Ebola painfully exposed the extent of global unpreparedness to face the challenge of epidemic disease despite the warning provided by SARS. But however heavy the burden of suffering in West Africa was, the world was fortunate that the calamity was not greater. By a consensus of informed opinion, Ebola reached the brink of spreading uncontrollably and internationally; it was on the verge of being transmitted across Africa and beyond, with incalculable consequences.
Such a degree of unpreparedness resulted from a combination of circumstances, which are still in effect today. One is the treatment of health as a commodity in the market rather than as a human right. Well before Ebola erupted, market decisions prevented West Africa from having tools to confront the emergency. Pharmaceutical companies prioritize treating the chronic diseases of industrialized nations, where profits are to be made, over the development of drugs and vaccines for the infectious diseases of the impoverished. As a result, tools to deal with diseases like Ebola lag far behind in the pipeline.
A further consequence of the perspective of health-for-profit was painfully evident in 2013–2016. This was the absence of functioning health-care systems accessible to everyone. Ebola circulated silently for months in West Africa because no means of surveillance were in place. A public health infrastructure and guaranteed access to it are the essential means needed to sound the alarm, provide timely information, isolate infectious cases, and administer treatment. In Guinea, Liberia, and Sierra Leone, no sentinels had been posted, so Ebola, undetected for months, circulated freely. Treating health as a commodity implies that decisions affecting the life and health of millions are placed in the hands of politicians whose power depends on generating development, trade, and profit. In theory, the nations of West Africa espoused the lofty goal of health for all as embodied in idealistic declarations such as the Millennium Development Goals of 2000, and they pledged themselves to creating health infrastructures at the Abuja conference of 2001. Those objectives were dear to spokespeople for public health, and to medical and humane interests. For political leaders, however, the very different principles enunciated by the World Bank, the International Monetary Fund, and the G8 countries—economic growth, privatization, and unfettered markets rather than public spending—took precedence. In practice, therefore, public health was abandoned. The siren song of military expenditure further completed the diversion of resources away from the construction of a robust health-care infrastructure, leaving West Africa perilously vulnerable.
Finally, Ebola was able to cause an epidemic because of the prevailing illusion that national borders matter in a globalized medical environment. As epidemic disease erupted in the “distant” Mano River Basin, the developed world slumbered in the peaceful belief that disease in Africa was a humanitarian issue at most, not one that raised the dismaying prospect that lives everywhere were directly at stake. But epidemic diseases are an ineluctable part of the human condition, and modernity, with its vast population, teeming cities, and rapid means of transport between them, guarantees that the infectious diseases that afflict one country have the potential to affect all. The public health disaster of West Africa was founded on the failure to make decisions regarding health from the perspective of the sustainable welfare of the human species as a whole rather than the unsustainable interests of individual nations. To survive the challenge of epidemic disease, humanity must adopt an internationalist perspective that acknowledges our inescapable interconnectedness.
The analysis here leads to a disconcerting corollary. The ongoing assault on tropical forests in Central and West Africa explains the fact that, since the emergence of Ebola in 1976, outbreaks of the disease have become more numerous and larger in scale. Nor is there any indication of a halt tothe progression. Indeed, at the time of this book’s conclusion in the fall of 2018, the Congo was experiencing yet another outbreak that was rapidly becoming the most extensive in the history of the country. This upsurge began on August 1, 2018—this time in the northeast province of Kivu where the country’s borders intersect with those of Rwanda, Burundi, and Uganda.
A hopeful factor in the emergency anti-Ebola response is the availability of a trial vaccine that offers promise and is being administered to healthcare personnel and people at serious risk. Unfortunately, however, the development of such a potentially useful tool is outweighed by powerful negative considerations in addition to the continuing advance of deforestation and the unpreparedness of Congo for a humanitarian emergency. One of these is the presence in Kivu Province of a million refugees from civil disorder. This large population is mobile, highly susceptible to infectious disease, and far beyond the surveillance of a fragile and crumbling health-care system. A further discouraging factor is the fact that Kivu is a war zone torn by strife among rival militias that make the attempt to provide medical care dangerous and largely impracticable. Indeed, the CDC has found it necessary to withdraw its emergency response personnel because they have come under fire and their safety cannot be guaranteed. For these reasons, the virologist Robert Redfield, the director of the CDC at the end of 2018, has warned that he fears two possible consequences that cannot be excluded. One is that, by escaping all control, Ebola for the first time may establish its presence as an endemic disease in Central Africa—with consequences that are unknowable. Redfield’s second anxiety is that the epidemic may spread beyond the Congo, with serious international repercussions. It seems likely that the human experience with Ebola virus disease is far from over.
For these reasons, the experience of Ebola clearly indicates three initial steps that urgently need to be taken to prepare for the inevitable—and possibly far greater—next health challenge, whether from Ebola virus or from a different microbe. The first is the establishment of functioning healthcare systems everywhere. As former CDC director William Foege argues, public health is the protection of the health of all, and it therefore implies measures of social justice. Second, it is essential to ensure direction and coordination from an internationalist perspective through a well-funded, competently staffed, and ever-vigilant World Health Organization. The West African epidemic revealed that neither measure has yet been implemented and that, in their absence, the world runs a severe risk of tragic and avoidable suffering.
Lastly, the relationship between the global international system and public health cannot be ignored. An economic system that neglects what economists euphemistically call “negative externalities” will ultimately exact a heavy cost in terms of public health. Chief among these externalities are the negative effects of certain models of development on the relationship between human beings and their natural and societal environments. The establishment of oil palm monocropping and chaotic, unplanned urbanization in West and Central Africa are just two examples among many. Epidemic diseases are not random events. As we have seen throughout this book, they spread along fault lines marked by environmental degradation, overpopulation, and poverty. If we wish to avoid catastrophic epidemics, it will therefore be imperative to make economic decisions that give due consideration to the public health vulnerabilities that result and to hold the people who make those decisions accountable for the foreseeable health consequences that follow. In the ancient but pertinent wisdom, salus populi suprema lex esto—public health must be the highest law—and it must override the laws of the marketplace.
From Epidemics and Society by Frank Snowden. Published by Yale University Press in 2020. Reproduced with Permission.
Frank M. Snowden is Andrew Downey Orrick Professor Emeritus of History and History of Medicine at Yale University. His previous books include The Conquest of Malaria: Italy, 1900–1962 and Naples in the Time of Cholera, 1884–1911.