- Written By: Chikwe Ihekweazu with Vivianne Ihekweazu
- Reviewed By: Patrick Okigbo III
The book offers a compelling account of Nigeria’s struggle against COVID-19 through the Nigeria Centre for Disease Control (NCDC) lens. It provides an insightful look into the challenges faced by the NCDC as it navigated a complex landscape of health crises, limited resources, and bureaucratic hurdles. It highlights the institution’s growth, resilience, and lessons from the pandemic. Through personal anecdotes and institutional analysis, the authors provide insights into the evolving role of public health institutions in crisis management and nation-building. It is a detailed case study and a reflective narrative of Nigeria’s evolving healthcare landscape.
NIGERIA’S “HANS BRINKER” MOMENT
Contextualising “An Imperfect Storm: A Pandemic and the Coming of Age of a Nigerian Institution” by Chikwe Ihekweazu with Vivianne Ihekweazu
The American author Mary Dodge published her novel Hans Brinker in 1865. Chapter 18, “Friends in Need”, recounts the story of a nameless Dutch boy who noticed a small leak in the dike while walking home one evening. Realising that a small leak could eventually lead to a catastrophic flood, the boy stuck his finger in the hole to stop the water from flowing. Despite the cold and discomfort, he stayed there all night until adults found him the following day and could repair the leak properly. Dodge didn’t give the heroic boy a name, so he is sometimes called the “Hero of Haarlem” or Hans Brinker. But I have jumped ahead. Let me start from the beginning of our story. We will come back to Hans.
Only God Can Save Us Now
January 2020 started slow and ended bleak. Something was happening in Wuhan, China, but despite the stoicism of Dr. Tedros (of the World Health Organisation), it soon became evident that the world had little control over the rapidly spreading coronavirus. By the end of that month, many people had to make critical decisions.
My family faced a similar dilemma. In March 2020, I attended an energy conference in Miami while my wife was on a consulting engagement in Sudan. Our kids were home with their ageing grandmother. We knew we had to cut short our trips and barely made it back before Nigeria’s airspace went silent.
Our return to Nigeria was not a vote of confidence in the system. However, if one must die, it would be best to do so on one’s bed. We knew that the country had only 0.4 physicians for every 1,000 people and high mortality rates. Our fears worsened when China built a 1,000-bed hospital in ten days in preparation for the virus. How many African countries can match this feat even in a year?
The projections were scary. While some analysts suggested that Africa’s hot climate would kill the virus, others, mainly from Imperial College London, saw the casualties in the millions. Hence, negativity bias took hold as we considered Nigeria’s densely populated cities, crowded public buses, open markets, and packed places of worship. As hopelessness turned to despair, Nigerians turned to God for succour.
Luck as Strategy
But did Nigeria have a strategy for the gathering storm? There must be a plan; after all, the government defeated the dreadful Ebola virus. But did it?
Here is the Ebola story. Nigeria had its first case when a Liberian arrived with the virus in July 2014. Serendipity took him to First Consultants Medical Centre, where Dr. Ameyo Adadevoh decided to quarantine him for further assessment. That decision saved Nigeria. By the time the government declared the country Ebola-free in September 2014, only eight deaths occurred, four of which were health workers who had treated the patient. Sadly, Dr. Adadevoh was one of them.
Unfortunately, government officials mistook luck for strategy. Instead of reflecting on how Nigeria dodged a bullet, they competed to take credit for beating the virus. Hence, Nigeria was not fully prepared for the COVID-19 pandemic, and most countries were not.
Nigeria’s case was precarious, given the overall fragile state of its healthcare system. For instance, by the end of 2019, Nigeria spent only $70 per person on healthcare, about half the average in lower-middle-income countries. It spent less than one percent of its Gross Domestic Product on its health system, which is significantly lower than the 5 percent recommended for achieving universal health coverage.,
The consequences of underfunding Nigeria’s healthcare are severe. At the start of the COVID-19 pandemic, Nigeria had only about 0.5 hospital beds for every 1,000 people, compared to South Africa, which had 23 beds per 1,000. Likewise, according to a 2005 study by Chikwe Ihekweazu, Ike Anya, and Enyinnaya Anosike, about 40 percent of Nigerian medical doctors emigrated within ten years after graduation., The situation is worse in the rural primary healthcare centres marked by poor service quality.
Would Nigeria’s luck hold against the coronavirus? The prognosis was terrible as countries with better healthcare systems were already struggling to cope. The worst part of this ordeal was the realisation that no cavalry was charging into town to save us.
Nigerians needed someone to interpret science honestly and tell us what to do. Yet, according to a Gallup poll, Nigerians had the lowest trust in their government at the start of the pandemic. This is a scary situation, as a 2022 study showed a strong correlation between low levels of government trust and higher infection rates. Who will they trust?
Enter Chikwe Ihekweazu, the founding Director General of Nigeria’s Centre for Disease Control (NCDC). He walked onto the stage and restored trust in a nation gripped by fear. His impressive educational and professional background inspired confidence. However, what won people over was his transparent communication about the pandemic numbers and his composure under pressure. His dexterity in navigating Nigeria’s political and bureaucratic corridors reinforced this trust. His respect and network within the international community facilitated a multi-donor response.
An Imperfect Storm
The book, “An Imperfect Storm: A Pandemic and the Coming of Age of a Nigerian Institution” by Chikwe Ihekweazu with his wife, Vivianne Ihekweazu, offers a compelling account of Nigeria’s fight against COVID-19 through the lens of the NCDC. It provides an insightful look into the challenges faced by NCDC as it navigated a complex landscape of health crises, limited resources, and bureaucratic hurdles. It highlights the institution’s growth, resilience, and lessons from the pandemic. Through personal anecdotes and institutional analysis, the authors provide insights into the evolving role of public health institutions in crisis management and nation-building. It is a detailed case study and a reflective narrative of Nigeria’s evolving healthcare landscape.
The book chronicles Chikwe’s unexpected journey from pursuing clinical medicine to leading the NCDC. It traces key events in Chikwe’s life and career, emphasising his focus on epidemiology and infectious disease control, which led to roles at the Robert Koch Institute, the Health Protection Agency, and the National Institute of Communicable Diseases, including his experience with the 2014 Ebola outbreak in Liberia.
Despite his extensive international experience, Chikwe had to contend with running a Centre for Disease Control with a capital budget of less than a million dollars at the time. Other challenges included establishing the agency’s legal mandate and navigating a federal structure that lacked constitutional clarity in healthcare responsibilities. From his early days at NCDC, while fighting a Lassa Fever outbreak, he focused on expanding and motivating the staff, digitalising surveillance systems, improving laboratory capacity, and enhancing communication channels.
The author emphasises the importance of partnerships in Nigeria’s successful response to the pandemic. He emphasises partnerships with other national public health agencies for funding support and extensive knowledge and experience sharing. He also highlights local partnerships with other Nigerian government agencies. However, he credits the relationship with the general public as one of the most significant wins from the pandemic.
The Coalition Against COVID-19 (CACOVID) and the Alliance for Epidemic Preparedness and Response were effective public-private partnerships. He pointed out the flaws in the global solidarity around equitable access to COVID-19 vaccines, with many low-income countries experiencing significant delays in receiving their vaccines.
Having made haste while the sun was out, NCDC was ready to activate its emergency operations centre, expand testing capabilities, prepare treatment facilities, and develop public health messages to address rising anxiety and stigmatisation when the coronavirus got to Nigeria.
But Chikwe was also lucky. At the pandemic’s start, he had his wife, Vivianne, who provided unofficial communication support to NCDC. As the Managing Director of Nigeria Health Watch, an organisation focusing on health communications and advocacy in Nigeria, Vivianne had the resources and network to develop health communication strategies and disseminate communication materials quickly. This support proved invaluable in spreading accurate information, countering misinformation and quack remedies, and garnering public trust.
As they say, everything with a beginning has an end. Hence, it was bittersweet for the Ihekweazus when Dr. Tedros of the WHO offered Chikwe an opportunity to lead a new WHO Hub for Pandemic and Epidemic Intelligence in Berlin. It was undoubtedly not an easy decision for a family with such deep love of country to leave for a new opportunity. The book conveys Chikwe’s pride in NCDC’s progress. It reflects on critical decisions and demonstrates his commitment to continue to serve Africa from a global stage.
“An Imperfect Storm” addresses broader challenges in Nigerian public institutions and the need for dedicated leadership. Ultimately, the author expresses hope for Nigeria’s future and emphasises the importance of rewriting the nation’s narrative.
Is the Leak Plugged?
When Chikwe arrived at NCDC in 2016, he saw the cracks in the dike. He knew the dike would not hold against an intense deluge. So, like Hans, he stuck his finger in the hole and went to work. He focused on the foundational need to transform NCDC into a model public institution. This was the finger-in-the-dike moment. He relied on his network and found some “friends indeed.” Hence, the dike held when the storm came, as imperfect as Nigeria’s preparation was.
Is Nigeria wiser after the Ebola and COVID-19 challenges? Does the country have a well-considered strategy and programmes to prepare for the next storm? Of course, the question is not if there will be another storm but when it will come.
Chikwe and Vivianne posit that the foundational structures are in place. They are proud of how, in five years, NCDC and its partners strengthened Nigeria’s public health capacities and built trust with Nigerians. By 2021, NCDC was one of the world’s most respected public health institutions, receiving accolades from various sources and being cited as a prime example of public health security best practices.
Chikwe is optimistic that NCDC will continue to prosper. He says, “watching NCDC staff thrive has been like watching a beautiful flower bloom.” However, he acknowledges the difficulty of reforming public institutions in Nigeria. Indeed, the challenges are formidable.
Building successful public organisations, especially in countries with weak institutions, requires knowledge of what works and what doesn’t. How can current leaders access this knowledge when past leaders have failed to document their experiences? It’s no wonder Africa is stuck in George Santayana’s loop: we fail to remember the past, mainly because we fail to document the experiences, so we are condemned to repeat the same mistakes.”
Africans should commend Chikwe and Vivienne for writing this book, “An Imperfect Storm.” They have gifted us ringside seats on how a poorly resourced public organisation held back a deluge because they were conscientious enough to stick their finger in the leak even before the clouds started to gather.
Hopefully, this labour of love will encourage discussions on what is required to build successful African public institutions. I strongly recommend this book to anyone seeking to understand Africa’s public health space and experiences transforming public institutions.
(Patrick Okigbo III is the Founding Partner of Nextier)
