In June, Caleb Ezechimere, a young medical laboratory scientist, died barely a month into his internship at the Lagos Military Hospital.
“He had bought some tigernut drinks from a vendor, and everyone who bought from the same vendor ended up in the hospital, but he did not survive,” recalled his sister-in-law, Jaachi Nwagbara, a doctor. how Mr. Ezechimere died of cholera.
“Until now, it is still a big loss. Everything reminds us of him. It was an avoidable death and that is the most painful type of death. “Avoidable deaths from infectious diseases like cholera are unacceptable in the 21st century.”
Photo of the late Caleb Ezechimere when he was inducted as a medical laboratory scientist
As of September 29, Lagos, Nigeria's richest state, had recorded 134 deaths from 4,667 cases of cholera. The state has the highest proportion of cases in Nigeria since the outbreak began in June. Being a water-borne disease, the recent outbreak has been linked to contaminated water sources, particularly unregistered tiger nut drinks, and inadequate water supply, especially in Lagos Island, the epicenter of the disease.
The fact that Lagos has become the hotbed of cholera in Nigeria raises a critical question: what is driving the surge? This analysis examines data on cholera over the years and the persistent problems of inadequate water supply and pollution.
Lagos: tops list for cholera in Nigeria
States such as Zamfara, Katsina, Bauchi, Cross River and Bayelsa were the hotbeds of cholera in Nigeria. However, in the current outbreak, Lagos accounted for 43 per cent of the 10,837 suspected cases recorded in 35 states and the Federal Capital Territory (FCT) as of September 29. Three local government areas (LGAs), Lagos Island, Eti Osa and Lagos Mainland, recorded the majority of cases in the state.
Newslodgereview of weekly cholera epidemiological and situation reports from 2015 to 2024 by the Nigerian Center for Disease Control and Prevention (NCDC) shows that Nigeria experienced the worst cholera epidemic in 2021, with 111,062 suspected cases and 3,604 reported in 33 states and FCT.
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The case fatality rate (CFR), which means the proportion of people who died from the disease among all diagnosed individuals, was 3.2 percent.
That year, Lagos ranked 11th with 2,551 cases and 12 deaths, while northern states such as Bauchi (19,558 cases, 320 deaths), Jigawa (15,141 cases, 517 deaths), Kano (12,116 cases, 368 deaths), Zamfara ( 11,931 cases, 244 deaths) and Katsina (9.20, 9 cases and 238 deaths) topped the list.
In 2018, when a total of 51,675 cases and 1,136 deaths were recorded across the country, no cases were reported in Lagos State. States such as Adamawa, Zamfara, Katsina, Bauchi and Borno topped the list. In 2017, 4,221 suspected cases and 107 deaths were recorded in 20 states.
Of the 23,763 cases and 592 deaths recorded in 2022 in 32 states and the FCT, Lagos State ranked 18th with 47 cases and one death.
However, the NCDC data for 2023 does not include Lagos in the list of 31 affected states, as Nigeria recorded 3,683 suspected cases and 128 deaths.
From January to December 2016, Nigeria recorded 782 and 32 deaths in 14 states, compared to 5,330 cases and 186 deaths in 18 states and FCT during the same period in 2015. Bauchi, Kano, Jigawa and Zamfara were the states with the highest number of cases in both years.
Nigeria reported 4,108 cases of cholera and 71 deaths in 2019, followed by 1,858 cases and 75 deaths in 2020.
Inadequate water supply
With an estimated population of over 24 million, Lagos faces significant challenges in providing safe drinking water to its residents. Despite the efforts of the Lagos Water Corporation and the allocation of N16 billion between 2019 and 2023, inadequate water supply remains a pressing concern.
While some residents have resorted to costly alternatives, such as drilling wells without adequate water treatment plans, others rely on vendors, known as “mairuwa,” who sell water in jerry cans.
In addition to the financial burden, this exposes residents to the risk of contracting cholera and other diseases, such as dysentery and typhoid.
In June, Nkoyo David, a 31-year-old woman who moved from Gbagada to Bariga, suffered severe diarrhea and vomiting after drinking well water because she was skeptical about drinking sachet water.
“I thought I was detoxing. I didn't know there was a cholera outbreak,” Mrs. David recalls. “It took me seven days to recover and I was lucky. “Some people weren’t so lucky.”
Ms. David's experience highlights the consequences of consuming water from unreliable sources. Residents of Adeniji Adele, Onola and Tapa areas of Lagos Island who spoke to Newslodgeexpressed frustration over the water supply.
Collage of two men caught urinating in the Adeniji Adele canal
“I have worked here for more than 10 years and there is still no public water supply. I buy water daily from vendors, which is not clean,” said Abiola Lawal, a trader from Onola.
Rasheed Egbafolorun, a landowner from Onola, also said: “We do not have public water supply; Everyone has to drill their own well. People who frequent the vendors are also at risk of contracting cholera because most vendors do not wash their drums.”
Poor waste management and open defecation practices aggravate the situation. At the Adeniji Adele canal, people could be seen urinating directly into the canal, and nearby business owners confirmed that some people even throw their waste into the canal during rain.
Pollution sources
The cholera outbreak in Lagos raises even more concerns about the city's water quality and sanitation infrastructure. Experts point to various sources of contamination that contribute to the spread of the disease.
Sources of pollution include flooding and poor drainage, septic tank leaks, poor waste management, canal overflows, inadequate sewage treatment, open defecation and lack of sanitation facilities.
According to WASH (Water, Sanitation and Hygiene) expert Mekwunye Kidochukwu, relying on individual wells exposes residents to contaminated groundwater, especially during floods.
WASH (Water, Sanitation and Hygiene) Expert, Mekwunye Kidochukwu
Kidochukwu, a hydrogeologist, environmental scientist and sustainable development consultant, said pollution spreads rapidly through sinkholes, streams, sewers and wells, creating a toxic mix.
“The main problems with the outbreak of cholera and other waterborne diseases are related to poor planning, waste management and the government's failure to provide drinking water to the population.
“Individual wells are not the ideal solution for water supply. It contributes a lot to groundwater pollution. Floods affect the wells, they go into the drainage canals, they mix with the stream, the canal and the well, and it all goes together.
“Until the government addresses water supply and waste management, we are going nowhere; “We will have more cases of waterborne diseases and the cases will increase,” he said.
Lagos, Nigeria's economic center and richest state, faces severe flooding, especially during the rainy season (April-October). During this period, Nigeria experiences an annual increase in cholera outbreaks.
Lagos State President of the Nigerian Medical Association (NMA), Babajide Saheed, said the flooding is aggravated by poor drainage systems and discharge from the lagoon, affecting wells and resulting in contaminated water.
“More than 50 percent of Lagos residents depend on wells. In some areas, they open the septic tank and allow it to flow into the drainage system, which can go anywhere.
“What they call pure water is expensive in Lagos, so people just look for anything to drink. Food vendors also contribute to unhygienic practices,” he said.
Population growth
Kidochukwu said population growth has contributed significantly to the cholera outbreaks in Lagos. The large population puts immense pressure on the state's small land mass, leading to inadequate settlement patterns and increased population density.
“Houses designed for one family now house three, tripling waste generation, and poor septic tanks cannot handle the load. “Some residents connect their drains to gutters, which dump waste into nearby water bodies,” he said.
Lagos tops the cholera cases, while Kano, officially the most populous state, ranks 19th with 809 cases and 46 deaths (as of September 29).
Blocked drain in Onala. Photo credit: Mariam Ileyemi.
Recommendations
Kidochukwu urged the government to prioritize water supply, improve waste management and implement effective water treatment systems.
NMA president Saheed said the government should be proactive in infection prevention and control measures.
“Lagos has to be proactive. The first is education and enlightenment as they used to; The second is cleaning the drainage system. The third is to review the buildings and how they impact free access to the drainage system,” he said.
According to the Director General of the National Institute for Policy and Strategic Studies (NIPSS), Ayo Omotayo, in a presentation at the Lagos 2024 Physical Planning Summit, clean and safe water and comprehensive sanitation services must be part of the strategies to the development of modern infrastructure in Lagos State.
The Lagos State Government recognizes the problem and says it is working to resolve it. In June, the state government activated the Public Health Emergency Operations Center (PHEOC) in response to the cholera outbreak.
The Commissioner for Health, Akin Abayomi, also announced the One Health Strategy, which he said recognizes the interconnectedness of human, animal and environmental health.
Health Commissioner, Akin Abayomi
According to Mr. Abayomi, the activities of the COESIP would include the implementation of the One Health approach through relevant ministries, departments and government agencies.
However, the cholera outbreak also highlights the need to improve epidemic preparedness and infection prevention and control (IPC) measures in the state.
Jaachi Nwagbara, doctor
NCDC recommends access to safe water, adequate sanitation and hygiene practices to prevent cholera. Strengthening disease surveillance and improving IPC measures, as experts like Saheed and Nwagbara suggest, are also crucial to preventing future outbreaks.