In 1976, a mysterious viral disease swept through the isolated forest village of Yambuku in northern Zaire. I was part of the international team that investigated the outbreak, identified the virus causing it, and named it after the nearby Ebola River. The deadliness of the disease — of the 318 people infected with the virus, 280 died — captured the world’s attention, briefly.
Twenty years later, Zaire came apart at the seams, was renamed the Democratic Republic of the Congo, and became the theater of operations for two wars involving nine countries and more than two dozen militias. Those conflicts, centered at the eastern end of DRC, killed more than 5 million people but barely registered with the rest of the world. Armed militias continue to hold violent reign there.
Last year, in the middle of the former war zone, Ebola re-emerged, as it has 25 other times in sub-Saharan Africa. In this latest outbreak, 2,850 people have been infected with the virus to date and nearly 1,900 have died — the second-worst Ebola epidemic on record — and we are not close to containing it, despite the best efforts of a thousand health professionals on the ground.
In 1976, we had everything to learn about Ebola. Today, we know much more: the symptoms of the disease and how it spreads. Most importantly, we have two new highly effective experimental treatments and a good vaccine, with the very real promise of a second.
Upward of 15 new Ebola infections are occurring every day. In Goma, a city of 2 million people that borders Rwanda, and has an international airport, four patients have been diagnosed with the disease and two have died of it.
We are at a precipice. If this epidemic is not brought under control quickly, it will spread beyond the DRC and possibly beyond Africa, as occurred during the West African Ebola epidemic in 2014 to 2016.
The World Health Organization’s recent declaration of a public health emergency of international concern in the DRC is a welcome step forward and will attract sorely needed resources. But it will take more — much more — to turn around this situation.
My good friend, Jean-Jacques Muyembé-Tamfun, an eminent viral specialist and head of the DRC’s National Institute of Medical Research, has led successful control efforts during the country’s nine previous Ebola outbreaks and was recently chosen to lead the current containment campaign. This outbreak, the worst the DRC has suffered, will test his experience. As many as half of all cases are going unreported, he believes, fueling further contagion. However, two new antibody-based treatments, with survival rates of 70%, could change the outbreak’s course by giving more hope to patients and communities, resulting in increased cooperation and survival.
Meanwhile, militia violence continues virtually unchecked in the very areas most affected by the outbreak.
The militia groups’ assaults on health workers complicate matters. This year, Ebola clinics have come under attack more than 200 times. Dr. Richard Valery Mouzoko, an epidemiologist from Cameroon working with the WHO, was murdered as he led a meeting at a local hospital.
People in these impoverished and neglected provinces face even worse scourges than Ebola. They regularly die of diseases like malaria, tuberculosis, and routine treatable infections. Measles has killed more than 2,000 people in the DRC in the past year. By diverting scarce health care resources, Ebola exacerbates the toll of everyday diseases.
Little wonder, then, that many villagers are not turning to the Ebola clinics when they get sick. They don’t feel safe and they don’t trust the health care system that has failed them for so long. Instead, they try to treat infected individuals in their homes, spreading the disease to family members and neighbors.
Strengthening security must be a top priority. The continuing violence is causing field workers to burn out from fear and exhaustion, and it is becoming increasingly difficult to replace them. In countries such as Afghanistan, Pakistan, and Nigeria, police and military forces protect health professionals as they administer polio vaccinations to vulnerable citizens. The DRC is home to the largest United Nations peacekeeping force, with more than 18,000 security forces. A disciplined military should provide security for medical and public health responders. A coordinated effort is needed to assure order.
Health workers must be able to safely visit households in all the affected villages so they can identify, isolate, and treat people with symptoms and track chains of infection. They must engage respectfully with local authorities; address the rumors, fears, and outright misinformation swirling around the epidemic; and share their evidence.
What’s more, the broken health care system must be repaired so people in poor communities receive proper treatment for malaria, diarrhea, pneumonia, and all the other common ailments that plague them. Properly functioning hospitals and clinics build community trust.
But science and public health alone will not contain Ebola amid widespread violence.
WHO Director-General Tedros Adhanom Ghebreyesus said at a United Nations meeting in Geneva: “Together, we will end this outbreak. But unless we address its root causes — the weak health system, the insecurity, and the political instability — there will be another outbreak.”
He’s right. We must intensify our efforts to stop the current epidemic while building infrastructure and preparing for the next ones, as Ebola and its close cousin, Marburg hemorrhagic fever, are endemic in sub-Saharan Africa. It’s time to treat Ebola like the global health threat it is — and that means addressing the conditions that make any disease too “viral: to contain.
Joel G. Breman, M.D., is the president-elect of the American Society of Tropical Medicine and Hygiene. He has served as an infectious disease outbreak expert at the Centers for Disease Control and Prevention, the World Health Organization, and Senior Scientist Emeritus at the Fogarty International Center of the National Institutes of Health.
I think the root cause is eating bats and bush meat as well. They will need to tackle that at the same time!
Thanks for bringing a better understanding of this looming health crisis, and the more chronic ones in this part of the world, to a wider audience. And thanks for all the good work you have done in the field of infectious diseases, including the eradication of smallpox–the world owes you and your co-workers a debt of gratitude.
Good article. One observation: the term “root cause” is unnecessarily metaphysical, makes one think of the elephants-all-the-way-down problem.
The causes are numerous. The most easily observable and immediate ones, are indeed health care quality and quasi-perpetual regional entropy. Yes, these countries need aid, yes UN troops could be used more effectively. I would add that reaching out to women and offering them some basic health and infection control education, and access to birth control which they do wish for, would help them feel part of solutions, enhance trust, and help mitigate the effects of future epidemics.
If there is one key determinant of so much of the entropy in the region, it may be that young women are not yet empowered to control their own fertility.
Killer epidemics come and go, what we need is to think long-term rather than merely rush from crisis to crisis.
The USA should focus on its drug related death problem. 80,000 Americans die each year from drug addiction
Well written macro view of the challenge and solution to a recurring health plague. Thanks for your unwavering commitment to world health, Dr. Breman (who also happens to be Dad), 8+ decades in.