Ebola

Introduction

As I write these words Gallup has just released a poll showing that America is almost as fearful of Ebola in October 2014 as it was of the H1N1 "swine flu" in May 2009: Fourteen percent of Americans believe Ebola is likely to sicken them or someone in their family in 2014, compared to 20 percent who thought the same of swine flu in 2009. The finding is staggering, considering that at this moment just six Americans have contracted Ebola, all of them infected while living or working in the African nations of Liberia or Sierra Leone. In contrast, by the time Gallup conducted its 2009 poll about H1N1, more than 14 million Americans were already infected with the flu, most without realizing it.

Ebola, a virus named after a Congolese river, has conjured special respect since its discovery in 1976 in Yambuku, Zaire. As I wrote in my first book, The Coming Plague, the deadly disease was utterly mysterious back then, when its first wave washed over the remote town to claim the lives of 90 percent of those infected. The small international team of virus hunters who gathered in Zaire's capital, Kinshasa, knew little about the strange disease except its horrible toll. Yambuku could only be reached via government planes and helicopters, and communication with the outside world was all but impossible. The scientists and physicians entered villages to find entire families sprawled inside dirt-floored huts, crying out in hallucinations, moaning in pain, and bleeding from every orifice—blood that was filled with contagious viruses.

After the weary Ebola hunters isolated the new virus and stopped the epidemic, their work and the horrors they had witnessed became the stuff of epidemiology and virology legend. Among those in the infectious disease tracking community, the mere mention of "Ebola" was enough to conjure gasps of dread and nodding respect for the disease cowboys who dared in 1976 to confront the microbe.

Nineteen years later Ebola reemerged in Zaire, hundreds of miles away from Yambuku in the large southern town of Kikwit. It started during Christmastime 1994, when Gaspard Menga walked into the dense rain forest that marked the edges of Kikwit in search of wood that he could burn down to charcoal and sell as fuel. Sometime during his days camping in the forest Menga came in contact with an animal; nobody would ever know what type of beast or the nature of the contact. From that animal Menga unknowingly caught Ebola, carrying it inside his body as he trekked back into Kikwit with a lucrative haul of charcoal on his back. A few days later Menga was dead, and his family, having lovingly tended to the ailing man, surrounded his body and posed for a mournful photograph.

When I met the surviving members of the Menga family a couple of months later, the Ebola epidemic was soaring, having spread from the local hospital to far flung villages and clinics across a wide region. I stared for a long time at the faces in that photo, seeing in them loss, grief, sorrow, and the start of a grave epidemic.

As I wrote in Betrayal of Trust: The Collapse of Global Public Health, in which the main text of this eBook first appeared, the Kikwit epidemic afflicted a town of some 450,000 people who lived crammed together, house to house, in what amounted to little more than a giant village lacking electricity, running water, sewers, telephones, an airport, or more than a couple of paved roads. The battle against the virus was waged with primitive, almost fourteenth-century methods: gathering up the ailing and dead, quarantining the sick, palliative care using soap and water, and burying victims in mass graves. The fight was waged by a heroic band of local Red Cross volunteers, a handful of medical students, three European Médecins Sans Frontières (Doctors Without Borders) physicians, and a group of two dozen scientists and epidemiologists from Zaire and a dozen other countries organized by the World Health Organizetion. Once the team was in place, the 1995 Kikwit epidemic was under control within three months.

Three years later I returned to Kikwit to see how the epidemic's aftermath had affected the place, the people, and the culture. Zaire's long-time dictator, Mobutu Sese-Seko, had died in 1997 in Moroccan exile, and the country suffered a short but brutal civil war. When rebels opened the vaults of the national bank they found only worthless Zaires notes: Mobutu and his family had looted the nation, stealing an estimated $5 billion in gold, gems, and foreign cash. The country had been poor in 1995, but now it was in a state of dire desperation. I could not have known as I walked the streets of Kinshasa in search of a travel agent to sell me a ticket to Kikwit that the country renamed the Democratic Republic of Congo would still be suffering from uprisings, wars, and brutal militias sixteen years later.

I found a "flight" to Kikwit, strapped atop an enormous crate full of agricultural tools in the hull of a WWII-era cargo plane. Remarkably, a uniformed flight attendant maneuvered among fellow passengers, also strapped to cargo, to serve Coke and cookies. And as had been the case in 1995, we landed on a grass soccer field, and I chose from a passel of hungry drivers my chauffeur for the duration of my visit.

As we drove over the rutted mud roads I eyed evidence of deterioration and worsened poverty. Children along the road held out their hands for food and shouted as they spotted my white face: "J'ai faim! Maman, j'ai faim! Aidez-moi, Maman!" The shouts of grief that filled the air in 1995 had been replaced by cries of starvation.

When we reached the hospital that had served as the Ebola quarantine center, my heart sank. The generators and rain cachement devices erected during the epidemic by MSF were long gone. A donated ambulance now served as the private limousine for the local politician-thug. Instruments were sterilized in large iron cauldrons of water suspended over bonfires. The hospital had been so thoroughly looted by marauding militias that it lacked doorknobs, light bulbs, water pipes, drugs, or valuable medical equipment of any kind. Surgery could be performed only by daylight, and physicians had nothing but rinses of water to protect themselves from their patients' microbes and to prevent germs from spreading into patients' open wounds. One young nurse who had contracted and survived Ebola in 1995 trembled as he described the fear that each day now brought, as he toiled in a hospital without disinfectants, soap, sterilizing equipment, latex gloves, or any protective gear.

I left Kikwit in a state bordering on rage. How could the international community have stopped the epidemic, only to abandon the people to conditions that were actually worse than those they lived in before Ebola?

Betrayal of Trust describes not only the Kikwit Ebola crisis, but numerous other cases I investigated all over the world, including inside the United States, illustrating the same pattern of response and abandonment, discovery followed by complacency, urgency that devolves to amnesia. One day's public health crisis is the next's job done—and forgotten.

By 2013 the world had witnessed twenty Ebola epidemics in Africa. The toolkit was little augmented: No vaccine, treatment, or cure has been developed over the thirty-seven years since Yambuku. In each case, from Congo to Uganda, hospital infection control, quarantine, and safe burial of the dead were the key to stopping Ebola. And as deadly as Ebola remained, the world grew numb to its horrors, losing interest amid a series of isolated, remote outbreaks.

Perhaps that is why rumors of Ebola's Christmas 2013 emergence in an area that hadn't previously seen the virus drew little notice. Even laboratory confirmation that the original 1976 strain of the virus was infecting rural villagers in the West African nation of Guinea garnered little more than a collective shrug from the world community. Only Médecins Sans Frontières came to Guinea's rescue, having fought back nineteen of the prior twenty Ebola outbreaks. In Geneva the World Health Organization downplayed the significance of the outbreak, even as it spread to neighboring Liberia and Sierra Leone.

By June 2014 the West African outbreak was the largest in Ebola's history. For the first time, Ebola had reached genuine cities with international airports—Conakry, Monrovia, and Freetown—and the epidemic's pace far exceeded the collective treatment capacities of Médecins Sans Frontières, local government clinics and hospitals, and an assortment of foreign missionary groups.

As of this writing humanity is battling Ebola on many fronts, the worst still in West Africa. The U.S. Centers for Disease Control and Prevention has forecast that—in the absence of a dramatic escalation in international assistance—Liberia and Sierra Leone will have at least 500,000 cumulative Ebola cases by February 1, 2015, and at worst, 1.4 million. That scale of carnage could mean the two countries would lose up to 14 percent of their populations, and the epidemic would continue to rage into 2015.

Here in America more attention had been paid to a single case: Thomas Eric Duncan, a traveler from Liberia who was diagnosed with Ebola in Dallas, Texas, on September 28, eight days after his arrival in the United States, and who died on October 8. His case, along with subsequent isolated infections in Europe, accounts for the state of fear noted in the Gallup poll of October 5, 2014.

Americans, Canadians, and Europeans are discovering the hard way that security in a globalized world cannot be bought with easy technologies or a few epidemic drills in local hospitals. There is no smart-phone app that can stop Ebola. The virus does not fear Google, nor does it disappear at border checks.

Public health is a trust, built on trust. Just as a fire department is a town's public trust, funded collectively through taxation and relied upon by all, rich or poor, so is public health. Moreover, public health works only if people trust their government to protect them from disease, and the disease fighters can trust the citizenry to abide by orders that are in the collective best interest, even if they may be individually inconvenient. According to Gallup, more than one third of the American people do not trust the federal government to stop Ebola from sickening them or their loved ones, and 88 percent of the respondents are sure the virus is "coming to America." A separate poll conducted by Pew Research found 32 percent of Americans convinced the virus might infect them or their families, and the level of fear correlated with race and political party membership: Black Democrats placed the greatest trust in government's response and expressed the least fear about Ebola, whereas white Republicans expressed far greater anxiety and distrust.

There is nothing partisan about a virus. But public health and politics have always mixed, often with terrible results. Joseph Fair, an American disease fighter advising the Sierra Leone government about Ebola, calls the current epidemic "Global Health's Katrina moment," a reference to the terrible Bush administration mishandling of the 2005 Hurricane Katrina devastation of coastal Louisiana and Mississippi. The world—especially poor countries like Liberia, Guinea, and Sierra Leone—had placed its trust in the World Health Organizaton and the disease-fighting agencies of the wealthy world. So far the world has betrayed that trust.

—Laurie Garrett, Brooklyn, October 2014

LANDA-LANDA

An Ebola virus epidemic in Zaire proves public health is imperiled by corruption.

The night air was, as always, redolent with the smells of burning cook fires fueled by wood, wax, propane, or cheap gasoline. The distorted sounds of overmodulated 1995 hit ramba music echoed from the few bars along Boulevard Mobutu that had electric generators or well-charged car batteries. Fully dilated pupils struggled to decipher shapes in the pitch darkness, spotting the pinpoint lights of millions of dancing fireflies. Gentle footsteps betrayed what the eye on a moonless night could not see; the constant movement of people, their dark skin hiding them in the unlit night.

From a distance a woman’s voice rang sharply, calling out in KiCongo, “Afwaka! Someone has died! Someone has died! He was my husband! He was my husband.”

As she continued her call to heaven, detailing the virtues of the just-deceased, the woman’s eerie cry was joined by a succession of her relatives’ voices.

“Someone has died! Someone has died! He was my father!”

“Someone has died! Someone has died! He was my son!”

The padding of feet on Kikwit’s mud paths paused as people turned their ears to catch the name of the latest landa-landa victim. In a city without newspapers, radio, television, telephones, or electricity, such cries in the night constituted local broadcast news. And no sooner had the flow of pedestrians resumed than another voice rang out from the opposite side of the emotionally electrified city-without-electricity.

“Someone has died!”

Landa-landa. Foreigners. Something called a virus. Something called Ebola. These things gripped the estimated 400,000 people of Kikwit with a terror unlike any they had ever felt. Fear was no stranger to them: hadn’t they lived under the brutal Mobutu Sese Seko regime for more than thirty years? Wasn’t death already a steady companion, fueled by malaria, measles, HIV, TB, and malnutrition?

But this landa-landa was different, more terrifying than all the other diseases that had taken the lives of Kikwit’s children and young adults. The victims died fast. But first, they bled, had long fits of hiccups, cried out in agonizing pain, even went mad, and screamed incoherent phrases of apparent devilish origin. They seemed possessed.

There were ancient ceremonies handed down by the ancestors that could purge evil spirits—they usually lifted the landa-landa. But not this time. The magic was too powerful. Surely it must be the work of an exceptionally evil one.³ Who was the potent fount of Satanism?

The rumors were numerous, and were spread in hushed tones so as not to be overheard by the evil ones. Only the Christian leaders, imbued with the strength of Jesus, dared decry the evil out loud. Pentecostal preacher Eloi Mulengamungu declared it the work of Satan, himself, allowed to roam freely over doomed Kikwit by God, in punishment. Kikwit, the preacher declared, had become a modern Sodom replete with prostitutes, corruption, illegitimate children, abandoned elderly parents, and other wages of sin.

From the Baptist Community of West Africa (CBCO) the people also heard of Satan’s mischief. As members of CBCO fell ill and died of the strange new malady their leader declared that Kikwit had lost sight of God. In the absence of a large core of true believers Satan could claim even a tiny pool of the pious. As his congregants also fell ill, Pastor Kutesa Mayele of the Assembly of God Church reached a similar conclusion: it was God’s punishment for Kikwit’s sins.

Only the Catholic church’s Monseigneur Alexandre Mbuka Nzundu accepted the outsiders’ verdict that there was no landa-landa, just a terrible virus that was passed by the loving touch one person gave another: a virus that exploited moments when a husband might daub the forehead of his ailing, feverish wife; a child might hand wash the bloodied sheets upon which his ailing brother slept; a mother might spoon-feed her delirious son; and a grieving family would reverentially wash down the body of their deceased relative, rinsing off the sweat and blood of his hemorrhagic demise.

It was not landa-landa; it was a mortal pestilence that passed from one human to another through acts of kindness and love.

The virus was named for the Ebola river in Northern Zaire, which passes near the site of the microbe’s first known epidemic in Yambuku, in 1976.⁴ Though the 1976 death toll in Yambuku was less than four hundred villagers and Catholic Belgian missionaries, those members of the international scientific team who were deployed to the region to conquer the mysterious outbreak still held Ebola in awe in 1995. In their meetings with other public health officials for years after the 1976 outbreak, surviving members of the Yambuku crew always placed the deadly filovirus in a special, particularly fearsome category: a small assemblage of hemorrhagic fever viruses that included Lassa, yellow river, Marburg Disease, and a handful of others, most of which were discovered only in the last three decades of the twentieth century.

The fear evoked by Ebola among Westerners was largely a matter of enigma: in classic European and American tradition, that which could be understood, even if still dangerous, was no longer fearsome. The act of explanation diminished Western terror. But nineteen years after the virus’s last outbreak in Zaire Western science still could not answer the most basic questions about Ebola: where did it come from? In what animal or plant species did it normally reside, when not infecting the human species? Exactly how was it transmitted from person to person? Could it, under any circumstances, pass through the air, infecting people who had no physical contact with patients? Precisely how lethal was the virus? Was it treatable with any drugs or methods available to 1995 physicians?

At the close of the century these issues would largely remain enigmatic. And in the absence of clear understanding of the elusive Ebola virus public health responses would rely on classic measures, practiced by scientists, physicians, and nurses during epidemics for a hundred years.

For the Zairois Ebola’s presence raised horror for very different reasons. The inexplicable nature of an event, or lack thereof, was rarely a primary cause for consternation among the people of Kikwit, as more than three decades of an increasingly brutal dictatorship had left few individuals with a sense of power over their own fates. The major shocks in their lives rarely involved circumstances of their own making or full comprehension, but might well result from an offhand remark made by the dictator the previous day in the faraway capital of Kinshasa. Besides, landa-landa served as the all-purpose explanation for otherwise mysterious horrors, deaths, pains, and traumas in life.

Nor could disease, alone, be the source of their collective trepidation. The United Nations Children’s Fund (or UNICEF) ranked Zaire number twelve in child mortality, meaning only eleven nations in the world witnessed higher proportional death rates among their under-five-year-olds.⁵ Every year the mothers of Zaire gave birth to just over two million babies. And 442,000 of them didn’t live to see their fifth birthdays. Nearly half of the nation’s children were, by strict medical definition, malnourished, 45 percent of them growth-stunted as a result. The major causes of child death were malaria (increasing due to drug resistance among the parasites), malnutrition, measles, and HIV.

If a child survived to age five, odds were good he or she would reach adolescence. Then the youngster would face a new series of threats: AIDS, tuberculosis, murder, maternal death in childbirth.⁶ Malarial episodes were frequent, as were the pains of syphilis, gonorrhea, and chlamydia. The main road of Kikwit—Boulevard Mobutu, named after the dictator—was lined with mud hut pharmacies offering everything from, literally, snake oil to out-of-date antibiotics as remedies to the long list of ailments that formed an assumed, seemingly normal, part of life atop the equator.

No, death and disease were not, in and of themselves, the causes of Kikwitians grave fear in the face of Ebola.