By Philip Obaji Jr.

Infection rates at the virus’ epicenter in Nigeria are likely a lot worse than we think.

The two sons of Destiny, a 48-year-old Nigerian businessman whose nephew had recently contracted the monkeypox virus, are already showing similar symptoms.

They have swollen lymph nodes, which started a couple of days after they developed a fever. Despite the rash on their bodies morphing into pus-filled pimples that have scabbed over, Destiny believes his sons are only feeling the effect of the heat wave sweeping Nigeria’s southeastern Cross River State, where they live. He has prevented his sons—both in their early twenties—from visiting the hospital, believing that the rash “will go away after some time.”

“In less than a week, everything will be gone,” Destiny said just outside his home in the town of Akamkpa in the southern region of Cross River. “We’ve started applying calamine lotion [a medication commonly used to treat mild itchiness] on it and we’ll soon start seeing results.”

Monkeypox, a viral zoonotic disease caused by a virus transmitted from animals to humans, was first discovered among monkeys kept for research in the Democratic Republic of Congo (DRC) back in 1958, and later in humans in the same country in 1970. The disease is currently endemic in rodent and monkey populations in West and Central Africa, including in Nigeria, where cases are surging and causing flu-like symptoms and rashes in infected people. Recently, the virus has cropped up in Europe and the U.S., raising alarm that the illness could soon spiral into a pandemic.

Few around Destiny’s compound seem to believe the disease really exists. As was the case with some COVID-19 conspiracy theorists, many believe it's another “so-called” illness conceived by the West for the purpose of introducing vaccines that will reduce the population in Africa. It’s the kind of belief that is already hampering coronavirus vaccination in Nigeria, with only close to 17 million in a country of 200 million people fully inoculated.

“America has started again with another talk of infectious disease outbreak,” one of Destiny’s neighbors murmured as he heard Destiny speaking. “They [Americans] saw that Africans didn’t buy into their COVID scam and so introduced this one [monkeypox] to scare people.”

But as many very close to Destiny live in denial, signs that the disease lives very close to them are glaring. A woman who developed a rash and swollen lymph nodes on her body blamed the occurrence on a “spiritual attack” by her enemies, according to her younger sister, and had to run to the home of a traditional medicine practitioner about 200km (120 miles) away for treatment. No one, her sibling said, has seen or heard from her since. Another 80-year-old man who died a week ago was said to have had symptoms of monkeypox, but did not seek medical attention.

“Many people are scared that if they come to hospitals and are diagnosed with the disease, they could be separated from their families and quarantined for a long time,” said Dr. Collins Anyachi of the Department of Family Medicine at the university teaching hospital (UCTH) in Calabar, the Cross River State capital. “They’d rather prefer to patronize patent medicine dealers or traditional medicine practitioners who’d only prescribe medicines or herbs and tell them that they’ll get well in a few days.”

Cases like those in Akamkpa show that Nigeria is almost certainly failing to document many monkeypox cases, especially in rural areas, where surveillance has been very poor.

Unlike in the West, the outbreak of the disease in Nigeria, where the illness is endemic, didn’t begin this year. It started in 2017. Between then and now, there have been more than 650 suspected cases with over 260 confirmed, one-seventh of which were recorded in the first half of this year.

But government records in Nigeria, where monkeypox cases are on the rise, don’t tell the true story of the disease that has spiked in Europe and the United States.

Officially, Nigeria has announced 141 suspected cases and 36 confirmed cases from 12 states between January 1 and June 12. But as seen in Cross River State, where official records show only two cases have been confirmed, many who likely have the disease are refusing to seek medical check.

“There’s also the fear of stigmatization,” said Anyachi. “When people are officially diagnosed with monkeypox, there is a tendency that the society will treat them with disdain. We’ve seen that happen a lot with people who suffered from leprosy.”

But beyond the people’s reluctance to visit hospitals, authorities have had challenges monitoring the outbreak of monkeypox. To start with, disease surveillance in Nigeria was generally hampered by the outbreak of COVID-19. In the case of Lassa fever for example, there were nearly 1,200 confirmed cases recorded in the year 2020 when the novel coronavirus emerged. That number came down to 510 in 2021, as overstretched health authorities paid more attention to the more contagious COVID-19. But with COVID no longer as dominant, the number of Lassa fever infections confirmed in the first quarter of 2022 alone rose to 751. Like Lassa fever, there was inadequate attention paid to monkeypox in 2021, meaning many infections went unnoticed.

To make matters worse, countries like the U.S. and U.K. are offering a vaccine produced by Bavarian Nordic—one that was approved for monkeypox by the U.S. Food and Drug Administration in 2019—to high-risk contacts, Nigeria has been unable to obtain vaccines or medicines to prevent and treat monkeypox, a virus the World Health Organization (WHO) says is “transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.”

In a country where there are only 40,000 doctors for 200 million people there’s genuine concern that if monkeypox cases expand in poor rural neighborhoods, where there’s over overcrowding and miserable sanitation, Nigeria’s health sector will be unable to handle it.

“The major fear is the possibility of misdiagnosis at primary health-care facilities, which is what’s available to people in rural communities,” said Dr. Elijah Akpe Orim, who has worked in community health for many years in Cross River State. “The people you often find in these health centers are community health extension workers who are not professionally trained on how to deal with such cases.”

Because of similarities in symptoms, according to Dr. Orim, who now works at the UCTH pharmacology department, “patients who may be suffering from monkeypox may be erroneously told they’ve been infected with a disease like measles and that doesn’t help in any way.”

As for Destiny, he says that he will only seek treatment in a hospital when his son’s ailments get “out of their control.”

“At this stage, we cannot begin to spend so much money [in a hospital] when it isn’t life-threatening,” said Destiny. “It is too early to waste money.”