This is the second in a series of quick-ish blog posts on Ebola in light of all the stuff going on. Last time, I talked to you about the virology of Ebola, what it is and what it isn’t. The main take-home point from that post is that it is an RNA virus that is tiny, that belongs to a family of viruses along with Marburg virus, and that you should have read this paper by Peters and LeDuc before today’s “lesson.”
We’re going to talk about the history of Ebola outbreaks today. There is a very good chronology of outbreaks as well as a history summary over at the CDC website. You can go over and look at those, but come back because I’m going to get into the details of the other history of Ebola, the social history.
See, the current outbreak of Ebola can’t be summarized in “people got the virus, people got sick, and people died.” There is so much more to that, a lot more. So we need to talk about all the other things that were put in place to lead us to where we are right now. So let’s start in 1976, right after the jump, of course…
The first known outbreak of Ebola occurred in Zaire (now the Democratic Republic of the Congo) and Sudan (now South Sudan) in 1976. Back then, only one other filovirus (the family of viruses) had been detected. That was Marburg virus, and it was detected in 1967 after a group of lab workers became ill with it. Up to 1976, Zaire had been suffering from growing pains after its independence from Belgium. It was a working nation with an authoritarian president, not a failed state. It was mostly rural in nature, with Kinshasa as its largest city.
On the other hand, Sudan had just gone through a civil war that left over 400,000 civilians and over 100,000 combatants dead in a country of about 14 million people. Nevertheless, the populations affected by this first-documented Ebola outbreak were rural, and the outbreak had probably been going for a while before word got out that it was happening.
As Peters and DeLuc write:
“International scientific teams that arrived to deal with these highly virulent epidemics found that transmission had largely ceased; however, they could reconstruct considerable data from the survivors. Medical facilities had been closed because of the high death toll among the staff, thus eliminating major centers for dissemination of infection through the use of unsterilized needles and syringes and the lack of barrier-nursing techniques. In contrast, patients in the affected villages were segregated through traditional methods of quarantine, a step that controlled the situation outside the clinics.”
Samples were brought back to the United States and tested. That’s where we get the most famous Ebola picture out there:
Between 1976 and the current outbreak in West Africa, there were a total of 32 other outbreaks, two of them in the US. The ones in the US had 4 known human cases, none of whom were symptomatic. The outbreak happened in Reston, Virginia, at a facility that housed monkeys for research. It didn’t go beyond there, and the people who were infected didn’t even know they had it until samples were taken and tested for antibodies.
A similar outbreak to Reston occurred in Italy in 1992, while laboratory accidents led to very small outbreaks in Russia and England. The only other place outside of Africa, England, Italy, Russia, and the United States where Ebola has been found was in the Phillippines. There, it was found in research monkeys and in pigs. In both instances, it was the Reston strain.
So let’s jump ahead to the current outbreak — the one we’re all interested in right now — and look at the history leading up to that one. Remember, the current outbreak is concentrated in three countries: Liberia, Sierra Leone, and Guinea.
The current outbreak began in Guinea in December of 2013. By August of 2014, the outbreak has spread to Sierra Leone and Liberia, and it was declared a public health emergency by the World Health Organization. By the time that happened, the cat was out of the bag, so to speak. But we need to go back a little bit more to get a full feel for why this is happening and maybe even how we can control it.
All three of these countries have gone through civil strife. Guinea had coup d’état in 2008, leading to governmental instability. Sierra Leone had a brutal civil war that lasted 11 years and ended in 2002. Not surprisingly, that lead to governmental instability. Liberia had civil unrest as well in the early 2000s, unrest from which it is just barely recovering from. In short, the three countries most affected by the current Ebola outbreak had social and political situations which severely weakened their government infrastructure. As you may or may not know, a stable and strong government is necessary to provide basic services like fire, police, and — most importantly in this case — healthcare.
Because of the lack of a viable healthcare system, humanitarian organizations like Doctors Without Borders and others are providing care for the people of those countries, and they’re providing care beyond the Ebola response. But they’re severely strained, and they will be even more strained if the projections on Ebola cases proves to be true. Ten thousand cases per week are projected by December, and we’re probably past the point of no return on that one.
Of course, it’s not just the political strife in those countries that is making it easy for Ebola to pop up and make so many sick. There are environmental issues as well. One of the speakers at the Ebola Forum at Johns Hopkins the other day said that there is strong evidence that the outbreak is now seen in cities because of deforestation. Ebola outbreaks used to happen in rural settings for the most part. Now we’re seeing these cases in cities, where people run to for cover during civil wars and where people take down surrounding trees to make room for more houses. If Ebola is in the bats, then those bats are now finding themselves contacting more people. In fact, several of the speakers agreed that Ebola would become endemic in West Africa.
Another complicating factor for this outbreak is migrant field/farm workers. Like in the United States, Africa has a population of men and women who travel in and out of the western countries for work. While we try to quarantine people, these workers will probably won’t stand to be quarantined because it will mean losing their livelihoods. They’ll move on to the next working area — somewhere else in Africa — and some of them will bring Ebola along for the ride.
Diseases are complicated things to understand within the human body. We have know how the pathogen enters the body, evades the immune system, and begins a disease process. Then we have to understand if and when — and how — the immune system catches up and counters the infection. And then we have to understand how medicines against these infections act against the pathogen and how they could affect the infected person. Now imagine trying to understand all that and how society, culture, government, economics, and migratory patterns of humans fit into the equation. No wonder people are staying up at night thinking about Ebola.
To understand and have a firm grip on how we’re going to stop this epidemic in its tracks, we need to understand all of its causes — from the biological to the societal. Unfortunately for us, too many public health authorities are compartmentalized into one way of thinking, like the proverbial blind men feeling an elephant and not being able to tell what it is.
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
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