infection risk.
Saint Joseph’s itself suffered drastically. Brother Patrick Nshamdze, the hospital administrator, died August 7, buried in a mass grave that included fifty-two other victims. Seven other staff members who treated Brother Patrick also fell sick.4 (One was Father Miguel Pajares, a seventy-five-year-old Spanish priest. He was evacuated to Spain, where he received a full course of ZMapp. The experimental drug did not work.) Weeks after its first Ebola case, Saint Joseph’s, the oldest hospital in Liberia, shut down.
Before the twenty-one-day incubation period was up, Sawyer began to feel feverish. He was hospitalized on July 17, though he left the hospital, against his doctor’s orders, a few days later. By July 20, he showed up at the airport for the flight, which connected in Togo, determined to deliver a lecture at the economic conference he was to attend in the Nigerian city of Calabar.5 It is not clear why Sawyer decided to defy his travel ban. His boss at first acknowledged approving Sawyer’s travel, then later reversed himself and denied issuing permission.
But while Nigeria could have provided Ebola’s vault to the global stage, officials at all levels had done something those in Sierra Leone, Guinea, and Liberia had not: they had prepared. If Africa’s most impoverished countries were an illustration of what happened when the global health system stumbled, Africa’s most populous nation, perhaps the most potent powder keg on the continent, would become an example of what happens when the health system works as it is supposed to.
With the outbreak raging out of control a thousand miles to the west of Nigeria, the major regional hub, Nigerian health officials were keenly aware of two very strong likelihoods: first, there were enough commercial and cultural connections between Nigeria and the three West African nations that it was almost impossible to screen every traveler coming by plane, boat, or bus across their borders. Second, they knew if the Ebola virus was going to spread globally, it would likely spread by way of Lagos.
Onyebuchi Chukwu, Nigeria’s minister of health, demanded his staff be ready in the event of an ill patient. Health-care workers across the country, and especially in the poorer neighborhoods of Lagos and the capital Abuja, were given crash courses in detecting a possible Ebola patient and in protecting themselves if and when that patient walked through their doors. The training was by no means comprehensive, but it was far more than health-care workers in West Africa had received.
The nation had other advantages, too: Nigeria, unlike the three West African countries that had suffered the brunt of the Ebola outbreak, has something approximating a modern health-care system. Nigeria’s oil wealth makes it the richest country in Africa, and some of that wealth had gone toward building medical capacity that would now become crucial to stopping the virus before it got out of hand. The country’s leading health experts also knew how to respond to outbreaks on grand scales. Though they had no experience with Ebola, Lassa was endemic to the region; that virus got its name from a small town in northeastern Nigeria, near the border with Cameroon. International organizations like the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) had spent decades fighting disease around Nigeria, making the Westerners in space suits known quantities both to federal and state governments and to the people they would be working to protect. Managed properly, the skepticism that international aid organizations faced in Liberia, Sierra Leone, and Guinea would not be a problem in Nigeria.
In those first hours after Sawyer landed, before most Nigerian officials realized they had their first Ebola case on their hands, they caught two crucial breaks. When Sawyer arrived on July 20, he had quickly been identified by immigration officials as a potential risk. Those officials had diverted him to a medical facility. The first break was that he had been allowed to fly at all. Had Sawyer arrived by bus, a more common mode of transportation through countries in West Africa, had he breezed by immigration agents, or had he been diverted to a public hospital, the index patient might have sparked a global catastrophe.
The second twist of good fortune appeared, on its face, as a stroke of incredibly bad luck. The day Sawyer landed, medical staffs at public hospitals were on strike. But that turned out to be a cloud with a bright silver lining: instead of being taken to one of Lagos’s major medical facilities, where thousands of patients and poorly trained health workers could have been at risk, he was transported to First Consultant Hospital, a small, privately run facility led by Dr. Adadeyoh.
Three days after arriving at the private hospital, Sawyer’s blood tests came back. Adadeyoh was startled, but not entirely surprised, to find that her suspicions had been correct all along: Sawyer had Ebola. The patient was less accepting of the diagnosis. Sawyer was irate. The doctors had gotten it wrong, he screamed. He insisted that he be allowed to leave. He pulled an IV line out of his own arm, spraying blood tainted with billions of Ebola virions around the room.6
Adadeyoh was pressured to free her patient from two other altogether more surprising sources: the Liberian Ministry of Finance and the Liberian ambassador. They both demanded that Sawyer be freed, first to continue on to the conference in Calabar, then finally, just to return home. Sawyer wanted to travel much farther than Liberia. His wife and children were waiting for him in Minnesota. Adadeyoh continued to refuse.7
In Abuja, news that Sawyer’s blood work had come back positive set off a mad, but orderly, scramble. Chukwu’s Federal Ministry of Health, CDC’s Nigeria office, and the national WHO outpost, led by Dr. Rui Vaz, declared an Ebola emergency that same day the results came in. CDC director Tom Frieden, traveling in rural Kentucky and struggling to maintain a cell phone signal, tracked down Babatunde Fashola, the governor of Lagos state. “Governor, if you don’t control Ebola, it’s the only thing you will ever be remembered for,” he warned.
Within hours, an Incident Management Center opened its doors to oversee the response. The center operated like a war room, dispatching dozens of teams to track down everyone who had come into contact with Sawyer, keeping tabs on those contacts, and mounting an aggressive public relations campaign to let Nigerians know: Ebola is here, but we are on it.
The contrast with the outbreak that began in Guinea could not have been more stark. Medical officials near Meliandou had not even suspected an outbreak had begun until two months after the toddler Emile had fallen ill. By that time, dozens had died and dozens more were infected. In Nigeria, officials knew they had their first Ebola case within seventy-two hours of his arrival.
The contrast was stark, but it wasn’t entirely an even match. Nigerians had decades of experience tracking down disease—which meant the populace had years of experience with the medical system that was now mobilizing to save them. Just two years before Ebola arrived, Nigeria had stepped up its efforts to eradicate polio, which was still endemic to the region. The government had been aggressive and innovative: The program used satellite-based global positioning systems (GPS) to ensure that children living in remote villages were vaccinated.
Then, the Ministry of Health had opened an Incident Management Center to track the fight against polio. Now, many of the same people who worked in the center reprised their roles as virus hunters; the deputy manager of the center during the polio campaign was promoted to manager. The same GPS that had been used to track villages where children were vaccinated against polio were now used to keep tabs on the growing list of those who had contact with an Ebola patient, who would need to be monitored for three weeks. Nigerian health officials opened a makeshift Ebola treatment unit in just fourteen days, twice as fast as anyone else had been able to open a new facility.
The center operated as the hub from which separate spokes branched out, all working together to stamp out any chance the virus might have of escaping their ever-contracting web. Separate units oversaw the response’s strategy and coordination campaigns; one was dedicated to case management, another to infection control. A media and public affairs team handled social mobilization, alerting community leaders of the virus in their midst and helping those communities build response strategies. A team of scientists oversaw any necessary laboratory services. Another team managed every point of entry into the country.
Each played a well-practiced role. The social mobilization team worked to spread as much information about Ebola as it could and to reduce the stigma of contracting the disease. (Ending the stigma, as West African officials came to learn, was critical to identifying the extent of any outbreak: if people are scared of being ostracized by their communities, they won’t come forward to be treated.) They personally contacted residents in about 26,000 homes.8 The team charged with watching ports of entry kept a vigilant eye out for anyone else who might carry the disease with them, checking temperatures of everyone who crossed into Nigeria, by plane or bus or boat. The strategy team organized shipments of protective equipment to health care centers around Lagos, then organized trainings for medical personnel.
Others worked with the media, traditional and religious leaders to teach them about the science of Ebola—the ease of transmission, the importance of getting early treatment, the danger in caring for a sick family member or preparing a body for burial following traditional guidelines. Traditional and religious leaders had worked with government officials on the polio vaccination program two years earlier. A parallel public relations campaign, broadcast over radio and television airwaves, featured prominent actors from Nollywood, Nigeria’s growing and hugely popular film scene.
Most crucial were the tracers, those dispatched to find anyone who might have been infected by Sawyer. Forty epidemiologists and 150 staffers trained in the art of contact tracing fanned out across Lagos. They hunted down passengers from Sawyer’s flight, the immigration officials who had stopped him, airport personnel, the driver who brought him to the hospital, any nurses or technicians or doctors who might have come into contact with him at the hospital. They searched through slums, where many of the houses had no street numbers. Any home or vehicle or public space that might have been contaminated got a thorough hosing with virus-killing chemicals.
Tracing Sawyer’s contacts and the contacts of others who came down with Ebola made a massive difference. In West Africa, Ebola had spread undetected through several successive generations of victims before contact tracers arrived to identify those at risk. The aggressive contact tracing in Nigeria meant that anyone who was infected would be identified, isolated, and treated as quickly as possible, severely curtailing the number of others they might infect in turn. Second-generation spread, a key metric epidemiologists track in any outbreak, was far lower in Nigeria than it was in Sierra Leone, Guinea, or Liberia.
Even under the high-quality care of a private hospital, it was too late for Sawyer. He succumbed on July 25, just two days after his blood work came back positive. But the contact tracers were still hard at work, identifying seventy-two people with whom Sawyer had had contact between the time his plane landed and his lab results came back positive. Anyone who showed symptoms was immediately moved to an isolation ward, their blood shipped across town to new high-tech facilities at the Lagos University Teaching Hospital for testing. If Ebola was in their blood, the patient would be transferred to an equally high-tech treatment center.
In spite of the Nigerian government’s quick action, Sawyer had managed to spread the disease. And as in West Africa, health-care workers once again bore the brunt of Ebola’s toll. Eleven of the twenty people who would eventually fall ill in Nigeria were health-care workers. Nine of those people had contracted the disease before Sawyer’s blood work came back.9 Many did not understand how they had gotten sick.
“I never contacted his fluids. I checked his vitals, helped him with his food,” nurse Obi Justina Ejelonu wrote in a post on Facebook. “I basically touched where his hands touched and that’s the only contact. Not directly with his fluids.” She was among the nine who got sick after treating Sawyer before his diagnosis came back.10 So was Dr. Adadevoh. The veteran physician, the anchor of the private hospital, died August 19.
The tracers found another 279 people who had contact with others who got sick in Lagos. Just one victim managed to slip the net by flying west to Port Harcourt, Nigeria’s main oil port. That patient, who left to seek medical treatment from a private physician, infected three others, including the physician, who died after two agonizing weeks, on August 23.
Again, tracers dispatched by the Incident Management Center went to work canvassing Port Harcourt. They were startled to find that the doctor had come into contact with hundreds of people in the ten days between his initial contact with his patient and his development of symptoms. Eventually, the number of contacts in Port Harcourt rose to 526—more than enough to set off an explosive outbreak in another densely populated city. Tracers kept close track of all 526 people for the three-week incubation period. Incredibly, only two got sick.11
By September 5, little more than a month after Sawyer’s death, the last of the twenty cases of Ebola Nigeria would experience was diagnosed. Eight of the twenty patients had died, while the final patient walked out of Lagos’s Ebola treatment center nineteen days later, on September 24, with a clean bill of health. On October 20, forty-two days—or two incubation periods—after the final case was confirmed, WHO officially declared Nigeria to be Ebola-free.
The spread of Ebola to one of the world’s largest cities represented the worst nightmare of epidemiologists and public health officials around the globe. But while other cities might not have been ready, in Nigeria the officials had been unusually prepared to defend Lagos. The preplanning—made possible by smart investments in a solid foundation of public health and prior efforts to stamp out disease through an organized campaign—left Nigeria with a blueprint for beating back an epidemic. Every player, from the minister of health Onyebuchi Chukwu to the contact tracers walking Lagos’s slums, knew exactly what they were supposed to do, and none tried to delay or deny the virus’s presence. Incredibly, the contact tracers from the Ministry of Health, and another team from MSF, tracked down all but one of the 894 people who had primary contact with an Ebola victim in Nigeria.12
“That was the moment of maximum terror,” the CDC’s Frieden recalled later. “It was literally days from being out of control. [Ebola] would have been all over Lagos, all over Nigeria, all over Africa for months and years to come. This was the moment at which the world was on the brink of a catastrophe.”
The city, the world, caught its share of breaks: that public hospitals were on strike limited the contacts Sawyer could have; that a sharp-eyed immigration officer spotted the ailing man. But without the years of preparation and groundwork Nigeria had laid, those bits of luck would have been but drops in the bucket. The fast action from Abuja to Lagos and Port Harcourt demonstrated how to handle an outbreak effectively enough to minimize danger, both to a crowded country and the world. They were lessons that those in Liberia, Guinea, and Sierra Leone—not to mention the World Health Organization itself—would learn from in the coming months.