West Africa: The Making of the Ebola Tragedy: Inequality, Mistrust, Environmental Change
October 9, 2014
The Making of a Tragedy: Inequality, Mistrust, Environmental Change Drive Ebola EpidemicBy Laurie Mazur
In August, armed men stormed an Ebola clinic in Monrovia, Liberia, releasing infected patients and stealing contaminated bedding. The following month, eight health workers were attacked and killed in a Guinean village as they tried to educate residents about the deadly disease; their bodies were found in a village latrine. Days later, Red Cross workers in western Guinea were assaulted as they tried to collect and bury Ebola victims.
Why? Gripped by fear and rage, the attackers either denied the presence of Ebola, or blamed health workers for intentionally spreading the disease.
These incidents underscore the extraordinary challenge of containing the Ebola epidemic, a metastasizing global health tragedy that could afflict up to 1.4 million people in West Africa by January. The emergence and spread of the virus raises warnings that must be heard worldwide.
It speaks powerfully of the risks posed by poverty, environmental degradation, and weak health systems, and of the need to bolster our collective resilience to epidemics and other disasters. And it illustrates the crucial role of trust in public institutions – government, health care systems, multilateral organizations.
Indeed, trust is an intangible social good that is perhaps best appreciated in its absence. It is especially elusive in times of crisis, when it is unfortunately needed most.
Months before the Ebola epidemic spiraled out of control, there was Patient Zero, a not-quite-two-year-old girl in Guinea. She likely contracted the virus from an infected bat, in an impoverished village where bushmeat is a dietary staple. Because Ebola so often afflicts caregivers, the child’s pregnant mother was soon infected, then other family members, then the midwife who nursed the mother through a miscarriage. Within months, the virus had arrived in the capital, Conakry, and seeded even larger epidemics in neighboring Liberia and Sierra Leone.
But the origins of the epidemic reach back further still. The virus may have been flushed out of the forest by multinational timber and mining operations that have clear-cut the (now misnamed) Guinea Forest Region, where the child was from. And population growth, partly driven by refugees from the brutal civil wars in Liberia and Sierra Leone, has driven settlements deeper into the remaining bush.
“As the forests disappeared,” writes Jeffrey Stern in Vanity Fair, “so too did the buffer separating humans from animals – and from the pathogens that animals harbor.” Zoonotic diseases like Ebola are on the rise worldwide, as habitat loss accelerates.
Climate change may have also played a role. A 2002 study found that abrupt shifts from dry to wet conditions are associated with Ebola outbreaks in Africa – and climate change is making those shifts more likely. West Africa is already reeling from climate impacts: Sierra Leone, for example, is coping with “seasonal droughts, strong winds, thunderstorms, landslides, heat waves, floods, and changed rainfall patterns,” according to the International Food Policy Research Institute.
1 Nation, 200 Doctors
Environmental change may have contributed to the emergence of the disease, but poverty and social dysfunction made it an epidemic.
“Large hemorrhagic fever virus outbreaks almost invariably occur in areas in which the economy and public health system have been decimated from years of civil conflict or failed development,” write Daniel G. Bausch and Lara Schwarz in the PLOS Neglected Tropical Disease s journal.
This is sadly true of the affected countries in West Africa. Liberia and Sierra Leone are still struggling to repair societies and economies devastated by war. Guinea, hobbled by decades of corrupt, authoritarian government, ranks 179 out of 187 countries on the UNDP Human Development Index, just behind Liberia (175) and above Sierra Leone (183).
In these impoverished nations, health care systems were completely inadequate before the Ebola outbreak. Liberia – a nation of four million – had fewer than 200 doctors. As the epidemic took off, health systems were quickly overwhelmed, turning away patients to be cared for by family and friends, who frequently became infected.
Hospitals in the region lack basic infection-control essentials like running water and protective gowns and gloves, so doctors and nurses catch the virus from their patients and pass it on.
As World Bank President Jim Yong Kim declared in early October, “[the Ebola epidemic] shows the deadly cost of unequal access to basic services and the consequences of our failure to fix this problem.”
Crowded Cities, Suspect Authorities
Urbanization has also shaped the trajectory of the epidemic.
Previous Ebola outbreaks took place in remote villages, where quarantines effectively contained the disease. But the last two decades have seen unprecedented migration to cities in Africa. As a result, the current epidemic is unspooling in urban slums with inadequate sanitation – ideal conditions for the transmission of disease.
As Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota told NPR earlier this month, “the virus hasn’t changed, Africa has changed. We now have this virus in an urbanized population among people who travel far and wide.”
Still, the epidemic might have been contained in its early stages, if not for widespread distrust in public institutions. The proven tools of disease control (case reporting, quarantine, contact tracing) rely heavily on the trust and cooperation of affected communities. Without trust, even the best-intentioned, well-resourced public health efforts will falter.
The roots of distrust run deep, and they can be difficult to untangle. Research shows that recent traumatic experiences and a history of oppression – perhaps not surprisingly – erode trust. Inequality also profoundly weakens the bonds of reciprocity that hold societies together. And, in times of crisis, societies predictably cleave along religious and ethnic lines.
All of these dynamics are at play in the West African Ebola epidemic, where the trauma of recent conflict remains fresh and the legacy of oppression – from slavery, colonialism, and other forms of exploitation – is inescapable. The divide-and-conquer tactics of colonial powers ignited ethnic conflicts that still simmer today.
Against that backdrop, it is easier to understand the response to those working to stem the epidemic in West Africa. Terrified of moon-suited health workers, wary of dysfunctional hospitals, families hid their sick and their dead. As Stern observes, again in Vanity Fair:
It’s very likely we would not be where we are today had there not been large population pockets that were not cooperating with authorities, and in some cases violently resisting them. Infected people hiding allowed the virus to spread unseen.
Lessons on Resilience
The West African Ebola epidemic is a singular tragedy, a perfect storm of environmental and social factors that converged to ignite the largest outbreak yet of one of the world’s most deadly viruses.
But the conditions that aided Ebola’s emergence and spread – poverty, environmental degradation, weak health systems, mistrust in public institutions – are certainly not confined to West Africa.
There are lessons here for the development community, and for those seeking to build resilience in a turbulent world. Ebola illuminates the devastating toll of poverty and stalled development. It underscores the importance of intact ecosystems and the need to mitigate climate change. It demands immediate attention to the infrastructure of public health, including sanitation and primary care. It calls for new efforts to repair broken trust – by redressing historic injustices, by healing ethnic tensions, and by promoting broad-based development that reduces inequality.
The question of trust – how it is built, why it fails – is of urgent relevance everywhere disasters occur, from Monrovia to the Lower Ninth Ward. It is a question that deserves more attention as we seek to cultivate resilience to the shocks and surprises of the future. But this much is clear: trust is essential, and it can’t be compelled. It must be earned.
Laurie Mazur is a consultant on population and the environment for the Wilson Center’s Environmental Change and Security Program and a writer and consultant to non-profit organizations. She is the editor, most recently, of A Pivotal Moment: Population, Justice, and the Environmental Challenge.
Sources: African Development Bank Group, American Society for Photogrammetry and Remote Sensing, Associated Press, Beyond Intractability, Biosecurity and Bioterrorism, CBS News, Foreign Policy, International Food Policy Research Institute, NPR, National Bureau of Economic Research, The New York Times, PLOS Neglected Tropical Diseases, Reuters, Stiglitz (2013), U.S. Centers for Disease Control and Prevention, UN Development Program, Vanity Fair, The Washington Post.
Photo Credit: Morgana Wingard/USAID; Ebola virus particles, courtesy of the National Institute of Allergy and Infectious Diseases.