How we treated Ebola patients with no drugs or vaccines – Prof. Akin Osibogun
Outgoing Chief Medical Director of the Lagos University Teaching Hospital (LUTH), Professor Akin Osibogun has revealed that the recent Ebola Virus Disease outbreak in Nigeria was the most chal- lenging national emergency he has had to handle in his eight years as head of the hospital. A former official of World Health Organisation (WHO), the soft-spoken Osibogun also opened up on how his team and other health officials had to treat Nigerians who were infected with the deadly virus with no drugs or vaccines.
In this chat with FEMI BABAFEMI and two others, Prof Osibogun explained that the battle against Ebola became more challenging when some of his staff had to abscond while some were threatened with divorce by their spouses. He spoke further on this and his total turn-around of the fortune of LUTH to a world class health institution during his eight-year so- journ as CMD which ends on October 10. Excerpts:
Having been Chief Executive of LUTH for eight years, do you feel fulfilled?
First, I will like to thank the Almighty God who has been able to uphold me for those eight years. It has not been an easy assignment but through the grace of God, one has been able to record some landmark achieve- ments in the place. I think it is a unique opportunity and I thank my country for giving me the opportunity to serve because there are many qualified people but my country has given me an opportunity to demonstrate my ability and make my contributions to its development.
So, I feel fulfilled. What are those things you have achieved that bring this feeling of fulfillment?
When I became the CMD, I had a clear idea in my mind of what needed to be done in terms of reposition- ing. In fact, in my letter of appointment in 2006, Mr. President gave me the challenge of turning the hospital around in two years. That in itself speaks volume be- cause there was an acknowledgement that the hospital was down and that was why Mr. president demanded of me to turn the place around within two years as clear ly stated in my letter of appointment.
My assessment is that you are running a system and what constitutes a system, you need equipment, you need infrastructure, you need men and women who have capability and you need defined processes to be able to get desired out- comes. So, with that in my mind, I set out as a major objective to revamp the infrastructure and re-equip the institution. I was fortunate that the Federal Government at that point had a reengineering programme for some teaching hospitals inclusive of LUTH.
So, I keyed into that too. Through the Federal Government ARMED engineering programme, we were able to get brand new Linear Accelerator for cancer management and we also got five new operating theatres. So, I quickly keyed into those additional infrastructural projects to in- crease our number of operating theatres to 12. Five from VARMED and then operationalized additional seven, to give a total of 12 operating theatres. For you to get a clear understanding of what that alone meant, you will realise that by 2006, when I was coming in, the National Post-Graduate Medical College, the West Africa College of Surgeons had all withdrawn accreditation to out surgi- cal residency training programmes because our theatres were not functioning and now to rapidly now to have 12 theatres in 12 months, that is our number one achievement.
Apart from the Ebola crisis, were there other major national disasters handled by the hospi- tal under your leadership?
LUTH is uniquely geo-graphically positioned, in a state with a population of about 20 million people and positioned historically because it is the first teaching hos- pital established by an act of the Nigerian parliament. I still concede that UCH has been in existence before LUTH, but UCH was not established by an act of the Nigerian parliament. It was established much earlier when we were still under the colonial rule. Because of our positioning, we have a leadership role to play in the provision of health services, in the development of human capital for health as well as in research.
When we had the case of Ebola, you can see the continued collaboration between the federal institutions and the state governments. Immediately the First Consultant hospital suspected, they contacted Lagos and federal authorities. It was suspicion at that time and they sent the blood sample to LUTH, because we had a system in place, the diagnosis was confirmed as an Ebola case and of course, it changed so many things. We immediately set machinery in motion to contain it. It was like this was war. So, federal and state governments had to work hand in hand, an emergency operation centre had to be immediately established and the different committees which I mentioned earlier on, had to be immediately put in place so we can have a multi-pronged approach to fighting the disease. Of course, the first thing was to try and break the chain of transmission since it is a contact infection. So, if we could identify all the people who had contact with the index case, we may be able to quick- ly contain them and stop the outbreak. So, we have to put foot soldiers onto the field.
Again, Lagos State government quickly recalled five of their LASTMA ambulances, I quickly brought in public health specialists from the hospital to do contact-tracing. We got in touch with FAAN for the manifest of all the people on the flight, we needed information on all the security contacts, SSS, Customs, Immigra- tion, because some of the, got in touch with him. So, we formed a list and we needed to know where they are and monitor them. The fact that they got in contact didn’t mean you have to put them under lock and key but you must know what is happening with them. In Lagos, they have Disease Notification Officers and health officials at local government councils and LCDAs who had to engage, apart from our own teams.
Our teams would go out, identify and then liaise with the Notification Officers and give them a mandate, monitor this patient in the morning and in the evening and at the earliest sign that there is a rise in fever, alert us. We had telephone num- bers. So, once there is a rise in temperature, we had an evacuation team, properly kitted at the centre, who would now go and evacuate the contacts developing the symptoms and all the contacts that developed symptoms that we got on time, all of them survived. So, once we get the contacts at the earliest stages of being symptomatic, we are able to save them.
How was that possible without vaccines or drugs?
We needed to understand what was the pathophysiology of the virus. I mean what it causes in the body. Once there is a high fever, the patient starts losing water, fluid and electrolytes because the high fever drains the fluid. Once there is diarrhea and vomiting, the patient loses even more fluid and electrolytes and the patient starts going down. By the time it gets to the stage that the patient is bleeding, you have lost that patient, because he has lost so much. But if you catch them early and as they are losing the fluid, you are replacing the fluid, not necessarily IV, just put a lot of oral dehydration therapy with the patient and be encouraging him to be drinking it, you are replacing the fluid being lost and got them healed without vaccine.
The pri cipal thing is the fluid and electrolyte power which will buy the body sometime. The body itself is a soldier, fighting the virus, but it is at a disadvantage when it is losing fluid and electrolytes. You also need to encourage the patient, since it was not easy to ask somebody to be drinking, considering there is already fear, panic and so on. So, that is why we add the pyscho aspect to encourage the patient. Some patients may benefit from infusion but those are the extreme, if they start bleeding to see if you could win some of them. But the big lesson which I took away from the Ebola importation into the country is that if we are determined as a people, we will achieve results, and where we work as a team, we will achieve results.
Because you could see where the federal and states worked together with a common objective and leaving politics out of it and allowing the professionals to do their job, we were able to achieve results.
How many can you recall were saved at the end of the whole crisis?
I think about seven survived. I think five visited Governor Fashola recently. I think we also lost about five Nigerians and the index case.
Would the Ebola crisis qualify as the most challenging national emer- gency you have had to handle?
To fully understand the import of Ebola, is to look at what has happened in Sierra-Leone and Liberia. In Liberia, soldiers had to be brought to condone off a whole community and in Sierra-Leone, the whole country had to be shut down for three days.
So, if we had not been pro-active, the story would have been different. A lot of people may be wondering what the noise was all about, it is because results had been achieved. If not so, in a population of 170 million, anything can happen. WHO declared global Ebola emergency because of Nigeria. Immediately the virus en- tered Nigeria, they were like eh, wahala don come o.
It was the most indeed the most challeng ing. I can tell you that one of my staffers for six weeks didn’t go home to his family. We were working because the operation centre was working round the clock and then most of the committee leaders had to be there from morning till night, sleeping at times at 11pm.
Where there people who abscond- ed among your staff during the crisis period?
Not all my staff but the staff that had to go to the centre, number one for tactical reasons, you cant be too active because at that time we were not too sure of what we had in our hands, but we were prepared to take a risk on behalf of our country but you still didn’t want your family to suffer for that risk, so you stayed away from home which means in an event that you get it, you won’t infect your wife and kids. So, I had to quarter them in a safe place in our hospital, from there they would go to the emergency operation centre and return when they finished, all by themselves.
So, it was more like national sacrifice for the country?
Yes, it was a national sacrifice. Well, not all my staff adopted that approach. You know some of these things at times, you have to ne- gotiate with your spouse. I know of a woman who wanted to volunteer and the husband told her, “once you step outside, don’t bother coming back.” Like this colleague of mine who I mentioned earlier, he just told the wom- an, “I have to go and do a job” and they both agreed that okay, just stay back there so you don’t bring anything home. You were in private practice before your appointment.
How did you find public service?
Well, the main difference is that in public service, you don’t have your own time. You don’t own your time, you don’t own yourself. I don’t switch off my phone, I receive calls 12 midnight, 2 am and some of such calls had saved lives. If you switched off your phone, then you miss it. There was a night I got a call from a professor from UNILAG who was in Abeokuta that night. A gentleman was shot in Abeokuta, the professor was there, he called me 12midnight to inform me about the problem. Of course, I knew the Ogun State University Teaching Hospital at Sagamu was on strike, so I quickly gave them that infor- mation, so the only option they had was to manage the patient to Lagos and they said they were going to try. Immediately I called my people, relayed to them the information I got. This is what happens abroad.
They are able to save patients because they have ad- vanced information, before the ambulance is moving, they know which hospital they are going, they would have informed the hospital and the people are prepared. So, our people were prepared and by the time they brought the young man to Idi-Araba, he was operated and he survived.
Are hospitals still rejecting patients with gunshot wounds?
No, I think that is a thing of the past now. Private hospitals, yes, maybe and the rea- son is simple, who is going to bear the cost, but public hospitals, it is a matter of routine, we don’t reject gunshot wounds patients at LUTH. We don’t request for police report. We have a police station which I established with the support of the then Inspector-General of Police. We will treat, stabilize the patient and then inform the police.
Given your experience with contain- ing Ebola, is Nigeria now better-prepared for future challenges like Ebola. My answer is a definite yes, because we gathered a lot of experience. What I think is noteworthy is that when you cooperate or collaborate, you are able to achieve results. Most of the times, we are busy bickering and this Pull-Him-Down syndrome at times, but when you work together, you are able to achieve more. This has also further strengtened the Nigerian health system because the Nigeria Centre for Disease Control, a new organisation that is being set up, was suddenly asked to come and be active.
In its attempt to become active, it has now recognised that it could tap from resources at LUTH, because they are all national resources.
LUTH is a national asset, the manpower there, is national. My resident doctors were also excited that oh this thing truly controls the disease. Before contact-tracing was theory to them but now they did it and it worked and now the WHO is commending Nigeria and they are proud to have been part of it.
Are there plans to recognise the unsung heroes and heroines of Ebola containment?
The way it works is that somebody provided leadership. If the operation failed, that person would have paid the price. Since the operation also succeeds, I will join others to congratulate the person who provided leadership; the Minister of Health, Professor Onyebuchi Chukwu. So, he had to take the credit that he was able to navigate the waters and helped us form this coalition.
We must also recognise the sterling qualities of Governor Babatunde Fashola. He was not sleeping throughout the period and his Commissioner for Health, Dr. Jide Idris who was also busy attend- ing every meeting we called. In fact, at one point, I was the one who advised him to go and rest, because he was not sleeping.
Does Nigeria still need to seek for vaccine help?
There are trial vaccines, but there are no vaccines that have been proven. You must have heard about clinical trials going on in the United States of vaccines and ZMapp is still an experi- mental drug, but there have to be clinical trials. Some people have volunteered now to receive the vaccine, only time will tell which vaccine works and which one does not work, and which drug works and which one doesn’t. But testing a drug in two people is not an acceptable yard- stick in medical practice. We can look at the use of ZMapp, two Americans received it, they sur- vived, one Spaniard received it, she died, another person received it and died and here we have seven people who didn’t receive ZMapp and they survived.
So, what is the role of ZMapp?
Unless and until you have done a clinical trial, you can’t say, which is the stage they are now going. With the global fright, the process of clinical trials of drugs and vaccines is okay. How much of roles did fright and ignorance play in the Ebola saga in Nigeria? The national fright has both its good and bad side. The good side was that at least, it created awareness but where I tried to caution some people with regards to the information they were putting in the press was where it was likely to start leading to unnecessary death because if somebody collapses at the airport, every body runs away, instead of assisting. In fact, there was a day they called the emergency operation centre that one man, a Liberian who had been in Lagos for 19 days, even before Sawyer, he was at the Redeemed Camp for the congress .
I think it was after people like him had arrived that the church announced that people from West Afri- ca should not come but he was already in the camp and stayed there for 19 days. Whether he was doing dry fasting, only God knows, when he was going back, at the airport, the man col- lapsed, possibly due to the fasting and praying. But immediately he collapsed, everybody took off (general laughter).
The man was sitting on the floor because we had photographs our team took when they went there. They then cordoned him off, then we sent an evacuation team. The man survived and he wasn’t Ebola positive but such neglect could cost others their lives out of fear. So, many were brought and quaran- tined without having Ebola? No, the protocol that we used was that if we suspect, we would put you in a ward we created called “Holden Ward”. We hold you there.
That was the one the press was hyping, distracting us that time and frightening the health workers and my health workers started running. But the protocol was that if somebody comes in and you suspect, you move to the Holden Ward and reduce contact. When the thing first landed, we trained a team, these are the people we kitted but everybody wanted to be kitted (general laughter). So they were saying the hospital doesn’t have equipment, doesn’t have kits, but it was not everybody that needed kits. Even those we didn’t ask to treat any Ebola. I already had a team that had been trained for that purpose. So, all I want you to do is indicate your suspicion and send the patient to the Holden Ward and notify us, for us to deploy the team who handled the treatment.
There is even a pro- tocol for sending the blood for test, not every body can send it because if you send it anyhow and it has Ebola, then you get it loosened on the community. So, these people had been trained for the triple layer packaging of the blood for test, before getting it to the laboratory.