Infectious Disease Control in Nigeria with Sade Ogunsola, FAS

• Ogunsola and Murphy met in 2004 when Murphy was the Nigeria country director for PEPFAR and Ogunsola was running a HIV/AIDs clinic in a slum on Bar beach in Lagos. They developed a partnership that has lasted since that time. 
• During her time as provost of the college of medicine at the University of Lagos (she was the first female provost in Nigeria), Ogunsola  worked with Murphy to establish first biomedical engineering department at the University of Lagos.
• During her career Ogunsola has played major roles in pandemics and outbreaks in Africa such as Ebola and COVID-19. She was involved in setting up the Nigerian Society for Infection Control. 
• During the COVID-19 pandemic Ogunsola said Nigeria had systems in place to respond early to the threat. They implemented masking before many other countries did. 
• Despite the devastation and death COVID caused in the West, it was not that severe in Africa. Ogunsola theorizes that many of the people who could have been vauklerabel in Nigeria were protected because their immune systems are exposed to so many more viruses than people in the West. 
• She also said there is no congregate care for the elderly in Nigeria. They live at home with their families. She thinks that helped keep elderly Nigerians safe from the virus. 
• Ogunsola says partnerships with Northwestern University and other universities in the U.S. and Africa have made it possible for more biomedical research and grants coming to the University of Lagos. Now many faculty and students are securing their own funding for research and clinical trials and she expects more to follow.

Rob Murphy, MD (00:06):

Welcome to the Explore Global Health podcast. I'm Dr. Rob Murphy, executive director of the Havey Institute for Global Health here at Northwestern University Feinberg School Medicine. As we have all discovered during the past two years, despite the resources and wealth of any country, managing a pandemic is extremely challenging. Today we are going talk about innovative programs and systems in place in resource limited settings in countries that are proven to be effective in preventing and controlling infectious diseases, such as HIV and AIDs. Joining me to discuss this topic is professor Sade Ogunsola, former vice chancellor, the University of Lagos in Nigeria and professor of clinical microbiology at the college of medicine at the University of Lagos. Just a note Sade is located in Nigeria, and it was a bit more challenging to record her audio for this podcast. So you may have to turn your speakers up slightly welcome Sade.

Sade Ogunsola, FAS (01:03):

Thank you very much.

Rob Murphy, MD (01:03):

Let me start by saying how we met. So we met approximately in 2004 when I was the inaugural country director for Nigeria's PEPFAR program. And PEPFAR stands for the president's emergency plan for AIDs relief, started under George W. Bush and Nigeria was one of the big recipients of that, that early program. Really, that's how we started at the time, Professor Ogunsola here was running a clinic on Bar beach in Lagos, maybe. Uh, Sade you could tell us a little bit about that setting.

Sade Ogunsola, FAS (01:39):

Kuromo is a huge slum in, uh, Lagos on the beach and it's actually was a settlement for people who had been displaced from another slum that was cleared, and it was actually quite a rough place. There were lots of commercial sex workers. There were a lot of rough types, but I got to meet them. And it's interesting that to find that the humanity in everybody, and no matter how rough a community is, however, they also had a high rate of HIV. You could almost say it was endemic there. And I realized that it was important to work with this group of people. They were very vulnerable. I met them one Sunday because there was a missionary working with them, a Nigerian pastor. And he said, why don't you come to Kuromo and meet the people? And I did. And just getting there, you could see the evidence of people who had aids, shingles. There was many, you know, dermatomes people with really fungal infections of the toes, you know, just almost classical. And so we decided that was somewhere I would like to work. Well, then it was the Bill and Melinda Gates, um, foundation that was, uh, that started that it continued with PEPFAR. And we set up a clinic on beach and set up a family clinic as well as HIV, because there was no care that we services, you know, it just grew. Then PEPFAR came and we started treatment. And also because it was such a rough area, we couldn't do surgical procedures at all. We couldn't deliver babies there. And so we connected with the primary health center that was not too far away. We were able to help to renovate their delivery room. And so we helped and started HIV services there. And then we went to another hospital because the patients go there. I, I sort of followed my patients and by the time we were done, I think we had set up HIV clinics in about six primary health centers and two large centers. And then we also set up a TB clinic in a major, uh, general hospital. So it was really a, an interesting time. And, um, the impact of having the kind of funds to do this was life changing for many of them.

Rob Murphy, MD (04:08):

Amazing. And you had quite a trajectory from that point at the University of Lagos, college of medicine, and working with, uh, the HIV and aids program there. Then you helped me when you became provost, the first female provost in Nigeria, provost of the college of medicine. And we set up the first biomedical engineering department, uh, at the university of Lagos in your decades, working now in academia and medicine. What was your biggest challenge? Either personally or professionally.

Sade Ogunsola, FAS (04:37):

That challenge was writing a research grant very first time. It was the first time I had written um, a major grant. I mean, I write proposals, but they were not, usually they're not for funded research and they were not competitive and I was young and you know, you don't have the systems in place, like you have. So that was a major challenge. And just being able to write that grant meant I had to overcome a lot of my fears. And I think I brought that to the grant because when we're doing the mentor research, I understood why people were not writing grants. It wasn't a lack of ability, but a fear of failure. And so when we, I did that, it was, I had pushed a boundary. I had overcome something that held me back. The other was actually coming female provost. The college of medicine has the existence for 50 years. it's one of the first five universities in the country. You voted for, by your peers. And the first time a female had applied for that, I think she got four votes. She didn't get very far. I had never really thought about applying for that because I'd never seen a woman there, there were no role models to, and somebody said, you can do it. And I thought, anyway, I did try. And that is a long story, which I wouldn't want to bore you all with, but I had to push the boundaries feeling funny about being the female, the only female, wondering if I could handle sort of the pushback that you get when you're female in a position they were only other men. And there was quite a bit of that during the campaign, but in the end, I think what worked for me were really some of my academic work. I, I pulled people with me, you know, I, I had lots of people that had sort of worked with, with me in the Kuromo, had worked with me as in, when I was setting up the reference laboratory. I had students, I had colleagues that had participated in things we were doing. And I think all those things sort of came together. Needless to say, I won. I remember there was a newspaper article that was written about breaking glass ceiling.

Rob Murphy, MD (06:58):

Well, you certainly, uh, smashed that one. I understand you were a founding member of the Nigerian Society for Infection Control in 1998. Can you tell us about that?

Sade Ogunsola, FAS (07:09):

In Africa we have lots of epidemics. We also have lots of outbreaks. We felt we needed to advocate for it to become institutionalized and for it to be something that was part of our routine healthcare. And there were people who were trained, particularly in infection control. And so we set up the Nigerian Society for Infection Control. We had training also to start putting together groups of people that could be part of outbreak management, both within the hospital and community outbreaks. And it's grown. We, at that time, it was the Nigerian Infection Control Association. It's later change to the Nigerian Society for Infection Control and presently, we it's still growing. I'm on the board, now recognized in the country. They've done quite a lot of they involved with, uh, writing policies and so on. So infection control is now growing in the country really exponentially. And it's had some major times during the Ebola epidemic, for example, many members of the Nigerian society for infection control we part of the outbreak. And COVID, they're, they're there again front and center. So it's, it's been a, it's been a successful story and, but there's still so much work to be done.

Rob Murphy, MD (08:31):

Let's go back to the Ebola because I was working in west Africa in Ebola and Mali fortunately they only had eight cases. Didn't have to suffer too much like neighbors in Guinea, Conakry, Liberia and Sierra Leone. I remember when that first case of the person coming from Monrovia to Lagos who got sick. And I remember, wow, Ebola is and Lagos. I mean, Lagos has over 20 million people. Everyone was just like shaking in their boots. Is this gonna take off in a city that size? Can you tell us a little bit about that? Cause I know you were involved in that.

Sade Ogunsola, FAS (09:07):

Yes. And I remember that morning. I was provost. We were having a meeting, we got a call and one of the people who was going to investigate it was, uh, was around the table and said, I just got a call. They think there might be Ebola in Lagos and everybody went silent. So, he went to the lab and they were able to show that it was a filovirus. That was how far we, you know, within our college, it was a college of medicine where identify and before it went on for confirmation, but we don't have filoviruses. I mean, we've never had Ebola, Nigeria. I knew that they were going to be doing some, you know, mobilization. So I remember phoning Nigerian Center for Disease Control, but I was available because I had worked on Ebola. I'd been deployed to Uganda before for Ebola. And so I sort of took time off from being provost for us to start working to stop this. Our greatest fear was for community transmission to occur because Lagos is dense, in some places it's about 50,000 people per square kilometer. We didn't want to contemplate it. And it, it was a horrible time because more people died from the fear of Ebola than died of Ebola. At the end of the day, we had only 20. And I think one of the things that helped was the fact that I think we had an outbreak of lead poison and had used this, uh, sort of network there and incident manager just replicated that. But the other thing that I think worked was that we had every partner that came to help together in a room so that we didn't have people going off and doing their own thing. We had a strategy and everybody was divided. Every morning we reported there, and we had this dashboard that told us how much we did the day before, what was left to do. And you were given your assignments for the day. Then you all go out and come back in the evening to report back. It was very well done. And at the end of it, as we were beginning to breathe easy in Lagos, we got another bad news. One of the patients had escaped from Lagos and to Port Harcourt and not only had he gone to Port Harcourt , he had gone to church and he, and they were praying over him, a huge congregation. So we all moved. We were all deployed to Port Harcourt the end of the day, we were lucky. I think we had only, 8 deaths and we had 20 cases all of them linked to the index case ... in nature. We really never had community transmission. Thank God.

Rob Murphy, MD (11:59):

After that, I understand that was kind of the spark that, uh, got the African CDC kind of off the ground. And I know you've played a part in that too. Can you tell us a little bit about that?

Sade Ogunsola, FAS (12:10):

You've been working more in the area of the infection control. I've been very particular about that. Partly because we do have lots of epidemics. We do have a lot of communicable diseases and unfortunately every time an epidemic is about to start healthcare workers die or because that's usually the sort of thing that brings it to light. So I've been very, um, particular about infection prevention and control and healthcare facilitated infections and what I call infection proofing our hospitals. So I've been working with Africa CDC in that sort of light through IPC and then during COVID the work has been more intense and we've done a lot more, especially if you remember everybody went home so it was Africa for Africa and it has actually improved the way we worked together. So we've, I'm on the think tank for Lego state on COVID I'm working, I'm in the steering committee in Africa CDC for COVID 19 research, the research pillar, the guidelines pillar and the training pillar. So, in the last two years, I think we've reached over 30,000 people, healthcare workers across Africa, on infection control in training. We've had quite a lot of interventions to strengthen primary healthcare centers on the ground to reduce the transmission. And they were also working with what with of Africa, CDC, as we developed the legal framework for infection prevent control in Africa. So it's been quite, uh, busy two years, but very fulfilling, very fulfilling,.

Rob Murphy, MD (13:51):

Moving up a little bit, uh, closer in time. Tell us about how COVID-19 has impacted Nigeria and Africa or the re west Africa region to date and how you've been able to use your existing programs and protocols to address, uh, this pandemic.

Sade Ogunsola, FAS (14:07):

One thing that came through is cause we do get a lot of infectious diseases we are actually quite good at responding. We may not have funds, but we do have the people, they know what to do and they respond early. And so you will realize that when COVID came, even before it came to Africa, many people had already locked down, you know, and had put things in place. And even before it became popular, we had gone for universal masking, partly cause where have a lot of, especially in their urban areas, we have social distancing, doesn't work. I mean, people live, you know, on top of each other. However, I think one of the things we could say is that Africa responded very early and very quickly mobilized. We increased the number of labs we had that could detect COVID-19 we, we, we, we mobilized, we, we had the field epidemiologists who went out, we had them cared for. So there was a lot of community mobilized on. We were scared. I have to say that because our capacity to deal with a huge COVID intensive care hospitalization, we don't have that capacity. The number of ICU beds in many parts of Africa. In fact, the, of Africa, I think you could say at the best, ... in every hundred, in some places it's almost negative. So we really, if we had the kind of infections you had, we couldn't have hope. But it didn't happen.

Rob Murphy, MD (15:43):

Yeah. It didn't happen. I mean, that's, it's really kind of a, a wonder to many people.

Sade Ogunsola, FAS (15:48):

I, I have some theories, a lot of the reaction and a lot of the hospitalizations we get for COVID is an overreaction of the immune system, hyper right? Now, many people here were bombarded every day by some infection or the other. I, I, I think essentially the immune system was not overreacting. It's just looked you, you know, just felt, oh, you're here. Okay, welcome. Join the rest. I will say in Nigeria, the people falling ill people, were in the higher income bracket, people who are more likely protected, who live in their own homes, who are not in slums. People are, they're not dying because slum people say, oh, maybe you're not counting it. You can't hide death. You might not ascribe it to COVID. But if they're dying, you'll see it. You know, that'll be fear. They call it any names, but people are not dying.

Rob Murphy, MD (16:43):

Yeah. That's clear. I, you know, everyone says, well, it's a young population. They had other coronaviruses. They had this, but actually it's probably inherent immunity. And the fact that you guys jumped on it when it came, I mean, uh, I don't think people realize the public health response really was good.

Sade Ogunsola, FAS (17:01):

And the other part of it was where we all came together. The countries that oftentimes we weren't really interacting, the CDC played a very pivotal role there and brought everybody together. And so there was a sort of cohesive response generally across the continents. That was really great.

Rob Murphy, MD (17:20):

It's really been quite impressive with maybe South Africa being somewhat of an outlier. The rest of Africa has responded fairly well.

Sade Ogunsola, FAS (17:29):

Part of it is also the elderly, in most of Africa, the elderly are not in care homes. They're not congregating. They elderly stay with you, you the family, or they have their homes. South Africa does, you know, they have more care homes than they're a little bit more westernized than. So one of the things we also said was that if COVID wants to kill the elderly, many parts of Africa, it'll have to go door to door and look for them. You know, it wouldn't find them conveniently one sport. I think that also helps.

Rob Murphy, MD (18:01):

I think there's many reasons that we have not really examined ourselves in the west here. Why this, why the Africa situation is not what was projected? May I ask you a question about what you're telling the young people, the students, medical students, other students, and you know, healthcare workers in Nigeria, what are you telling them, what they should do to help prevent this continued epidemic, future epidemics and what homegrown solutions you've seen from your people in Nigeria? What are you telling the young people?

Sade Ogunsola, FAS (18:35):

One of the things we're talking to them about first of all, is even believing that there's an epidemic. They're not seeing it. So we're trying to get them to mask up. They're not, you know, and to take their vaccines. There's so much rubbish on WhatsApp now we're, we're convincing them about the importance of the vaccine. So in general, I think the other, the last part of it and what COVID has done for us is show us that we can do it. We thought without help, it may be tougher, but that the solutions are in our hands because in the last two years we had help. But for the beginning we were alone, everybody was dealing with COVID in their continent. And a lot of the things came down to simple things, work, simple solutions, washing your hands, masking up, making sure that you do things such that there's reduced transmission works. You don't need to wait till you have to do some things that are highly technological. What came out of the epidemic for us was really that we really could be self-sufficient and, uh, we're pushing that all sorts of innovations came out. Suddenly we had people developing ventilators. I know that a group in university said ventilators, that you could use in rural areas that didn't need too much electricity that was solar powered, people developed robots that could feed patients in isolation.

Rob Murphy, MD (20:05):

I got one last question for you since we've worked together so long and you work with many other US investigators, you've got your investigators at Harvard and you know, other schools, how do your partnerships with the us universities, including us help push your goals forward?

Sade Ogunsola, FAS (20:25):

What the partnership has allowed us do is to be able to some achieve some our dreams to investigate something. No matter how good it is, if you don't have funding, it doesn't, it's not going anywhere. I think the most important thing I think, because of this partnership, many more researchers have developed. We younger people have come up. Who've also gone on to develop their own networks who also have applied for grants and who have sort of overcome that fear. So we have a lot of them, who've got K awards. We've had, we now have a lot of them who are applied for bigger grant. I know one of my younger friends who is running two clinical trials, presently, you know, yeah. Funded from the US. We, the partnerships are not just about US now. We have partnerships in Europe, you know? So there's been this explosion of confidence. And I would say the loss of the fear of applying for grants, that's sort of just gone from the college of medicine. So we've, and now we're also doing a lot more south collaborations. So what it has really done is exposed so many more people and it's, and I think it hasn't just been because you Rob you and I work together. You already, you also are working now with more people in the college of medicine. You you're meeting the younger ones too. It's just growth. It's been exponential. And one of the things that came through was that we also, the university went on to do the times higher education ranking. The citations from the college of medicine was through the roof relative to the rest of the university. It was amazing. So it's been very impactful in the area of academia. And so many of these young people are making their own way now. And I mean, it's amazing what I'm seeing. It's just amazing.

Rob Murphy, MD (22:25):

Yeah. I agree with you. It's been, uh, certain, an eye opener for myself and my colleagues and we love watching this growth together. It's uh, was a pleasure having you on today and thank you very much for joining us.

Sade Ogunsola, FAS (22:39):

Always a pleasure.

Rob Murphy, MD (22:45):

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