INSIGHTS FROM NIGERIA : 'FEARONOMICS' OF EBOLA

The following article is the transcript of my short talk at the Triangle Global Health Conference 2015 held in Durham on 5th November 2015. ​

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The 2011 thriller movie ‘Contagion’ had an interesting tagline ‘Nothing spreads like fear’. Never was this truer than during the recent Ebola epidemic in West Africa.

I witnessed this  ‘fear’ of Ebola more than 5000 miles away from West Africa when I returned to the US earlier this year from Nigeria for a meeting in Dallas. My temperature was normal in Lagos when I left but somewhere in-between, my temperature shot up to 102 degrees. At the hospital, my husband, the nurse, and I were quarantined together in a room. Everywhere that I had touched outside was being bleached. I had just landed from West Africa with high fever, dehydration, and a high heart rate- the horror! I could see the fear in the nurse’s eyes. She was on phone panicked speaking with her family. Forget the fact that Nigeria had been Ebola free for almost a year, and that I had not been in contact with any suspected cases. “You could have been sitting next to someone on the plane”, she said. It took a few hours, and a few calls from the CDC before my husband and I were allowed to leave with the advice to monitor my symptoms at home. If this was what happened here in the US a year after the outbreak, can you imagine what it was like in West Africa during the outbreak?

I can. Over the last few months, this has been an important focus of my research as I evaluated the role of the private sector in Nigeria’s Ebola response. Unlike Sierra Leone, Liberia, and Guinea, Nigeria surprised the world by containing the Ebola outbreak within 4 months. Ebola reached 3 cities, infected 20 and killed 8 people in Nigeria - a success given that over 28,000 people were infected across West Africa. There are many reasons for Nigeria’s success - an established contact tracing method for Polio, clinical governance, swift government action, and a pro-active private sector response. It is a fascinating story that I would love to share with you at some point, but it is not the focus of my talk here today. Today, I would like to speak to you about the ‘Fearonomics’ of Ebola.

Ebola has resulted in immense human suffering. However, the effects of the disease have been significantly amplified by fear and misinformation. In a survey that I conducted in Lagos on the transmission of Ebola, 68% believed that Ebola spread by touch. 23% believed it spreads via air and 28% believed you could get Ebola by eating pork.  Misinformation and fear go hand in hand. In Nigeria, a rumor that drinking salty water prevented Ebola caused almost as many deaths as Ebola. A famous Nigerian preacher claimed to have holy water that could cure Ebola and even sent 4000 bottles of it to Sierra Leone. In September 2014, when a British diplomat collapsed at the airport in Lagos due to a heart attack, no one helped him and he died. You see, a few weeks earlier, a Liberian-American diplomat had arrived in Nigeria. He too had collapsed at the airport. That man was the index case of Ebola in Nigeria. What is ironic is that he had reportedly broken his Ebola quarantine to come to Nigeria to get the said holy water.

However, the worst affected by the fear and stigma surrounding Ebola were Nigeria’s hospitals. This was especially true of the private hospital that was the epicenter of the outbreak in Lagos. Despite the hospital’s reputation and key role in collaborating with international authorities to contain the epidemic, the hospital & its staff were stigmatized.  The landlord evicted the children of one of the infected nursing aides. The fiancé of one of the survivors was sacked from her job. Children of one of the other doctors at the hospital from the hospital were barred from coming to school. Post-ebola, the patient volume dropped by 90% even after the hospital was disinfected & declared Ebola free. A year after Nigeria has been declared free, only 20-30% of the hospital’s patients have returned. In the words of the director of the hospital “it was if they had stepped on a grenade”. One of the doctors from the quarantine center told me how medical peers refused to shake hands with him at conferences. It was this fear of stigma and infection that caused most other private hospitals to refuse to admit or even attend to patients with fever. As a result, much more people in Nigeria died from Malaria than Ebola during the outbreak.

This sort of aversion behavior is not limited to people. 34 countries enacted measures such as border closures and travel bans. A number of international airlines suspended flights to the affected countries against the advice of the WHO & CDC. Almost all airlines stopped flying to Sierra Leone, Guinea, and Liberia, which severely disrupted Ebola containment efforts. Yet, all but one airline, continued to fly to Nigeria. There were 2 main reasons for this: first, Nigeria was too big a market to suspend operations and second, the government in conjunction with private sector acted swiftly to increase confidence.  Ongoing flights protected Nigeria somewhat from the Ebola ‘fearonomic shock' that so badly affected the other Ebola hit countries.

I know what you’re thinking though…wasn’t the fear of Ebola spreading across international borders was what brought Ebola to international attention? Yes- but after the disease has taken thousands of lives, and shoved many more into poverty by affecting health systems, productivity, agriculture, private sector, and investments in the Ebola affected region. Just like SARS (which worldwide cost 40 billion US $), 80% of the economic damage of Ebola is due to fear. According to the World Bank, Sub-Saharan Africa lost 550 million US $ in foregone output to the Ebola outbreak. Liberia, Sierra Leone, & Guinea lost 1.6 billion US $. That is more than 12% of their combined GDP. Yet, these estimates overlook the informal sector, which not only makes a crucial component of their GDP but was also one of the sectors worst affected due to aversion behavior. So, if fear is so bad in an epidemic aftermath, then what is the right thing to do?

The right thing is to mitigate the ‘fearonomic' impact, minimize aversion behavior; by create awareness, eradicating misinformation, and acting swiftly during an epidemic.  All these are areas where public sector and private sector partnership s can go a long way.  Let’s learn from Ebola. After all, as Primo Levi once said, “It had happened. Therefore, it can happen again."