Cholera crisis in Africa – the situation in Nigeria


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Courtesy of OpenStreetMap

In my post about the Cholera outbreak in Cameroon, I mentioned that the suspected cause of the current situation is infected people fleeing the violence taking place in Nigeria (mainly related to Boko Haram). There are a large number of cases in Nigeria (both historical and current) and it’s worth taking a look at what’s going on.

Since the beginning of 2014, there has been a large number of reported cases. I have to stress that they are ‘reported’, as some may not go to hospital for one reason or another. From my previous posts about Nigeria, I have noticed that some of their organisations have problems with statistics too. The Assessment Capacities Project report that (as of August 2nd), there has been 24,683 cases. This outbreak started in Bauchi State, where there were 15,500 cases. As of July, the threat in that state has ended.

However, it is ongoing in other areas. In Kano:

“We have recorded 16 deaths from the cholera outbreak in the past six days, which has so far infected 701 people with 20 severe cases,”

Those are the words of Surajo Alkassim, from the ISMA Medicare Initiative. However, it’s worth noting that Abubakar Labaran Yusuf (the state’s health commissioner) has announced that there have been 6 deaths from 46 reported cases. I would normally trust the government statistics, but I am inclined to believe what ISMA said, based on the government’s past problems with information. They are also dealing with cases on the ground, whereas the government may only be getting periodic updates. There is still a substantial difference in the numbers of reported cases though. ISMA has warned that the current outbreak could become a “pandemic”.

There are many examples of other cases in other states too. I mention Kano because it has one of the worst historic records with Cholera in Nigeria. Perhaps the sanitation and water supply is particularly bad in that area. Cholera is a disease which causes an infection of the small intestine and is spread by e.g. problems with the water supply.

Historical outbreaks

Source of figures – The WHO Global Task Force on Cholera Control

As I have mentioned, this isn’t the first time that Cholera has been present in Nigeria. In fact, it started around the same time as it did in Cameroon (1970/71). As you can see from the graph above, the number of reported cases has varied greatly and a couple of the years have seen noticeably more reports than the current outbreak. You can’t just look at the cases though. They might show the scale of the outbreak, but improvements in medical care and treatments mean that the CFR (the fatality rate) has gotten much lower over the years – and stayed at a relatively low level.

In 1971, there were 22,931 cases and 2,945 deaths. This means there was a CFR of 12.8%. The outbreak in 1991 had a similar CFR. Treatment definitely improved though because in 2010, when there 41,787 cases, but only 1716 deaths. This meant the CFR was 4.1%. The 2011 outbreak had the lowest CFR yet (3.2%). I should mention that part of the chart is from February to October. The World Health Organisation’s Health Statistics tell me that there was 23,377 cases for the whole year. The CFR won’t change that much though.

The affected parts of Nigeria for those outbreaks were (states, unless otherwise stated):

  • 1991 – Kano, Akwa Ibom, Bauchi, Niger, Oyo
  • 1999 – Kano LGA (not Kano State), Tofa (Kano), Adamawa, Edo
  • 2001 – 18 LGAs
  • 2002 – Kano
  • 2007 – Obi LGA (Benue State), Guma LGA (Benue)
  • 2008 – Eastern states
  • 2009 – Eastern states
  • 2010 – 222 LGAs in 18 states (Borno, Bauchi and Katsina were most affected)
  • 2011 – 195 LGAs/25 States

I have no information for the 1971 outbreak, although that was some time ago. ‘Eastern states’ could mean the likes of Borno, Bauchi and Adamawa (see the map at the beginning of this post). It’s interesting that the most recent outbreaks aren’t necessarily larger in terms of numbers of people, but they are more spread out across the country. Perhaps this is an indicator that people are more mobile nowadays. It could also mean that some sanitation has stayed the same or become worse, due to lack of investment.

It’s worth comparing the country to Cameroon. They share a border and recent Cameroonian cases have been caused by people from Nigeria. The first outbreaks were around the same time and their biggest outbreaks had roughly the same number of cases. However, Nigeria’s was the biggest of the two and in one year, whilst Cameroon’s was from 2009-2011. Nigeria’s biggest CFR was 12.9% (1991), but Cameroon’s was worse with 15% (1971).

The state of Nigerian healthcare (and related infrastructure)

As I have previously mentioned, Cholera can be caused by poor sanitation. In 2012, only 31% of Nigerians had access to what is known as ‘improved sanitation’ (e.g. toilets with flushes and sewer systems). This was in comparison to the relatively good 62% in Cameroon. However, many of the Nigerian cases are in rural areas, where access to this type of sanitation is even more limited. Investment in this is affected by ongoing Boko Haram-related violence (remember that Nigeria is one of the biggest economies in Africa).

When you consider that the population in 2012 was 168,833,776, that meant 47,273,457.28 didn’t have the capability to flush a toilet. This was the equivalent of 74% of the population of the UK in 2012.

In terms of aid provision, 23.74% of the current UK aid budget for Nigeria is given to healthcare. However, none of it is directly focused on Cholera or sanitation.

Medical services can be corrupt and it’s a serious issue when their are big outbreaks and pandemics. It can seriously affect treatment and the CFR. In 2013, 85% felt that corruption had increased in some way in Nigeria. 41% of people felt that medical services were corrupt or extremely corrupt. However, only 9% of people reported paying a bribe to someone in that sector. It’s worth noting that it’s much worse in Cameroon.

In terms of health and primary education, Nigeria ranks 146 out of 148 nations in 2013/14. This was a factor in giving them a Global Competitiveness ranking of 120/148.

This is bad, but it’s worth noting that Nigeria isn’t the only country to have these problems.

Finally…

It would be great if the Cholera crisis got more media attention. As I have said before, Ebola is dangerous. However, Cholera is just as bad (if not worse).

Nigeria has suffered from this disease for many years and it has affected neighbouring countries. There is no clear sign that the problem will be come negligible any time soon, despite improvements to treatment over time. This is because there are serious and long running issues with investment and infrastructure that need to be addressed.

There is a Presidential election early next year. Hopefully the winner will do something.

So, what do you think?

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