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Lagos cholera outbreak and what to do about it 15 Jul 2024

On 9 June 2024, the Lagos State Government declared a cholera outbreak in the state, prompting the activation of the Emergency Operations Centre (EOC). As of 12 June, the EOC had reported 324 suspected cholera cases, including 15 fatalities and 40 recoveries. This outbreak is part of a larger national cholera crisis. Since 1 January 2024, the Nigeria Centre for Disease Control and Prevention (NCDC) has reported 1,141 suspected cholera cases across 30 states.

Cholera, an acute diarrhoeal illness caused by ingesting food or water contaminated with the bacterium Vibrio cholerae, thrives in conditions of poor sanitation and where access to clean water are limited. This makes impoverished communities particularly vulnerable.

The cholera outbreak in Nigeria highlights the devastating link between the disease and poverty. It is a stark reflection of the country's worsening poverty and soaring food inflation rate, which has risen to about 40.66% yearly. As a result of higher food prices, many Nigerians are resorting to unhealthy food options, increasing their risk of contracting cholera. With cooking meals becoming unaffordable, people are turning to roadside food vendors, who often prioritise profits over proper hygiene. A drive through Lagos would reveal the proliferation of roadside food stalls, which often operate in unsanitary conditions, with vendors selling food near gutters and customers eating in open spaces.

As fresh, uncontaminated food becomes increasingly out of reach, impoverished individuals often resort to consuming rotting foodstuff, clinging to the hope that thorough cooking will eliminate harmful bacteria. Unfortunately, this is not always effective; the consumption of contaminated food remains a significant transmission route for cholera.

While the NCDC has blamed the outbreak on poor sanitation, personal and environmental hygiene, and lack of access to clean water, it is essential to acknowledge the significant contribution of rising food inflation to this crisis. Data from “The Price of Everything” report shows that the top 30 fastest-rising commodity prices are for household essentials, indicating the severe economic strain on Nigerians. This has forced many to make desperate choices regarding food consumption, exacerbating the outbreak. To drive home the point, the surge in pepper prices has forced households to opt for cheaper, rotten alternatives, further highlighting the desperate situation.

Apart from the high cost of food, access to clean water has become a luxury for many Nigerians. The skyrocketing water prices have forced people to resort to unsafe alternatives like rainwater collection and borehole water. The cost of a sachet of water has increased dramatically over the years, from N5 in the early 2000s to N50 in some areas today. Bottled water, which in recent years cost N50, now sells for N200. Soft drinks have also seen a steep price hike, with a 50cl bottle of Coca-Cola jumping from N200 to N350. As a result, many people turn to cheaper, roadside bottled tiger nut drinks, whose water quality is uncertain, posing further health risks.

Real-life stories from affected communities paint a grim picture. Families often walk miles in rural areas to fetch water from contaminated streams. The onset of the rainy season brings a surge in cholera cases, exacerbating the crisis. Access to pipe-borne water remains a significant challenge, even in urban areas, where supply is often erratic and unreliable. Sometimes, even such water is not purified, and energy poverty means boiling water is not a viable solution. Recently, gas, kerosene, and charcoal prices have increased astronomically.

Alternative sources like shallow wells, boreholes, and open water bodies are contaminated with harmful pathogens, putting consumers at risk. The lack of clean water has severe public health implications, contributing to the spread of waterborne diseases like cholera, typhoid fever, and diarrhoea. These diseases disproportionately affect children under five and vulnerable populations in impoverished communities, accounting for a significant portion of morbidity and mortality in Nigeria.

Another sobering factor is the lack of adequate sewage systems. Nigeria has the highest rate of open defecation globally, creating a breeding environment for diseases. In many areas, human waste contaminates water sources, further polluting water sources. This is compounded by poor waste management, evidenced by an inefficient waste collection and disposal system. It is common to see garbage piles in streets and informal settlements, taking months to be collected by the Lagos State Waste Management Agency.

When waste accumulates, it contaminates water sources during the rainy season, creating conditions perfect for cholera outbreaks. Clogged drains and uncollected waste cause flooding, mixing sewage with drinking water and spreading disease. Despite being a basic necessity, Lagos State does not have an effective waste management system. This incompetence has turned Nigeria into an incubator for diseases that could eventually affect the global population. The high population density in Lagos exacerbates the issue, making it easier for diseases to spread rapidly, and worse, to metastasise.

Nigeria's lack of proactiveness is also a significant challenge. The country has not taken preventive measures despite previous cholera outbreaks in various states in the last three years. For instance, Borno State recorded a cholera outbreak between September 2022 and December 2022. During this period, the state recorded 12,496 confirmed cases with 394 deaths. In 2021, Nigeria had 10,833 suspected cholera cases, with 112 confirmed cases and 289 deaths, and with the most affected states being Plateau, Bauchi, and Gombe.

This culture of mediocrity pervades every aspect of Nigerian life, including individual actions and regulatory standards. Many individuals fail to take extra precautions to protect themselves from water-borne diseases. Some even drink well water without the barest minimum of boiling it, an action that has been proven to kill 99% of pathogens in such water. Rather, too many people in Nigeria rely solely on visual inspection before concluding that water is safe to drink. Many companies selling sachet water operate under poor hygienic conditions, filling sachets with unpurified tap water. This systemic failure is compounded by the lack of public health infrastructure and limited access to medical care.

The health sector in Nigeria faces significant challenges, including a massive brain drain of qualified doctors due to poor wages, living conditions, and access to facilities and equipment. The primary health care system is almost entirely broken, making it difficult to respond to and handle cases like cholera, which require prompt attention. According to SBM Intelligence’s Health Preparedness Index, all Nigerian states, including Lagos, have poor health infrastructure and service delivery, with no state scoring above 40%. In the last index, Lagos, while placing fifth overall, scored only 27%, highlighting the massive gap in the state’s healthcare system.

A multifaceted approach is necessary to address these challenges, beginning with defining the national interest. Unfortunately, the Nigerian elite have shown little concern for the average citizen, believing they will not be affected by the country's problems. This is shortsighted. To put it simply, your house-help or ‘maiguard’ is more likely than not to mix with his or her relatives in the poorer parts of town, and this increases the risk of them bringing exotic pathogens into your exclusive neighbourhood. The Nigerian elite’s shortsightedness and lack of concern stems from the absence of a defined national interest. If the goal is to lift as many Nigerians as possible out of poverty within a specific timeframe, such as ten years, we will see significant progress. However, this conversation has yet to take place.

Investing in water and sanitation infrastructure is crucial for long-term solutions. It is unacceptable that Nigeria cannot provide something as basic as pipe-borne water. Effective waste management is also essential to reduce environmental contamination and limit the breeding grounds for pathogens like the Vibrio cholerae bacterium. Furthermore, comprehensive improvements in public health infrastructure and practices are urgently needed. Community involvement and education are vital to promoting behavioural changes that prevent future outbreaks. While immediate measures can mitigate the current outbreak's impact, sustainable solutions are essential to prevent future occurrences.

Cheta Nwanze is Lead Partner at SBM Intelligence.