26 January 2016

Nigeria: Lack of Trust in Health Sector - the Underlying Cause of the Large Lassa Fever Outbreak in Nigeria

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Strange deaths in a community in Niger State in 2015 left the community confused, this was followed by a period of uncertainty and anxiety, and they reached out to the only rational explanation they could imagine - the supernatural.

By the time the public health authorities were informed and a diagnosis of Lassa Fever was made, the outbreak had spread to many states. Control efforts included a mixture of persuasion to report suspicious cases to health authorities, establishment of task teams, and even an emergency meeting of the National Council of Health. One patient is reported to have "escaped" the hospital where he was being treated. The community was scared; they did not know who to trust.

The Nigerian Centre for Disease Control is evolving and Prof. Abdulsalami Nasidi has promised that its new Reference Laboratory in Kaduwa, Abuja will be ready for commissioning soon. On a morning television broadcast on the Nigerian Television Authority on the 20th of January he praised the efforts of the seven diagnostic centres in the country and promised to redouble control efforts. Colleagues in the Nigerian Field Epidemiology Training Programme, as an epidemiologist myself, there is little that will make me prouder than a vibrant, professional Centre for Disease Control in Nigeria.

However, the reality of this Lassa Fever outbreak, and all outbreaks that I have worked on in my many years as an infectious diseases epidemiologist have taught me that while epidemiology and diagnostic capacity are important components of health security, the most important line of defense may not be improved technology or quicker response times by my colleagues - epidemiologists, virologists, clinicians or surveillance officers.

The single most important factor in the control of outbreaks is trust in the health care system by the citizens of a country. A great "Centre for Disease Control", is worth very little in the context of a public health care system that is largely dysfunctional, which its citizens do not trust.

A lack of trust would not have prevented a few cases of Ebola emerging, but it was at the centre of the exponential spread of the Ebola outbreak in Liberia, Guinea and Sierra Leone, and at the heart of the challenges we faced during the response that I participated in, on the ground in Liberia. The need to focus on building trust in communities, and with their health care system is the most important lesson that I learnt from the response to the Ebola outbreak. A lack of trust in the public health care system is the most important reason the current Lassa Fever outbreak continues to spread.

The most likely transmission mechanism for the current Lassa Fever outbreak is person-to-person transmission. While rats are the likely source of initial infection, it is extremely unlikely, given the geographical distribution of cases that there is any on-going zoonotic source of infection. Therefore, to break the chains of transmission of the Lassa Fever virus, people must trust the health authorities enough to inform them of any signs of illness and not seek alternative sources of relief. Those infected and affected must trust that the healthcare workers' that they report to will treat them and care for them humanely in the presence of overwhelming historical evidence to the contrary.

When a potential Lassa Fever patient declines to go into a primary health centre or hospital for care, this is often described as "irrational" and "illogical" behavior. Yet in the past the same healthcare workers have often failed to care for his child who had severe malaria, or failed to prevent the death of a sister following child birth? How could he be expected to suddenly trust the same health care worker that was never in his/her clinic all these years when he needed them?

When this outbreak is over, the most likely scenario in Nigeria will be the re-start of the celebratory mode of the post Ebola period, rather than a period of introspection and retrospection. We will make speeches and pat ourselves on the back. However, this 'outbreak narrative' fails to capture the complexity of the underlying factor, trust, which I believe is largely responsible for the rapid spread and failure of initial control attempts of this outbreak. If we continue business as usual, we must expect the next outbreak pretty soon.

The most important line of defense for us in Nigeria is to rebuild our confidence in the capacity of our government to prioritize the health to its citizens. This will require a complete turnaround in our health systems' capacity to respond to the "routine" health needs of a population. It is only by responding to these in "peacetime" and building trust, will we have the capacity to respond better to the next crisis. Trust in our health systems will not prevent outbreaks (outbreaks of infectious diseases will always be with us), but it would most likely have prevented large outbreaks like the Lassa Fever one that we are experiencing. To do this, we need the Nigerian government to earn the confidence of its citizens in their ability to serve their interests and protect them.

As an infectious disease epidemiologist, my career has been built around measuring infectious disease burdens, determining trends, assessing risk factors and measuring the impact of control measures; this is my comfort zone. But I have learned that not everything that can be measured matters - and not everything that matters can be measured.

Trust exemplifies this. When a society loses confidence in those to whom they would normally turn to in times of need, they resort to actions that can be generally considered "irrational" and illogical" and unwittingly spread the disease further. Recognising this limitation has changed the way I view the relevance of my profession in the context of outbreak control. Learning from and applying this knowledge will be the most critical challenge of the post Lassa Fever outbreak period.

Nigerians want their existing primary health centres to work. Only when trust is restored in the capabilities and compassion of the public health system can we hope to prevent large outbreaks from occurring. Restoring trust in existing primary health centres is much more important today than building 10,000 new ones.

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