We are working towards tackling strange disease in Sokoto — Dr Larai Tambuwal

Dr Larai Aliyu Tambuwal, a public health practitioner, studied in Bulgaria and has worked with the World Health Organisation (WHO) in Nigeria for more than 10 years. She is currently the Executive Director of the Sokoto State Primary Health Care Development Agency. She spoke on the challenge of an unknown ailment ravaging parts of Sabon Birni and Isa LGAs of the state with Mannir Dan Ali on Trust TV’s interactive programme ‘30 Minutes’. Read excerpt from the transcript:

Sokoto, of recent, has been in the news pertaining to your area of work, health. There have been reports since late March into April that there were some strange diseases that are not very well known. What exactly is the situation now?

Assalamu alaikum. Really, the rumours you heard or the reports that you have been getting about a strange disease, which some other people call an unknown disease, are true. Sokoto State, in early March, experienced an outbreak of some strange disease that had not been seen before in Sokoto, or rather, I would say, it had not been reported like that in Sokoto.

Is that the reason why it’s called strange or unknown; because I thought medicine knows almost every disease?

Once you have not investigated and established the etiology and know the clinical manifestation of certain conditions, you cannot immediately say what those diseases are.

So, a similar disease happened last year in Zamfara State and some cases were reported in Sabon Birni and Isa in Sokoto State, but they have not been investigated. So since that time, it has gone down and nobody cared again.

And you know, recently there has been a transition in government, so before people took offices and started acting in their areas, we started seeing this disease again. This disease is characterised by gradual abdominal swelling.

The stomach gets dis-intended?

The stomach gets dis-intended with what we call asities, as per medical condition.

What is that asities?

It is a collection of water inside the abdominal cavity. It can be from various types of diseases, ranging from poisoning with heavy metals to liver disease, and so on and so forth.

So we started seeing these cases. Children were mostly affected—from one year to 10 years old—but we see sporadically cases of adults coming down with the same kind of condition.

And so it was associated with pain in the heart, abdominal pain and lethargy. Those children were weak; they could not even sit, and some of them were even vomiting; they could not retain food when they ate.

Did people die from the disease?

Yes, some of them died; at least three children died from this disease, and I was thinking because maybe they did not report very early so that they could be given at least some symptomatic treatment.

And also, there could be cases of people who never go to the hospital, who may even have died because, you know, a lot of people think the hospital is not their favourite destination…

First of all, this disease is unknown, or rather, the conditions have not been seen earlier, and the people did not know what to do and, the majority of our rural populace don’t have this good health-seeking behaviour.

It is when they try the traditional methods and fail , that they now start coming to the hospital, but most of the time, if they try traditional methods and succeed and are getting well, they don’t even report to the hospital.

Whatever we see in the hospital is just the tip of the iceberg. So that is one of the reasons why some of them even died before reaching the hospital.

It is interesting that you mentioned Isa and Sabon Birni, which also happen to be the areas in Sokoto State that are affected by a lot of insecurity. Some of the areas are more or less ruled by bandits like Bello Turji and what have you. Did it have any connection with that or insecurity?

Well, really, ab initio, we were thinking maybe it was the bandits that were poisoning the water. We were also thinking of the extension of the mining product down the river from Zamfara State, where illegal mining is occurring.

So we were thinking of poisoning with heavy metals, but we could not determine it from the beginning, and then it kept extending from east of Sabon Birni; it is now in Ilela and we are beginning to see sporadic cases from within the towns that are not at that extreme end, like Tambuwal and Bodinga.

Which are completely in different areas?

They are different areas, but most probably those people traveled to those sites and have now traveled back, and they were spotted in the internal areas.

So when we saw that some of the cases were bad, they were referred to the General Hospital in Isa before being transferred to the Specialist Hospital in Sokoto for adequate management.

And that was why, when we heard about it, the honourable commissioner, who is the chair of the committee that was created to investigate this matter and report to his excellency, she swung into action.

And from the preliminary information she got, she made a call to his excellency while he was in Saudi Arabia, and he gave her the go-ahead, and they gave her a squad of soldiers to collect all the stakeholders, go to Isa/Sabon Birni, visit the victims, see the situation there, and try to get what the reason was behind all this.

So she was given heavy security cover to be able to visit the area because the area is more or less ungovernable?

It is so insecure, and the insecurity situation is so fluid because today you can go there and pass normally and come back, but tomorrow you may hear that the bandits have blocked the way and were killing people there.

And I recall that area where, about a year or so ago, a bus and everybody on it were set on fire, and only their charred remains were found. The situation is that bad?

That is true because the bandits have more or less ruled some of those areas, and they give instructions that if you don’t follow, they will do anything they want to do to you.

So people are scared to go there, and the people there are also scared to come out, you know. It’s not frequent that you see somebody just take their car and just go there.

So what happened, the assessment, the commissioner went with the security cover; were they able to access some…?

We have the indigenous people that are working there and some of the health workers posted from the state level that are normally staying there; maybe the bandits are using them; maybe they are even treating their families without knowing. So they don’t touch those people.

If you, as an outsider, tries to access that place, you may come across them and they will be merciless. That’s why people are afraid to go there.

But at least we are getting some of the information and then we are depositing some of the medications and then the supportive logistics that the governor approved to be moved there to support those communities.

Have you been able to determine exactly what sort of disease it is now. Is it something to do with the metals, or is it something else. Could it be lead poisoning, or could it be something else?

You know I told you that some of the cases started late last year, but they were not investigated properly. But this year, with this event, the director general of the National Centre for Disease Control and Prevention visited Sokoto State. He paid a courtesy call on his Eminence, the Sultan of Sokoto, Alhaji Saad Abubakar III, and then he also paid a courtesy call to the deputy governor, who is the chairman of the immunisation task force, as well as other PSC services and their related health matters.

So, in fact, the deputy governor was key in providing the security cover for them to go a second time and visit the communities where the incidents happened.

They took with them teams of experts and logistics to support the communities. The team of experts, those that will collect samples from the children affected, their blood samples or any other samples, then soil and water samples and also inspected the environment.

They even took veterinarians with them to see whether the animals were also affected so that holistic care could be provided.

And from the preliminary, though it is not concluded, investigation is indicating lead and arsenic poisoning and this could result from the extension of the water from the Zamfara illegal mining communities.

But in those areas, both Isa and Sabon Birni, there are no such informal or illegal mining activities going on?

They have not detected such so far.

And there’s no history of that in that particular area, which is probably why you are pointing at Zamfara?

Yes, we have not had that evidence coming from there, so we only think that it could be extended from Shinkafi, Maradun and thereabouts, coming down through the water, and well, it could have been the reason.

The situation is still under investigation, I do not want to conclude anything, but these are the things that we know for now.

But it is interesting that all this is happening when it is not raining because you will assume that it’s when it’s raining that lead, those heavy metals, could be washed and flow into the water sources in far-off areas like Isa and Sabon Birni. So what could explain that, or could it be residues of the previous rainy season? How do you imagine it?

You know that the rivers are there permanently. Whether they are full volume or low volume due to the variance of the season; they may be fuller now that the rainy season has started, but they are there permanently and the water keeps flowing, so that’s why even our own perception is that it may be from the water that is extended.

And some of them also take water from shallow wells, and we are also thinking of the sinking of those heavy metals into our shallow wells, from which the people are collecting and utilising water.

When are we likely to have a definitive result for all these because, while it’s taking time to do, the people are still living there and probably still taking the same water if water is the source of the ailment?

Yes, really the NCDC is on top of the matter. WHO is also on top of the matter. Together they are collaborating to see that a definitive diagnosis is established because you cannot just use assumption but you can say due to experience and previous knowledge that this thing is in flow with certain diagnosis.

 

But you cannot until you see the sample processed and also the diagnosis brought out, the laboratory part of it which will complement the clinical part.

Now, there are two labs and they said the one we have in Nigeria for analyzing those kind of sample is in Sokoto and also it has some logistics issue but it is not working properly so the DG has actually asked the honourable commissioner to go and find out whatever is missing, so that he can give support and whatever case is brought can be easily processed and the diagnosis brought out.

 

 

 

But has there been any communication with your neighbours, the Zamfara government. Because if you are suspecting that, shouldn’t you give them a head start, because I assume that the illegal mining is still going on?

 

 

 

Yes, the surveillance system is a holistic one for the whole country, that’s the IDSRS (the Integrated Disease Surveillance and Response System) and we are in communication with our neighbours and all other parts of Nigeria.

 

There are times when we see cases in Sokoto but those cases belong to other states, we quickly call the disease surveillance officer and hand him the full details of what we had been doing or what we have done so that he can continue from where we started. We don’t keep quiet or diseases will spread among the community members.

 

So we are in communication with Zamfara State and whatever other information they have we collaborate; we correspond all the times.

 

 

 

Dr you have spoken on the heavy metals challenge suspected, at least at the initial stage, of being responsible for the strange disease that appear to be ravaging parts of Sabon Birni and Isa LGAs. Let’s come to the state capital, Sokoto, which is also one of the areas giving the federal health authorities and even the WHO and other stakeholders concern because in the area of polio and some of the other immunization exercises, Sokoto still seems to have issues.

 

 

 

Yes.

 

 

 

Why is that so?

 

 

 

Well, in the area of immunization, immunization services have been going on since 1996 in Sokoto State. Some of the activities have been conducted over this period of time and some are new.

 

We are leveraging on the global polio eradication initiative which calls for strengthening routine immunization so that at least 85% of the targeted children are vaccinated against the vaccine preventable diseases and then we supplement some of the antigens to a certain age.

 

And then we also conduct surveillance of disease to ensure that we detect AFS which are a syndrome indicating polio infection.

 

 

 

And that is the same polio that we’ve been told has been eradicated in Nigeria, some variants of it is still available?

 

 

 

Yes, so because that global polio eradication initiative is after wild polio virus, there are three types – type one, type two and type three – and other similar viruses.

 

So, among the other similar viruses, we have eradicated the wild polio virus and you know Nigeria saw our last case in 2018 and we were given the certificate of eradication in August of 2020,

 

 

 

Of that same year?

 

 

 

No, that is three years after the last case; that was the condition. You must see the last case at least three years back before you are given the certificate.

 

Unfortunately, we have those other types of polio viruses, the circulating vaccine-derived polio viruses because the oral polio vaccine that we administer is a live viral vaccine and it replicates in the guts of the children that are given and it provides immunity.

 

But unfortunately, when there are conditions that allow that virus to be shed in the stool sample, it goes into the environment especially where you have indiscriminate open defecation, indiscriminate refuge disposal including feces and other things.

 

So it will go into the environment and mutate. It will have other characteristics, so that if somebody by coincidence swallowed food or water contaminated with this polio vaccine that is swallowed by the child, it will be like you have given polio vaccine to that child, it will boost his immunity.

 

But if it has mutated, it will behave similarly like the wild polio virus and it will cripple the child because it goes after the bone marrow and affect the anterior horn cells which are responsible for movement. For that child, anywhere that is affected, the nerves coming from that side into the hands or into the legs or into the rib muscles that help us to respire, it will paralyze them.

 

 

 

So it still has big dangers, this mutated one?

 

 

 

It has the same danger as the wild polio virus and that is why our fight has not finished; we have to continue to vaccinate using the routine immunization, using the supplemental immunization activities while we put our eyes out in surveillance to see if we can see anything polio or similar to polio and that will gauge our own response to it.

 

 

 

You mentioned open defecation, even here in Abuja there are places where you have to hold your nose when you are passing, it’s still very rampant. What can we do about it?

 

 

 

Yes, we have similar areas in Sokoto State where some of the inhabitants of those areas near our sewage system where we have open gutters, collecting water from all the areas of the settlements; they also have pipes from their toilets direct in the gutters.

 

And when they now put out the excretion, they come into contact with community water, and animals and children that are playing around. And even where pipe-borne water pipes are broken, it can contaminate our water.

 

So we see the spread of the viruses and majorly it affects children that have less immunity because if you give the child routine immunization from birth to one year that child is supposed to have at least three doses of polio vaccine.

 

 

 

And when you mention routine immunization it is good to break it down; you mean immunization against all the different childhood diseases, which are six or seven of them?

 

 

 

 We call them childhood killer diseases, those ones that we have vaccines against them.

 

So we have a schedule in Nigeria whereby you provide these vaccines from birth, 6 weeks, 10 weeks and 14 weeks of birth and at 9 months. Now we even open it up to 2 years so that the polio injectable vaccine can be given additionally at 14 weeks and at 24 months.

 

 

 

But still there is a lot of skepticism. I know it’s gone down and especially up here in the North and probably very strong in Sokoto. There are still some, what do they call them, the non-compliant, the anti-vaxxers as they call them elsewhere, because even in America there are people who don’t want to take vaccination.

 

 

 

It is true. Really the social media and other people that go underground and create negative messages against vaccination are causing a lot of trouble.

 

Anybody who is, I will not say only the religious people, anybody who is sensible knows that the smallpox which was ravaging people is no more available, the goiter is no more among our community members and then measles have gone down also because of vaccinations.

 

So if you are now wake up today and somebody is telling you the vaccines are there to reduce your fertility so that they will reduce the African population, that person is just lying to you.

 

Some are even saying the vaccinations are there to input into you HIV infection. We have been vaccinating people for the past 40 years and it has not been proved that it causes this HIV or lowers fertility.

 

 

 

But there are still gullible people. Now one of the new issues is the human papilloma virus (HPV) vaccine, the one that helps prevent cervical cancer. It is available for girls but already there is controversy about it.

 

 

 

Yes, you know, the education and also the knowledge in healthcare is always evolving. When you find new facts and also new medications and vaccines, you introduce them to the population.

 

But many people create rumours like I said earlier, misconceptions and attach them to either culture or religion so as to prevent people from getting the benefit of those interventions.

 

But like this HPV vaccine now, people are rumouring, they are even creating voice notes and sending them out that it is to make the girls infertile so that before they are now mature they can no more give birth to children. It is not true.

 

Even polio people said that but believe you me, today, the girls that took the polio vaccine they are the ones having multiple births; there is even more births, more deliveries than before because people are becoming healthier, people are becoming more versatile in their economic and their health perspectives.

 

So, this one that people are saying 9–14 year olds are given HPV vaccine just to kill them, to stop them from being fertile, it is not true.

 

It is to prevent the human papilloma virus from infecting them before it infects them, before they become sexually active. We want to prevent that because the human papilloma virus exposure is gotten more from sexual intercourse.

 

 

 

But some are exactly hinging on that and saying look it is just to make our girls amorous, to be having lot of sex partners, to make them go against our religious belief…

 

 

 

No, that is not true, in fact we are targeting girls that have not even commenced sexual intercourse so that they have not been exposed to anything and they can have preventive measure before they are legally or illegally exposed to sexual intercourse. This is so as to prevent cervical cancer and breast cancer which are the two leading causes of death among women.

 

We have other causes also contributing to the overall mortality among women, including maternal mortality due to pregnancy and child birth but these two cancers have been seen to be leading in killing or making our women morbid; that is making them sick.

 

And especially breast cancer is amenable to early detection because the woman can even examine herself and know when she has some sign and symptoms.

 

But cervical cancer is hidden, you only know when it comes out, when it is very late. So it is better for people to collect the prevention and cross their fingers and continue to pray and do any other thing that they are supposed to do so as to prevent themselves because death, as we Muslims believe, has time. When your time comes, you must go; it is suffering that is not welcomed.

 

 

 

On a final note. What will you say are your biggest challenges being the person in charge of primary health care in one of the most conservative states in Nigeria, Sokoto?

 

 

 

I’m happy you said conservative because people come to Sokoto and say people in Sokoto are so strongheaded. They are, you know, they are non-compliant, you cannot educate them, no.

 

Sokoto is the city of knowledge as far as I’m concerned because the daughter of Usman Dan Fodio, Nana Asma’u, was the pioneer of all this education and writings particularly on Islam and Islamic jurisdiction and also guiding people towards doing what is right.

 

 

 

But is that tradition still there in Sokoto, I mean look at how far the daughter of Usman Dan Fodio, Nana Asma’u went, is this still the case, are there still women who…?

 

 

 

We are some of the trailblazers that she left. So I was going to say yes, people in Sokoto are conservative because they are knowledgeable and before you can convince them you have to bring convincing evidence…

 

 

 

So superior knowledge is what…?

 

Superior knowledge; and you also have to come through their culture and their religion before they take anything you are introducing to them. They are not just people that you meet and say come and do this and they will follow you and do it.

 

You have to explain to the best of your ability, you have to provide all the evidence that will make them to believe that yes this thing is good for me, this thing is not going to cause harm for me or my family.

 

And we listen to our community gatekeepers, the traditional institution, the religious institution and if you don’t go through these structures, whatever you bring, even if it’s money you are less likely to succeed in making people to accept it.

 

So we are actually going through them, sitting with them, explaining to them the essence and even everything about anything that we want to introduce.

 

And we have acceptance and we are trying gradually to go into the community members and bring them forth, dialogue with them, tell them, allow them to ask questions because that is their right, that is what we are doing.

 

 

 

Thank you very much Dr Larai Aliyu Tambuwal for coming on this show.

 

 

 

Thank you so much sir.