IBADAN, Nigeria — The severity of a country’s outbreak of COVID-19 is largely measured by its official national statistics. But not only are there wide variations in the reliability of these figures, they can also mask the severity of localized outbreaks in cities and states.
The pandemic response across the globe
In a federal country like Nigeria, the success or failure of COVID-19 control measures often hinges on state governments taking the lead.
“Most governors are ... proactive and are investing state resources in [the] COVID-19 response,” said Chikwe Ihekweazu, director general of the Nigeria Centre for Disease Control. But in a few states, getting a true picture of the pandemic is becoming difficult.
One such case is the southern state of Cross River, which until last week was the only state without a confirmed case of COVID-19 — despite the state chapter of the Nigerian Medical Association sounding the alarm in June about increasing reports of people with “flu-like symptoms, respiratory symptoms and loss of smell/taste in hospitals.”
NCDC has been working hard to ramp up testing capabilities across the country since the start of the pandemic but cannot control who is tested or what happens to the samples. The Nigerian Medical Association is now threatening the health commissioners of Cross River and another state, Kogi, with a lawsuit for allegedly obstructing COVID-19 testing and control measures.
The absence of accurate data across the country limits Nigeria’s ability to tackle the coronavirus. Linked to this, the politicization of the pandemic and a lack of interinstitutional and public collaboration are emerging as key challenges.
Sometimes it is a sense of rivalry or personal pride that leads governors to downplay the caseload of COVID-19 in their state, said Oyewale Tomori, a Nigerian virology expert and World Health Organization adviser. But without more unity and cohesion, the whole country will suffer, he said.
Emerging from lockdown
While Nigeria’s national COVID-19 strategy is being centrally developed, it relies heavily on individual state governments to localize and enforce national guidelines. It is rare for states to actively flout the orders of the federal government but more common for them simply to fail to enforce the guidelines.
In late March, a strict lockdown was imposed in Lagos — where almost 40% of the country’s cases have so far been concentrated, according to the available data — the neighboring Ogun state, and the capital Abuja, requiring residents to stay at home except for essential journeys. In lesser-affected states, lockdown measures varied.
Now, some states are easing restrictions as the country seeks to live with the pandemic and limit economic damage — even though the number of new coronavirus cases continues to rise by several hundred a day.
“The most important tool, as far as the pandemic is concerned, is citizens’ compliance with prevention measures. It is in the hands of all of us.”— Chikwe Ihekweazu, director general, Nigeria Centre for Disease Control
Although the federal education minister has said it is too early for schools to reopen, this has not stopped one state — Oyo — from going ahead with it.
The federal government has also given approval for the resumption of intercity travel, with the first domestic flights taking off on July 8 from Lagos — with social-distancing measures implemented at the airport but not on board the planes.
Government officials admit that reopening most sectors of the Nigerian economy could lead to a rise in coronavirus cases but — in line with the advice of WHO’s Africa office — they say the extension of lockdowns would threaten gains made in other areas, including the fight against diseases such as malaria, tuberculosis, and HIV. Lockdowns have also led to a spike in domestic violence and threatened livelihoods in a context where there have been few measures to cushion the economic effects.
But across Nigeria, the reopening is feeding misconceptions that the pandemic is not real, while also exposing the reality that social-distancing and hygiene measures will be hard to enforce as people get back to normality.
In June, places of worship finally reopened after months of shutdown, with hand-washing stations and space between worshippers in accordance with government guidelines.
But even pastors are skeptical of how long that will last. “When the talking drum came on the loudspeaker [during the service] and the keyboardist and other instrumentalists started a dance tune, I knew my people couldn’t maintain social distance for long. Everyone wanted to dance,” said Pastor Adeniyi Adeoba, who leads a church in Ibadan, southwestern Nigeria.
It is hard to alter some elements of the regular service to comply with social distancing, he said. “During the thanksgiving and child dedication sessions, when everyone comes to the altar to pray for the babies that were delivered during the lockdown, how do you maintain social distancing, and how do you conduct [an] anointing service while maintaining social distancing even though the Bible clearly mentioned laying on of hands?” he said.
Unlike the Nigerian Ebola outbreak in 2014, which was characterized by widespread cooperation with regulations, NCDC’s Ihekweazu noted that the major challenge now is convincing people to take the recommended measures more seriously.
“The most important tool, as far as the pandemic is concerned, is citizens’ compliance with prevention measures. It is in the hands of all of us,” Ihekweazu said.
The steady growth in the number of confirmed cases in Nigeria is an indication of citizens’ low risk perception of the virus, he said.
“I don’t know what else we can do to push the message. I think people just have to look at countries like Italy, Mexico, and Brazil to understand the potential impacts of the virus.”
One approach is a recent decision to introduce precision lockdowns in 18 local government areas that account for 60% of confirmed cases. This primarily affects Lagos state, home to 10 of those 18 areas.
But this strategy only works as far as the local data on coronavirus cases is accurate.
‘If we do our science well, everybody will be promoted’
Genome sequencing — which could indicate variations in the virus as community transmission continues — is another area where cooperation has been lacking.
At the outset of the pandemic, Nigeria’s African Centre of Excellence for Genomics of Infectious Diseases — or ACEGID — rapidly published the continent’s first SARS-CoV-2 genomic sequence from the sample of Nigeria’s index patient. Four months later, that remains the only published sequence from Lagos — the current epicenter of the outbreak, which has had more than 10,000 cases. Despite having one of the highest caseloads in Africa, Nigeria has published fewer sequences overall than the Democratic Republic of the Congo, Uganda, Senegal, Kenya, and Morocco.
ACEGID’s director, Christian Happi, told Devex that those in charge of the COVID-19 response in Lagos have decided not to send samples for sequencing.
“They are keeping the samples. We asked them to send the samples to us for sequencing, but they didn't want to share and I can’t force them to do that. You can’t force people to collaborate,” he said.
Lagos state’s health commissioner did not respond to a request for comment, and Ihekweazu noted that “NCDC does not have the authority to intervene in decisions around research taken by states.”
In the meantime, Tomori, the virology expert, said Nigeria is losing out as important information that might be contained in the sequences from Lagos may not come in soon enough to influence control strategies.
“These are the things that are going on that affect science ... because [people] are not interested in science — [people] are interested in self, self-promotion,” he said. “But the error we make is that if we do our science well, everybody will be promoted.”
Tomori argued that divisions such as these will continue to make the science community in Nigeria less relevant to the needs of the people and less able to contribute to global knowledge about the virus.
“The primary thing should be the country — and not the individual — and the pride of ‘It’s my country.’ That patriotism — making sure that we do whatever [needs] to be done,” Tomori said. “This is still lacking in Nigeria’s COVID-19 response.”