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Ebola Outbreaks Are About Inequality

The deadly disease is a security threat only because it's neglected as a social justice issue.

Pamela Tulizo/AFP/Getty Images

Living conditions in the Democratic Republic of the Congo’s eastern province of North Kivu were already precarious when the first cases of Ebola were reported there last July. Only eight days earlier, officials had declared an Ebola outbreak on the western side of the DRC over. Suddenly, World Health Organization officials faced an outbreak they feared would be much worse.

The North Kivu epidemic—which has killed more than 1,800 people thus far—is the DRC’s tenth reported Ebola epidemic since the virus was first observed in 1976. Increasingly, epidemiologists are arguing that Ebola, contrary to how it’s covered in the media, is less an improbable crisis and more a chronic—and escalating—threat. The virus, which repeatedly sparks panic far beyond Central Africa, endangers millions mainly because of how little the world invests in routine non-Ebola care in its countries of origin. By ignoring entrenched heath injustices, the international community fuels catastrophic outbreaks that become difficult to contain.

Ebola, like common North American diseases such as Lyme disease and toxoplasmosis, is what scientists call zoonotic, or animal-based: It circulates among bats and infects humans who come into contact with the blood or excretions of infected animals. Once the virus spills over into humans—say if a human eats fruit collected below a bat roost—it can spread from person to person, through contact with infected blood or body fluids.

Spillovers are nearly impossible to witness and document: A brush with bat droppings goes unnoticed, and symptoms of infection usually don’t appear for at least a week. Early symptoms are generic, too. Fevers, chills, and joint pain can be easily misdiagnosed as flu or malaria. In the hours and days before Ebola is diagnosed and gloves, masks, and gowns are put on, the virus can spread swiftly. Caregivers and health workers, in closest contact with the sick, are at greatest risk. Twenty-six people were sick and 20 people had died before the North Kivu epidemic was reported by the provincial health authority.

Because people who survive infection carry Ebola-specific antibodies, researchers are able to examine blood samples from the DRC and neighboring countries to check for exposure. Earlier this year, a team of researchers did just that, finding that exposures to the virus were rare, but not exceedingly so: Two percent of people surveyed from Kinshasa, the DRC’s capital and largest city, were exposed to the virus, with higher numbers in some rural regions.

It may seem like a paradox: “Spillovers are a rarity and an inevitability,” Emma Glennon, lead author of a separate study which analyzed the spread
of the infamous 2013-2016 outbreak, told me. The University of Cambridge team Glennon was a part of estimated that the majority of ebolavirus outbreaks went undetected: stuttering chains of infection that spread locally, and quickly went extinct. “There are so many spillovers happening all the time. Almost all die out on their own, especially in a place that has adequate infrastructure,” said Glennon.

Ebolavirus has likely been quietly spilling over into humans for millennia, said University of California, Los Angeles biologist James Lloyd-Smith. But human networks have changed: “Even if spillovers are occurring at a fixed rate, because of increased mobility, globalization, and urbanization, the risk that any given spillover will cause a significant outbreak is rising.” All too often, viruses introduced into today’s interconnected world are detected late, after the crucial window for early intervention that can determine the fate of an outbreak. The key factor that turns a spillover into a national, potentially a global, crisis is lack of routine medical care.

“Large outbreaks clearly are becoming more common. There have been two unprecedented, runaway outbreaks. The first shocked the world. This [ongoing outbreak] shows that wasn’t a one off,” Lloyd-Smith said.

“Infectious disease will always be with us. Epidemics are manmade,” Gregg Gonsalves, a MacArthur Fellow and epidemiologist at the Yale School of Public Health, told me. “Things get out of control when we let health systems crumble.” In a country still rebuilding from two recent civil wars, 4.8 million people are internally displaced. Seventy percent of the population does not have access to basic health care and five million children suffer from acute malnutrition. Ebolavirus can spread quickly and uncontrollably here—much like other diseases less likely to make international headlines.


While the world outside the DRC fixates on reports of Ebola, “a substantially more fatal measles epidemic is sweeping through the country,” said Freya L. Jephcott, a co-author of the recent Ebola spillover study and former head of the Médecins Sans Frontières epidemiology team, told me. Over 130,000 measles cases have been reported this year so far, even though vaccines can easily prevent the disease’s spread. In 2017, tuberculosis killed 50,000 people in the DRC, even though antibiotics can cure most TB cases.

“The way you stop Ebola is the same way you stop many other diseases: access to primary health care, local public health officials, and infrastructure in place so that you can implement low-tech, cheap interventions,” added Jephcott. When the virus slipped across the border with Uganda this past June, a well-financed response quickly halted further spread.

Neglect of persistent epidemics makes it hard for humanitarian organizations to intervene in acute crises. Many working in the region say that a lack of trust in relief groups undermines efforts to fight ebolavirus. But, “trust that what will happen?” asks Adia Benton, a Northwestern University anthropologist studying development and global health. “They trust that [international organizations] do not care about them,” Benton told me. “They need to trust that someone will care for them and make them better.”

Focus on containment of the virus often comes at the expense of caring for the sick, said Benton. During the 2013-2016 epidemic, concern and media attention piqued only after isolated cases of Ebola began to be reported in Western Europe and the United States.

“No one cares until there’s an outbreak that excites the imagination,” Gonsalves said. “How much was the DRC in the news before this outbreak? There has been devastating human calamity; war has killed tens of thousands of people. This doesn’t register as much as epidemics with smaller death tolls.” The question, he said, is not so much “Could we avoid this?” It’s: “Do we even care enough to do so?”

Gonsalves likes to quote Rudolf Virchow, often called the father of social medicine, about who we allow to get sick and who we protect: “Medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged.”

In the North Kivu epidemic thus far, 1843 have died: 1841 in the DRC and two in Uganda. Almost 30 percent of the dead are children.