Misinformation triggered fear and promoted high-risk behaviour

It was the information; the major thing at that period was the information. People were panicking more because of lack of information.—(Male, Nigerian, Corporate Affairs, Oil & Gas)Many people drank salt water. One of my brother's friends drank and ended up in the hospital because he was hypertensive. Luckily he didn't have a stroke.— (Female, Nigerian, Head Matron at a facility in Victoria Island, Lagos)Because we've heard so much about this disease, about how you touch somebody and you have it.—(Male, Nigerian, Business Development Executive, Pharmaceutical Sector).From the way it was presented, its so easy to contact and spread through door handles, stairways hand rails, through mere contacts like hand shakes.—(Female, Nigerian, Sales Manager, HospitalityThis staff is okay he left today he was okay, the next day he comes to work, how are we sure he is okay, how are sure he has not touched someone that has that.— (Female, GM, External Affairs & Communication, Oil & Gas)

Misinformation and myths regarding Ebola were fuelled by the novelty of the disease in the region, international media attention and the lack of accurate information about the disease. As Ebola was a novel disease in Nigeria, there was a significant lack of information regarding its transmission, aetiology and case management. Consequently, after the first case of Ebola was reported in Nigeria,11 social media platforms saw a sharp increase in conversations regarding Ebola.22 Social media activity fuelled rumours as people sought any available information on Ebola—whether it came from credible resources or not.

According to our survey in Lagos (n=110); social media (71%), television (68%), radio (47%) and friends (52%) were the top sources of information on Ebola (figure 2). Although reliance on television and radio is similar to another study on Ebola conducted in Lagos,23 we report a higher reliance on social media. This disparity could be attributed to a higher proportion of younger respondents in our consumer perception survey (89% were aged 18–40 years, compared to 75% in the other study) and a significantly higher proportion of postsecondary educated individuals in our sample (73% compared to 31% in the other study). While social media can facilitate the rapid dissemination of information, its credibility may be compromised.22 Unsurprisingly, Ebola rumours circulated quickly, reflecting general panic and mistrust of political leadership.24

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Figure 2

Social media, television, and radio were top sources of information during the Ebola outbreak in Nigeria (n=110). We asked respondents about how did they source their information on Ebola during the outbreak. The respondents ticked all that applied among the given choices. About 71% respondents mention social media as a source of information, 67% mentioned television as a source of information, while 52% and 47% mentioned friends and radio hosts as source of information. NGOs, non-governmental organisations.

Almost all interviews mentioned the rumours of drinking salt water or bathing in salt water to prevent Ebola. One of the nurses interviewed mentioned how 80% of patients who came to the facility at that time confirmed that they bathed with salt and water before visiting the hospital. Rumours and misinformation about prevention and transmission of Ebola (drinking salt water, bathing in salt water, Ebola transmission from pork or suya or through touch) encouraged high-risk behaviour and created a false sense of security, which proved fatal in some cases.2 ,22 ,25 ,26 Another notable example of misinformation in the Nigerian context were claims of ‘holy water’ touted by a Nigerian Pastor to have the ability to cure Ebola and other infectious diseases.27 Access to this ‘holy water’ was one of the main reasons the index patient broke quarantine to travel to Lagos, a fact that was highlighted in three separate interviews (two males and one female).

After the outbreak, the Nigerian government took strict measures to ensure that such claims were no longer made.28 Despite awareness efforts, misconceptions regarding the transmission of Ebola continued to circulate. Our survey confirmed the common misconceptions that Ebola could spread via touch (68%), pork consumption (28%) and even air (23%) (figure 3). For example, while some interviewees highlighted their company's awareness and disease education efforts, they went on to mention that Ebola could be transmitted from touch—evidence that misinformation is difficult to dislodge. Interviewees working in places with strong temperature checks were still worried that the disease could ‘spread through door handles’. The clustering of the disease at the index hospital bolstered the belief that Ebola could be transmitted through touch. However, it is important to note that Ebola becomes highly infectious with the appearance of symptoms and ultimately spreads through body fluids.29 ,30

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Figure 3

How is Ebola transmitted? The respondents were asked to tick all that applied on how Ebola is transmitted (n=110). Red dotted lines highlight prevailing misinformation on the transmission of Ebola. About 68% respondents thought Ebola is transmitted through touch, while 28% and 23% respondents thought Ebola was transmitted through pork and air respectively. All three instances reflect the hysteria and misinformation on the transmission of Ebola.

Fearonomic effects amplified the impact of the disease on the economy

But then, if you look at the effects again, a lot of businesses went down, the airline industry was severely affected, hospitality industry severely affected, in fact, a lot of the hotels, people stopped coming, and it took quite a while again to start getting them back to come. Some sporting facilities, golf clubs, foreigners stopped coming; schools were shut for a while, a lot of the hospitals were shut. That is another issue again. More people died of diseases other than Ebola.—(Male, Nigerian, Lagos State Government)

One of the most prominent observations from our study was that the perception of Ebola carried more weight than the disease itself. While Ebola is not highly contagious except at death, the media misrepresented it as a highly contagious disease, thereby reinforcing misinformation and enhanced aversion behaviour.2 People were terrified of the disease due to its high fatality rate and its misrepresentation as a highly infectious disease. All interviewees mentioned a change in consumption habits in the face of fear and misinformation during the Ebola outbreak in Nigeria. These effects of fear-based aversion behaviour and misinformation exhibited by individuals, organisations and countries led to ‘fearonomic effects’ on businesses and the economy. For instance, people started shopping earlier in the day to avoid crowds and the mix of goods they purchased was different compared to the period before the outbreak. People stopped going to crowded areas such as open markets, cinemas, clubs and super markets. This behaviour change was also reported in the survey (figure 4). According to our survey, 75% of respondents stayed away from crowded places, 65% decreased the use of public transport and 48% said they reduced the number of times they went to a store (figure 4).

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Figure 4

Altered behaviour due to fear of Ebola. Respondents were asked Yes or No, to questions on altered social habits, behaviour or visits to certain businesses during the Nigerian Ebola outbreak. Respondents were asked to tick all that applied if due to Ebola outbreak they performed the aforementioned activities. Numbers in blue represent percentage of respondents that said yes (n =105) while red represents the percentage of respondents that answered no. (* ) Refers to themes that were reported in the interviews.

The fear of Ebola also led to an increase in mistrust, as people were unable to freely talk to each other, hug or shake hands. These changes due to misinformation and fear-induced aversion behaviour, in turn, affected the retailers in the marketplace leading to fearonomic effects. The effects of fear-induced aversion behaviour are multidimensional, and affect the economy through distinct effects on the health and behaviour of individuals, the financial performance of businesses, and disruptions to business continuity (figure 5). While the fearonomic effects due to Ebola were inter-related and ultimately affected the entire economy, they also impacted individual lives. According to our survey, 16% of respondents reported losing jobs due to Ebola, while 28% experienced a loss of income, 38% bought food in bulk and 29% paid higher food prices (figure 6). These statistics illustrate how the fearonomic effect can potentially lead to temporary financial insecurity during an epidemic.

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Figure 5

Framework describing the fearonomic effect of an Ebola on businesses and economy Misinformation, disease's case fatality rate, perception of disease due to media hype, knowledge gap due to disease being new to the area or a new/emerging disease are all factors that amplify fearonomic effects of an epidemic by enhancing misinformation and/or fear-based aversion behaviour. We define fearonomic effects as the direct and the indirect economic effects of both misinformation and fear-induced aversion behaviour, exhibited by individuals, organizations, or countries during an outbreak or epidemic.

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Figure 6

Fearonomic effects of an infectious disease outbreak or epidemic can lead to financial insecurity due to fear and aversion behaviour. Respondents were asked if because of Ebola they experienced any of the aforementioned options between July and October 2014 (n =110). About 16% respondents reported losing jobs due to the Ebola outbreak, 29% respondents reported higher food prices in 2014 due to Ebola outbreak, 38% respondents reported they brought food in bulk amount due to Ebola outbreak, 28% respondents reported loss of income due to the Ebola outbreak and 79% respondents reported they stopped hugging due to the Ebola outbreak.

Fearonomic effects included stigma, discrimination and collateral loss of lives

One of our housekeeping officers were ejected alongside her husband, because they believed they had Ebola, in short, they believed we all working here escaped from where we were locked up somewhere to spread the virus.- (Male, Employee, Index hospital)The tricycles wouldn't go to Obalende because everybody knew XXXX (index patient) was taken to a hospital in Obalende.—(Female, Corporate Communications Head, Foundation)There was a doctor at XXXX hospital. It happened to be kids of hers or something, happened to be in our one only Indian school and all these parents of this Indian community said to the school that their kids would not be coming to school, we will not be sending our kids, that's one sad thing that happened.—(Male, Country Manager, Retailer)

Even as a new hands-free greeting emerged during the Ebola outbreak, heightened fear led to an increase in social mistrust.2 ,31 Our informants reported a decrease in trust, particularly directed towards those from poorer socioeconomic backgrounds, healthcare workers, people from Ebola-affected countries and the visibly ill. Multiple interviewees recounted cases such as that of the British Deputy High Commissioner, who lost his life to cardiac arrest when no one came forward to help him due to suspicions of Ebola.32 Misinformation also resulted in unwarranted malicious behaviour towards individuals and businesses, endangering livelihoods or community's health. During the interviews, numerous accounts of stigma and discrimination faced by healthcare workers (HCWs), Ebola survivors and their families were shared. Our interviewees highlighted instances such as, how one of the nurses who had survived experienced stigma at a meeting when the host publicly announced that he would not hug her to protect himself. Out of fear, a landlord evicted the children of one of the victims, while the fiancée of another victim was fired after her death.

Fearonomic effects included the disruption of health services

Patients were not coming; they would stay in their houses. They prefer over the counter drugs. They don’t come. They manage themselves at home until it is even critical that's when they come. It really affected the patients' attendance.—(Female, Head Matron, Private Healthcare Facility)Even until now, people are still afraid of entering, but we keep on telling them that there are no traces of Ebola in here anymore.—(Medical Director, Index hospital)

Ebola-impacted Nigeria's health sector in a unique way through fear-induced aversion behaviour from both HCWs and the healthcare seekers. Hospitals suffered major financial losses due to reduced health-seeking behaviour among individuals, resulting in a sharp drop in patient volume. All hospitals interviewed reported a negative impact on revenue. The patient volume decreased by 35–50% even without a case of Ebola in the facility. One private sector hospital reported a 50% reduction in overall patient volume. In another facility, outpatient volume dropped by 35% during the outbreak, while the emergency room usage decreased by 40%. A public sector hospital with an Ebola-infected patient reported a reduction of patient volume by 40–50%, even after the hospital was declared Ebola-free. There was significant fear of visiting hospitals. One facility recalled a case where the patient refused to have her blood pressure checked out of fear of Ebola. The fear of HCWs and hospitals was partially attributed to the uses of personal protective equipment (PPE). Patients thought the staff dealing with febrile patients looked like astronauts. The attire combined with the risk of being sent to the isolation facility exacerbated the level of fear. These qualitative findings were consistent with the survey conducted in Lagos. According to the survey, 43% of respondents mentioned they reduced their visits to hospitals more than usual (figure 4).

One of the worst affected among the healthcare facilities was Ebola's ‘ground zero’ in Nigeria. The facility that admitted the imported index case of Ebola in Nigeria lost key members of staff to the disease, and both its employees and the institution were subjected to stigma. Apart from the loss of expertise and capacity, the hospital lost significant market share, revenue and brand equity to the fearonomic effect of Ebola. Patient volume declined by 90% after the hospital was declared Ebola-free and a year later, only 20% of patients had returned to the facility. The aforementioned hospital was a stark example of how a leading healthcare facility could lose market share and revenue after a case of Ebola. As a result, other hospitals started turning febrile patients away, violating their obligation to provide care—a phenomenon that has also been documented in the prior literature.33 Some hospitals started referring all febrile patients to the Ebola isolation facility, which could have created significant pressure on the facility if the outbreak continued over a longer period.

Owing to reduced patient volume and the resulting decrease in hospital revenues, salaries of HCWs were delayed in some facilities. This, combined with the fear of stigma and getting infected, also led to an abandonment of hospitals by HCWs and non-clinical hospital staff in Lagos. For example, at the hospital with the index Ebola patient, a few nurses quit their positions to escape the stigma of working with patients with Ebola. Another hospital reported the resignation of 10 staff members. Interestingly, both fear and absenteeism/abandonment was reported to be more rampant among non-frontline medical staff than frontline staff. This could be due to non-frontline staff feeling more vulnerable without the PPE that must be provided to the HCWs.

Fearonomic effects impacted on a broad range of businesses

I had stopped selling pork because I think it was somehow related to Ebola virus, so we stopped selling pork to our customers, we stopped serving pork. We started selling only chicken and beef in our menu.—(Male, Nigerian, Manager, Retail Mall)Sales declined because people didn't go to hospitals. People were self-medicating. So sales declined but not huge.—(Male, Nigerian, Managing Director, Pharmaceutical)Because Nigeria is a big market for all the airlines and they cannot afford to stop flying to Nigeria.—(Male, Nigerian, GM West Africa, Major International Airline)We saw a greater demand for antibiotics.—(Male, Managing Director, Pharmaceutical).We were not prepared for it (sanitizer demand surge) commercially because we didn’t have the large volume of products to manage the situation locally. So it was during the outbreak we had to start importing. So what we could have shipped, we had to fly it down, and the cost was higher so we couldn’t take advantage of the situation.—(Male, Head of Compensations & Benefits, FMCG).As far as the average man was concerned, the world told the average man that hand sanitizers were the way to go.—(Male, National Sales Manager, Pharmaceutical company)They were having losses during that period, so that period is not the time to lend.—(Male, Directorate Head, Lagos & West Africa, Major Bank).One of our vessels was suspected to be carrying an Ebola patient which was not true. Turns out to be just a fever, but because of that suspicion the vessel had to be diverted, returned back, and that was a lot of money apart from the cost of gas and cost of transportation back to Nigeria and all that was involved.—(Male Corporate Affairs, Natural Resource Company).

Despite swift control efforts, no business was immune to the fear surrounding the disease. The outbreak was a period where revenues dropped, and operating costs spiked due to investments in protection measures and staff shortages. Across all sectors, meetings were rescheduled and projects were delayed due to consultants and contractual staff's inability to travel to Nigeria out of fear. This led to opportunity costs in the form of missed commercial opportunities. For example, during our interview, a major oil and gas company estimated its cost of rescheduling meetings due to the outbreak to be US$2–3 million, while telecom companies reported a transfer of projects to outside Africa altogether and cancellation of overseas training for Nigerian employees.

Hospitality and retail: Limited mobility coupled with fear can lead to severe negative effects particularly in service sectors such as tourism and trade. Companies involved in travel and hospitality were affected as individuals who feared infection limited their movements. Occupancy rates in two hotels interviewed dropped precipitously from 80% to 12% and 20% respectively. Another adverse effect of Ebola on the hospitality sector stemmed from online cancellations. Many hotels offer restricted discounted rates online—rates that are cheaper but are non-refundable in case of cancellation. During the outbreak, hotels had to relax their refund policy regarding cancelled bookings to include those that booked the discounted rate. Given the significant number of online cancellations, this had a drastic impact.

All three mall retailers interviewed reported a 30–40% reduction in foot traffic, which reflected the 20–40% decline in revenue of malls highlighted in a previous study.34 Changes in consumption and mobility also impacted retailers, restaurant owners and the informal sector as people exhibited aversion to any food products not made in front of them. Sales of street food, pork, meat and bakery were particularly affected due to fear-related aversion behaviour and misinformation on how Ebola was transmitted. Reduced consumption of aforementioned products due to fear was highlighted in the retailer interviews and the consumer survey (figure 7).

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Figure 7

Change in consumer consumption behaviour during the Nigerian Ebola outbreak (n =114). Respondents were asked questions if they brought certain commodities or products more or less or same during the Ebola outbreak. Blue signifies increase in purchase, red signifies decrease in purchase, while grey represents no change in purchasing habit. Numbers represents percentage of respondents out of the total respondents. The green dotted lines highlight products consumed more than usual that was also reported in the interviews. Red dotted lines highlight products consumed less than usual that were reported in the interviews as well.

Aviation: While international flights were halted to other Ebola-hit nations35 ,36 against WHO's advice,37 they continued to serve Nigeria. This was due to Nigeria's importance as a commercial hub and Nigerian government's rapid implementation of screening measures. Many airlines that continued to fly to Nigeria had stopped flying to the other three Ebola-hit countries, which were much smaller markets. The continued flights between Nigeria and the rest of the world supported the previous evidence of minimal risk of Ebola transmission through air travel with the implementation of exit screening38—Nigeria never exported a case of Ebola despite the continued flights. Nevertheless, load factors decreased drastically during the outbreak for all airlines interviewed due to the sensitivity surrounding air travel and travel restrictions on Nigerians to certain countries. As airline routes in Africa often mimic government restrictions on travel, regional airlines were the worst affected, with few routes left in operation due to travel restrictions39 on Nigerians and other Ebola-affected countries. In fact, two airlines reported 40% and 70% reduction in flight occupancy of flights to and from Nigeria during the period of Ebola outbreak. Another interesting impact on the aviation sector was the change in policy regarding transport of human remains from outside Nigeria. Nigeria is a funeral society, where significant cultural importance is given to the rites of a funeral. As per our interviews, this action further decreased airline revenue since the transport of human remains represents a sizeable contribution to the overall income for a few regional carriers.

Pharmaceuticals: Despite their perceived ability to profit during an outbreak, several pharmaceutical companies incurred economic losses. Fear-induced aversion behaviour leading to lost sales for pharmaceutical industry was a major theme. One company reported an overall reduction in sales by ∼10–15% during the length of the outbreak. Another pharmaceutical and medical devices company highlighted how their growth rate dropped from 22 to 23% to ∼1% during the year of the outbreak. The reduced growth rate was attributed to both Ebola and Boko Haram attacks in the north. According to our interviewees, since patients were apprehensive of hospital visits, sales of prescription medication and medical devices dropped significantly. However, this drop in sales was offset to some extent by greater disinfectant sales and the increased sales of antibiotics, as individuals preferred self-medication to hospital visits. A marginal increase in sales of antibiotics was also observed in our consumer survey data (figure 7). The period during the Ebola outbreak in Nigeria also saw an increase in the demand for disinfectants and other products used for sterilisation. According to a pharmaceutical and medical device company, sales of products such as an effervescent Chlorine-based tablet (sodium dichloroisocyanurate), which is four times more potent than bleach for disinfection, rose by 200% from 2013 to 2014. Nevertheless, a 50% drop in sales was reported for other medical products (such as products for hernia, stitching, etc).

Consumer goods: Consumer goods companies were unable to translate the 200–400% surge in demand of sanitisers (figures reported in interviews) into profit because of stock-outs and higher procurement costs. The surge in demand for sanitisers overwhelmed the existing supply chain of retailers and the suppliers, who had to resort to more expensive means to meet the demand. These costs were, in turn, transferred to the consumer and led to 100–200% increase in the prices of sanitisers.40 Contrary to the popular perception that many pharmaceutical companies and consumer goods companies exploited the conditions to make profits, findings from this study reveal that increased prices was a function of more expensive alternative procurement methods to meet demand. One common method used to procure additional sanitisers was to import them quickly via air-freight from international manufactures. For example, in an interview, one supplier described flying product in from a sister factory in Indonesia, which further added to the consumer price. Another retailer flew sanitisers from London to keep up with the surge in demand.

Despite the availability of cheaper hygiene alternatives to sanitisers, misinformation on protective measures for Ebola led to a disproportionate increase in sanitiser demand relative to the more effective sanitiser substitutes. The alternative product manufactured by a leading Nigerian pharmaceutical and consumer goods company was supposedly superior to (if not, as effective as) sanitisers. Leveraging their brief window of opportunity during the outbreak, efforts were made to spread awareness about the product, maintain a price ceiling, eliminate stock-outs and to position the brand clearly against the alternatives. The brand tried to position itself in the market by creating pocket-friendly bottles. However, consumers seemed to be relatively unwilling to adopt this cheaper alternative disinfectant product in comparison to the sanitisers. Simply put, consumers were obsessed with hand sanitisers.

Banks: According to our findings, the one sector that fared relatively better than the rest was the banking sector, where lending practices smoothly switched over to commercial lending and there was a minor surge in new accounts. While two of the banks interviewed did not report any change in cash flow, two banks with international branches reported a minor increase in cash inflow. This could also be because people may have considered international banks more reputable and trustworthy as places to deposit their money. The increase in cash flow (in Nigeria as well as other Ebola-hit countries) was also attributed to an increase in cash transactions for humanitarian reasons and even because of fraud, as some criminals took advantage of the situation to approach people to donate to the cause of Ebola. As risk perceptions of certain sectors changed, banks became cautious in lending to small businesses, hospitals, schools and the hospitality sector. Banks significantly reduced lending to individuals and all four banks interviewed reported that they had become more careful in their lending practices during the Ebola crisis. At least two of the four banks delayed and scrutinised loan applications from people in medical fields or hospitals more closely. Furthermore, schools were shut down for 1–2 months beyond the holidays. As a result, educational institutions were also regarded as more risky clients. Other interesting observations from the banking sector were that banks reported an increase in the number of new accounts even though they had to reduce their marketing calls. The increased difficulty of securing credit by individuals and small enterprises could have potentially delayed attempts at entrepreneurship and attempts to pursue opportunities for economic growth.

Natural resources: Finally, Nigeria's most prominent sector—oil and gas—was adversely affected as well. Although the potential for loss in this sector was particularly high (due to its economic importance), the outbreak did not directly affect commercial production. Instead, most of the economic losses were traced to shipping disruptions, travel restrictions of contractual staff and the unwarranted fears of clients and suppliers in other countries. Before the interviews, a search of news accounts revealed that one supplier of ships and crew to energy producers suffered a US$6.3 million loss due to delayed projects.41 One company interviewed reported that consignments never arrived because of the Ebola scare, leading to millions of dollars of additional costs for the company. Another company also reported an incident in which a rumour of a suspected Ebola case led to the diversion and eventual return of that vessel. This resulted in increased transportation costs for the vessel. The same company also mentioned that certain countries, such as Mexico and other developed countries, altogether stopped accepting vessels from Nigeria leading to huge costs for the company. A third company's drilling project was cancelled and their Nigerian office had to incur the cost of evacuating the staff. The cost of the outbreak was significant for the foreign joint-venture partners of the oil and gas companies in Nigeria, as they did not conduct business during that period. However, swift recovery efforts helped mitigate the impact. The stock prices of oil and gas companies were not affected as the outbreak was controlled quickly and the Nigerian state and federal governments acted proactively.

Telecom sector: While the Telecom sector was not directly affected, meetings were rescheduled, leading to delays in client engagements and finalising of contracts. One telecommunications company described how a Master's Training Programme for all of its African employees, scheduled in Seoul, was cancelled by South Korea. Another company described cancellation of a product launch due to travel restrictions. Sector's access to technical resources was limited during the period leading to delays in project delivery. A major telecommunications company from the Middle East reported that due to the inability of getting consultants to come to Nigeria, projects were stalled. Moreover, in one case, the venue of a project was moved from Lagos to Dubai.