Pockets of cholera outbreaks are routine in parts of the states and often nipped in the bud before they turn epidemic. But the recent interplay of poverty, poor sanitation, unaffordable cost of food, the stark absence of sanitation and hygiene infrastructure is fast pushing the spread beyond remedial efforts, with a major epidemic already on the cusp. As underreporting and difficulty in establishing causal relationships between food contaminations, resulting illnesses and deaths thrive, experts recommend improvement in oversight from government regulators around food safety to curb reduced productivity, increased healthcare burden, as well as deaths, IJEOMA NWANOSIKE and FELICITAS OFFORJAMAH report.

Somewhere in the Agege area of Lagos State, 19-year-old Shedrach Ochuko, approached a popular middle-aged woman selling fried potatoes, yam, bean cake, and others in the neighbourhood. Ochuko, a sales boy, was on an errand to buy N500 worth of fried potatoes and yam on behalf of the boss.

“Anytime my boss is hungry, that’s where we buy something light for her to eat. But that day as I was waiting for the yam on fire to get done, I saw the sweaty woman inserting a fork inside her bra to scratch her itching skin. It was the same cutlery she deployed in picking pieces of yam for her customers.

“I was stupefied and I didn’t even know whether to collect the paid sum, or forfeit same, and thereafter let my boss know why I did not buy food from the woman. But I eventually bought what I was asked to buy for my madam,” he told The Guardian.

At the Tanke part of Ilorin, in Kwara State, an elderly woman was busy picking used pet bottles near a dumpsite. Findings later showed that the bottles were soon deployed to package Zobo and blended tiger nut drinks – both locally produced beverages for sale to unsuspecting members of the public.

These and many other scenarios present a succinct picture of why the health challenge is of alarming proportion in the country and a little wonder that Lagos and parts of the country are battling one of the worst cholera epidemics in modern times.

Internal medicine practitioner at the Federal Medical Centre, Abeokuta, Ogun State, Dr Olusina Ajidahun, said cholera is on the increase because poverty levels have also increased due to inflation, and people can no longer afford three square meals.

“As things are getting more expensive, people no longer have access to basic amenities including water,” Ajidahun said.

For instance, sachet water used to be sold at N5. It is now N100 for three sachets! “Someone who cannot do this would drink water from a river or other unsanitary sources. And we know that people readily defecate in rivers. So, this kind of disease can spread easily due to poverty.

“This is also an indicator of the poor state of our health indices. Specifically, it shows that we are doing poorly, health-wise, to still be having cases of cholera outbreak in 2024 when there is famine, war or drought,” Ajidahun said.

Cholera epidemic on the prowl
THE clear and present danger that cholera poses to the country, which is on the cusp of declaring a state of emergency on the disease, is looming larger by the day if revelations by the Nigeria Centre for Disease Control and Prevention (NCDC) are anything to go by.

Transmitted through food, water, faeces, and fingers among others, its major drivers include, inadequate wash infrastructure, challenges of open defecation, and flooding associated with climate change, which leads to flooding, and ultimately contamination of water sources. Added to this, is the jostle for just any available food in a country where the hunger quotient is upswing.

Cholera is an acute diarrhoea infection caused by ingestion of food or water contaminated with the bacterium, Vibrio cholera. And at the root of its spread, is the failure of governments to provide adequate water sanitation and hygiene infrastructure. Largely associated with the rural poor, and the economically downtrodden, the soaring rate of multi-dimensionally poor Nigerians, therefore presents the likelihood of things going south if the situation is not swiftly arrested.

Despite efforts to control it, cholera has remained a major public health challenge in many developing countries, including Nigeria, where the major cholera in history was recorded in 2021 with over 106,000 cases, and over 3,000 deaths.

Be that as it may, since its maiden appearance as an epidemic in 1972, intermittent outbreaks have been recorded, including the latter part of 2010, which was marked by a severe outbreak that began in the North and then spread to the other parts. It left in its wake, about 3,000 cases and 781 deaths.

Despite being preventable and easily treatable, Nigerian children have continued to suffer from the potentially fatal disease.

However, from January 1 to June 13, 2024, the country has recorded 1,141 suspected cases of cholera, with 30 deaths in 30 states, but that figure grew to nearly 1,300 cases as of yesterday – Thursday, June 20.

As the country gets into a race against time to contain an epidemic, the scenario is further complicated by the prohibitive cost of living, which has forced a greater majority of Nigerians to devise ways of staying afloat in an economy that appears to be defying prescribed medications, and also showing no signs of healing soon.

According to the centre, 10 states: Bayelsa, Zamfara, Abia, Cross River, Bauchi, Delta, Katsina, Imo, Nasarawa and Lagos presently bear 90 per cent of the burden in the country.

With Lagos as the epicentre of the disease, the state Commissioner for Health, Prof. Akin Abayomi in identifying the strain in the state, said that it was highly aggressive and contagious, with significant potential for widespread dissemination.

A timely caution from the United Nations Children’s Fund (UNICEF) to the Federal Government was to ensure that the outbreak is not allowed to spread to schools.

Poverty, poor sanitation, rising food costs as triggers
ENOUGH appears not to have been said of the causal relationships between food contaminations and resulting illnesses and deaths. This perhaps explains why to commemorate the 2024 World Food Safety Day, the World Health Organisation (WHO), and experts called for the transformation of food systems to make food safe, healthy, and sustainably produced for all.

With a high prevalence of food-borne illness due to a range of factors, Nigeria as a developing nation as well as the most populous nation in Africa has enormous challenges connected with food safety culture. This makes food safety a critical issue, but little to no attention is paid.

Research has also shown that food safety culture is a complex subject in the country due to its heterogeneous and diverse nature, as demonstrated by its over 250 ethnic groups. As the country becomes more urbanised and incomes continue to fluctuate at robust rates, only a handful of Nigerians are conscious or concerned about food safety.

For instance, a study done by the Food and Agriculture Organisation (FAO) of the United Nations revealed that an estimated 2.5 billion people eat street food worldwide every day. Appreciated for their unique flavours, convenience, and for being inexpensive, they are frequently seen as a serious concern to the public’s health especially because of improper food handling.

According to FAO/WHO, foodborne illness is responsible for 420,000 preventable deaths yearly, with high prevalence factors like poor food handling practices, inadequate food safety regulations and enforcement, and a lack of awareness about food safety. The groups also reported that children under five years of age carry 40 per cent of the disease burden.

Studies have further shown that street food vendors in the country adopt poor hygiene and sanitary practices, even as up to 60 per cent of food vendors prepare their foods in unhygienic environments, fail to dress appropriately as well as fail to store leftovers properly. Above all, their sheer lack of basic knowledge and training in hygiene poses serious health risks to Nigerian consumers.

Sadly, this burden of food-borne diseases to public health and the economy has often been underestimated due to underreporting and difficulty in establishing causal relationships between food contaminations and their consequences.

Experts, therefore, recommend improvement in oversight from government regulators around food safety. They also noted that to produce and provide safe, secure, and nutritious food, consumers and food businesses must abide by a set of shared values known as food safety culture.

A public health expert and an associate professor at Lagos State University Teaching Hospital (LUTH), Dr Adeyinka Adeniran, told The Guardian that the level of poverty and increasing cost of food at present constitutes a major reason people do not care about the safety of what they eat.

“Poverty, high cost of foodstuff is putting a whole lot of people into a situation where they just have to work with what they know they can get. Before now, people could still go to the market to buy food and get what they needed to cook, but currently, as someone told me, it is cheaper to patronise roadside vendors than to cook in your house; I don’t know how true that is,” he said.

The don explained that there is poor regulation of food safety in the country and as a result, anyone can simply decide to sell food anywhere, and nobody questions the safety of the food, or whether the vendor has been certified accordingly.

He said: “Because of poor regulations, people can just wake up and cook from wherever they are and start selling to people on the streets. Although we have some local government task forces trying to see how they can curtail this, I am not sure such efforts are successful. So, we still have these food vendors all over the place.

Food vendors are supposed to have ‘code handlers screening’ at least twice a year to check them for certain infections, we call it food-borne diseases like typhoid, hepatitis A or E, but most of them are not checked, and a whole lot of them may be carrying a lot of food-borne infections, and at the end of the day those that patronise them pick up these infections.”

Speaking on the consequences of eating contaminated food leading to food-borne diseases, Adeniran mentioned said diseases like dysentery; typhoid, hepatitis A&E, and cholera can cause immediate death, especially among children below five years of age due to underdeveloped immune systems.  “The major issue that we should be concerned with as public health experts are food-borne infections and some of these infections are epidemic, increasing among the populace.

He added that chronic anaemia and night blindness are some of the long-term effects of food-borne infections due to their accumulation in the body. “The long-term implication especially when we continue ingesting these parasites is that they start eating up blood in the body causing chronic anaemia over a long period. Other implications include micronutrient deficiencies, which can result in scurvy, rickets, and even night blindness amongst others. There are a lot of problems associated with this even though it may not be visible immediately especially in children and could affect their brain development too.”

A nutritionist, Maduabuchi Chinazo Sylvian added that reduced productivity at work and home is one of the consequences of contaminated food consumption, stressing that getting sick from eating contaminated food increases the nation’s healthcare burden since it is something that can be avoided or prevented.

“The first long-term consequence is reduced productivity. If a mother has eaten contaminated food and she has been employed by the government, she has left a vacuum in her office space, reduced productivity at work, and reduced productivity at home, which means that she will not be able to take care of the children properly and that has reduced human capital, affecting the nation at large. These children, if she dies, are going to have less basic care and less childcare. It also increases our healthcare needs because this is something that can be avoided.

‘Innovating’ with dangerous substances to beat cost puts lives, food safety at risk
Findings by The Guardian revealed that street food vendors are increasingly using transformer oil to reduce the amount of money spent on groundnut or vegetable oil. They do this by combining the transformer oil with vegetable oil to fry chips, yams, beans cake, chicken parts, and other finger foods to maximise profits.

Polychlorinated biphenyls (PCBs) are industrial compounds produced between 1929 and 1979. Its physical characteristics and lack of flavour or fragrance are comparable to those of regular vegetable oils. Because of their toxicity and potential health risks associated with exposure, they were outlawed in the United States.

Nonetheless, many African nations still utilise transformers and other electrical equipment that contain PCBs.

Transformer oil has been used for cooking by certain food vendors in African nations and Nigeria is one of them. It’s cheap, sometimes even free, and because of inflation and other economic pressures, many vendors

Regrettably, PCBs can lead to non-communicable diseases like cancer and are quite dangerous. It also has deleterious effects on the neurological, endocrine, and immunological systems. Furthermore, pregnant women and nursing mothers are especially vulnerable since it can be transferred from mother to child through the placenta or breast milk and result in birth defects, developmental disability, harm to the growing brain, and increased susceptibility to diseases.

Also, in a bid to save time and satisfy mounting demands, some food vendors are tempted to adopt unhealthy methods to make food cook faster such as using analgesics, including paracetamol tablets to tenderise meat, or adding nails to a boiling pot of beans to make it soften fast.

The use of paracetamol to soften meat had been popular in canteens and eateries but the poisonous effect was bothersome to those who are aware of such practices.

According to the National Institute of Health, “Acetaminophen (paracetamol/APAP) is one of the most popular, relatively cheap, and ubiquitous over-the-counter drugs that induce serious toxicity challenges when misused.”

They further revealed that “acetaminophen (paracetamol) during cooking hydrolyses into a toxic compound known as 4-aminophenol, which damages the liver and kidney, and results in organ failure.”

A consultant Nephrologist at the Lagos State University College of Medicine, Prof. Olugbenga Awobusuyi, had warned that the abuse of pain-relieving drugs could result in kidney damage.

Saying that it could affect blood flow to the kidney, the consulting nephrologists stated that food vendors and other individuals who have developed the habit of preparing meat with paracetamol should be educated.

“It is wrong for people to use paracetamol and other pain relievers to cook or soften meats. When pain relievers are abused, it can damage the kidneys. I think such a thing is practised in isolation, but we have to educate them on the hazards and ensure they understand the effects on the liver, kidney, and intestine. We don’t know how many tablets they put in their soup to make the meat in it soft, nor do we know how much of it goes into the body of the patients or individuals. What we know is that using pain relievers to cook or soften meat is bad,” he added.
Other harmful substances used as tenderisers include kerosene, tyres, potash, detergents, or cleaning agents (to accelerate the fermentation of cassava, or to make fufu among other things) are used to speed up the cooking process in restaurants and eateries.

Keeping casualty figures low with improved personal hygiene, early warning mechanisms, others
FOR a public health physician at LUTH and the Public Relations Officer of the Association of Public Health Physicians of Nigeria (Lagos branch), Dr Blossom Maduafokwa: “Cholera is a disease that is a respecter of persons; it respects personal hygiene and sanitation. So, the reason we see this outbreak, this time, is because cholera usually happens around the rainy season when sources of water are contaminated by infected materials that are washed into it by flood and the rains.”

In a city like Lagos, she said: “When you get to the markets, you see people washing fruits and vegetables with water that is from questionable sources. Sometimes, traders can inadvertently wash vegetables with water that is infected with cholera, and their customers buy them and can get infected through that process.

“Personal hygiene is very important, so people should frequently wash their hands with soap and clean water. Wash your hands before and after you eat, and after using the toilet. That way, you protect yourself and others around you. If you are unsure of the source of your drinking water, boil it before drinking. Also, when you want to eat fruits and vegetables or anything raw, make sure you wash them with clean water. If you are unsure, peel off the skin. Furthermore, communicate with people around you so that they will also be aware of what to do as a community to discourage open defecation, and ensure that we have proper sanitation facilities.”

Prof. Emmanuel Aguwa, a public health physician with the University of Nigeria, Nsukka (UNN), and an honorary consultant at the UNTH Enugu told The Guardian that poor sanitation accounts for the major reason cholera is flourishing in the country.

“A child might have diarrhoea, and you think it is like any other. Then, you clean up the child without washing your hands. You are indirectly getting infected from the bacteria that caused the child’s diarrhoea if it is cholera,” Aguwa said.

While advising Nigerians to stop eating uncooked foods and vegetables for the time being “because you don’t know where they are coming from, and the hygiene practice of the people peddling it,” he added: “Wash your hands as frequently as possible, maintain appropriate hygiene, be sure of the sources of your drinking water, and if you are eating outside, you have to be sure that whatever you are eating is well-cooked.”

Aguwa also recommended a reduction in the consumption of uncooked foods like soaked garri, Abacha, vegetable and fruit salads “because you don’t know where they are coming from. The easiest way to get infected with food poisoning is through salad. Wash your hands as frequently as possible, maintain appropriate hygiene, be sure of the sources of your drinking water and if you are eating outside, you must be sure that it is well-cooked,” he said.

The United Nations International Children’s Emergency Fund (UNICEF), while responding to the outbreak in Lagos and other parts of the country, noted that recurrent cholera outbreaks critically affect children and populations at large.

Specifically, the Chief of UNICEF, Lagos Field Office, Celine Lafoucrier, explained that outbreaks underscore the urgent need for improved access to clean water and sanitation in many areas.

“Despite the state government’s efforts to provide water to its population, the current outbreak demonstrates the need for an urgent government focus on ensuring the water provided to the population is clean and risk-free,” Lafoucrier said.

The UNICEF chief who noted that under-fives are the most vulnerable and are prone to severe dehydration and higher mortality rates, said that addressing the challenges of cholera outbreaks requires a deliberate focus on state policies to provide high-standard water and sanitation facilities, as well as strengthened healthcare systems capable of responding to demand in times of outbreaks, and state-led educational campaigns on cholera prevention to protect children and the population at large.

“Ultimately, access to clean water and sanitation is critical in preventing outbreaks. Communities must take collective action to ensure clean water access and maintain good hygiene. Identifying and empowering positive role models within the community can encourage the widespread adoption of healthy practices,” Lafoucrier added.