PROFILE
Professor Ernest Kenu is a Professor of Medical Epidemiology and Head of the Department of Epidemiology and Disease Control at the University of Ghana School of Public Health. As Programme Director of the Ghana Field Epidemiology and Laboratory Training Program (GFELTP), he has played a pivotal role in strengthening field epidemiology, disease surveillance and global health security in Ghana and across West Africa. His research spans HIV/AIDS, tuberculosis, non-communicable diseases, outbreak investigations and pandemic preparedness, with significant contributions to infectious disease surveillance, emergency response and health systems strengthening. He has authored over 240 peer-reviewed publications and successfully mobilized more than US$22 million in research funding to support public health workforce development, laboratory systems and disease control initiatives.
Beyond his research, Professor Kenu has provided distinguished leadership in academia, national health governance and international public health. He serves on several University of Ghana, national and continental committees, chairs the African Field Epidemiology Network (AFENET), and co-chairs the African Union Health Workforce Task Team. A dedicated educator and mentor, he has trained hundreds of field epidemiologists, supervised numerous postgraduate students and provided technical expertise to organizations including the Global Fund, WHO, CDC and ECOWAS. Through his teaching, consultancies and policy engagement, Professor Kenu continues to translate epidemiological evidence into practical interventions that strengthen public health systems and improve health outcomes across Africa.
ABSTRACT
“Disease Smuggling”: The Unseen Cargo in Global Health Security – Lessons From Cholera and Covid‑19 in Ghana
Background
Every day, Ghana’s borders are crossed by more than just people and goods, something less visible, yet far more dangerous, slips through unnoticed. Not gold, not fuel, not cocoa but disease-causing germs otherwise known as pathogens. Disease smuggling is the silent, unintentional transport of infectious agents across geographical, ecological and behavioural boundaries. It does not present itself at checkpoints nor at ports of entry. It travels in crowded buses, contaminated water and even within the very systems meant to stop it. Based on evidence from the 1970 cholera invasion to the global disruption by the COVID-19 pandemic, I argue that disease smuggling is not a border patrol problem but a system failure. The problem is the contaminated pipe borne water, the unregulated street vendor, the overwhelmed treatment centres that amplify infections and the surveillance system that detects the disease too late.
The Past
In September 1970, a Togolese traveller collapsed at the now Accra International Airport. This marked Ghana’s first documented cholera case, but that moment was only the spark, not the source. The real origin of the epidemic was far more unsettling: a smuggled corpse: relatives, honouring tradition, brought home a Ghanaian fisherman who had died in Togo, unknowingly carrying Vibrio cholerae, the germ that causes cholera. Through funeral rites along the coast, the pathogen moved silently, swiftly and efficiently, a disease disguised as dignity. The late Professor Gilford Ashitey of UGMS then at the US Centres for Disease Control, had contemplated deliberately smuggling cholera into Ghana to force sanitary reforms. History rendered his experiment unnecessary. The disease arrived on its own terms and unfortunately our sanitary conditions have worsened. Since then, the country has recorded more than fifteen distinct cholera outbreaks. This pattern is not new. In 1854 in London, John Snow traced cholera to a contaminated water pump, laying the foundation for modern epidemiology. Again in 1847 in Vienna, Ignaz Semmelweis who introduced hand washing pleaded with doctors to wash their hands, linking hand hygiene to survival of mothers who had newly delivered babies. Yet more than a century later, Ghana confronted the same invisible cargo being smuggled, moving not just through borders, but through systems left vulnerable. In my lecture, I’ll show how our work finally revealed how the “smuggling” occurred. In Greater Accra alone, 20,199 cholera cases were recorded in 2014 and nearly 80% of index cases country-wide were linked to prior travel to the capital. During the 2016 Cape Coast outbreak, visiting a Cholera Treatment Centre was associated with a twelvefold increase in your chance of getting infected. The healers became the vectors confirming a return of Semmelweis’s “ghost”. Handwashing with soap and running water breaks the chain of transmission for numerous illnesses, with studies indicating a 32% - 48% reduction in diarrheal-related illnesses. Handwashing programmes can deliver a $2 return on a $1 investment, or substantially more with high levels of uptake and adherence.
The Present
COVID-19 arrived in Ghana in March 2020, smuggled not through physical cargo but in the lungs of travellers from Turkey and Norway. The response was swift, Ghana closed its borders, locked down cities and launched enhanced surveillance, testing everyone within 1–2 km of a confirmed case, a novel idea I defined. What my study uncovered was startling: among the first 17,763 confirmed infected persons, nearly 80% cases showed no symptoms. The silent cargo spread everywhere, yet even as systems intensified, human behavior lagged behind. Our work on observations in public spaces revealed hand hygiene adherence at just 12.3%, while nearly 60% of individuals wore face masks incorrectly. The gap between policy and practice became another pathway for transmission. My work uncovered another weakness, lab results delayed (up to 10 days in a factory outbreak) and this allowed the smuggled goods to keep moving. As part of my work, we compared three outbreak settings; a training institution, a construction camp and a factory, and concluded that early diagnosis and stakeholder engagement can interrupt transmission, but only when test results arrive quickly and communities cooperate. When borders reopened, we integrated COVID-19 into existing Influenza-Like Illness surveillance, a masterstroke of efficiency. Then came an unexpected twist, one that reveals the paradox at the heart of disease smuggling. Between 2021 and 2023, based on all the information we had gathered, we initiated a Phase II clinical trial for a new cholera treatment. Ethical approvals were secured and imported the investigational drug from Hungary and prepared study sites across the country. But there was one problem, there were no patients. The very handwashing and hygiene measures that Ghanaians struggled to maintain, as low as they were, had suppressed cholera transmission so effectively that the trial closed without enrolling anyone. The bitter irony of disease smuggling where one cargo had eliminated another smuggled cargo. Handwashing programmes have similar cost-effectiveness to that of immunization and oral rehydration therapy. It is the single-most cost-effective health intervention available at an average cost of just US$3.35 per DALYs-averted. Poor sanitation and inadequate hygiene practices currently cost Ghana $290 million–$500 million annually, accounting for roughly 1.6% of the country's GDP.
The Future
The next smuggler is already on its way with its cargo: an antimicrobial-resistant cholera strain, a novel coronavirus variant, a little known hanta virus, an old foe, Ebola haemorhagic fever or an unknown pathogen from the forest belt. Ghana cannot build walls high enough to keep them out. But we can build systems smart enough to stop them. In my lecture, I will recommend among others, the following Public Health interventions from work we have carried out: invest in capacity building for FELTP, decentralise lab capacity and invest in community-based surveillance. Integrate digital surveillance platforms into a real-time early warning system. We must finally learn what Snow, Semmelweis and Ashitey taught, as well as what my team found from our research into disease outbreaks. The lesson is consistent: the smuggler and his cargo thrive where water stays unsafe, sanitation remains absent, the environment is altered (as with galamsey) and politically will falters.
Conclusion
Disease smuggling will never stop at passport control points. It ends where the system begins to function effectively, when we treat health security as daily, local and invisible labour. It ends when every hand is washed properly with soap and running water, every leaking pipe is sealed, every treatment centre carries out infection prevention and control practices and is safe, and every citizen serves as a sentinel. A clear call to action is for us to honour the past by fixing the present. Let us build the system that catches the unseen cargo before it becomes an outbreak. This lecture would explain the potential future threats and what the health system needs to do the stop these smugglers. The next smuggled disease is coming. Will Ghana stand ready?