Insights from Nigeria: "Fearonomics" of Ebola

Photo_from_Ebola_Center

Published November 12, 2015, last updated on October 5, 2017 under Voices of DGHI

By Dr. Sulzhan Bali, second year MSc-GH student

This post was presented as a talk on November 5, 2015, at the Triangle Global Health Conference in Durham, North Carolina.

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 5,000 miles away from West Africa when I returned to the United States earlier this year from Nigeria for a meeting in Dallas, Texas. 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 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 U.S. 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 four months. Ebola reached three cities, infected 20 and killed eight people in Nigeriaa true success, given that more than 28,000 people were infected across West Africa.

There are many reasons for Nigeria’s successan 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 spread 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 4,000 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 and 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 and 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, many more people in Nigeria died from malaria than Ebola during the outbreak.

This sort of aversion behavior is not limited to people. Thirty-four 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 and CDC. 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 two 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 it the fear of Ebola spreading across international borders that 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 cost 40B US$ worldwide), 80% of the economic damage of Ebola is due to fear. According to the World Bank, Sub-Saharan Africa lost 550M US$ in foregone output to the Ebola outbreak. Liberia, Sierra Leone and Guinea lost 1.6B US$. That's 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 shock”minimize aversion behavior by creating awareness, eradicating misinformation and acting swiftly during an epidemic. All these are areas where public sector and private sector partnerships 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.”

Related News