Ebola: Crisis of infrastructure
Ahmad Ebrahimi examines the root cause of the Ebola epidemic
What has allowed an apparently insignificant virus like Ebola to evolve into a potentially global epidemic? First identified near the Ebola river in the Democratic Republic of Congo 38 years ago, it has been the source of a number of small outbreaks in countries of central and west Africa. All these either petered out or were brought under control after deaths counted in tens and occasionally hundreds. The largest previous epidemic was in Gulu district in the north of Uganda, with 425 infections and 224 deaths.1 As I write, the fatalities for the current outbreak are officially approaching the 5,000 mark.
Viruses cannot reproduce themselves and need a living host in order to survive and propagate. Once inside a host, they hijack their cellular mechanisms to reproduce and multiply. They then need a mechanism to pass over to the next living organism. And human beings are not a natural host for Ebola (rather it is the fruit bat). Killing the host before the virus has time to reproduce and pass across to a new host is self-destructive. But that is what Ebola does, which is why humans do not provide for a successful environment. Contrast this with HIV, which does not kill its host for eight-10 productive years, before passing on its progeny (by sex or needles in this case).
Ebola can be controlled by nothing more imaginative than isolating all people who have been infected and exposed to infection. Since no treatment is currently available, the only medical management consists of providing palliative care to the infected persons - hydration, food and treating secondary infections. Patients who survive will be immune for at least 10 years, and probably more. And, of course, healthcare workers must also be protected from infection and steps must be taken to avoid cross-infection in hospital and healthcare settings. These precautions were effective in controlling all previous outbreaks, which fizzled out without causing too much devastation.
To explain the new epidemic which to date has infected more than 10,000 people, some have suggested a new mutation, although there is as yet no evidence for this. So to understand the underlying mechanisms for the current explosive spread of Ebola we need to look at the other cases over the last three decades for clues. All the more severe outbreaks occurred in areas of civil war (DRC, south Sudan, northern Uganda), where there were large population movements and huge numbers of refugees criss-crossing the porous borders. And all previous outbreaks, big or small, had taken place in countries bordering the DRC, where a civil war has been endemic. That is, until the current epidemic, which began in Guinea on the border with Liberia and Sierra Leone and rapidly spread into those two countries and beyond. Why?
I think there are three factors that set the scene for the current epidemic, which has allowed it to totally escape any control. During the 1980s, with the rolling out of neoliberal policies, the mantra of the World Bank, International Monetary Fund and World Trade Organisation was the privatisation of all state-funded institutions, including healthcare. This was the precondition for any loans from the global banking system. The result was a devastating collapse of the already sparse and rudimentary healthcare facilities across Africa.
The entire continent - already hit by a period of inter-state and civil wars, stoked by outside powers either directly or by proxy - was left exposed from a public health point of view. Wars in Katanga (Belgian Congo, now the DRC), Uganda, Mozambique, Angola, Guinea Bissau, Zaire, Nigeria, Namibia, Rwanda, Burundi, Ethiopia, Eritrea, Chad, Somalia, Sudan, Zambia, Zimbabwe (Rhodesia), Uganda and Western Sahara had displaced millions of people. When HIV passed from chimpanzees to humans in Cameroon some time in the early or mid-1900s and began its long march across central Africa and beyond, there was little by way of public health infrastructure to confront it.
Ebola crossed the species barrier after the civil wars in Sierra Leone, Liberia and the Ivory Coast, and the involvement of the Guinean military had further uprooted entire communities. These civil wars were not merely over tribal rivalries, but were also about the scramble to mine and smuggle diamonds, in which outside firms and states were deeply and criminally involved. The current epidemic started in the border regions of Guinea and rapidly spread to the two neighbouring countries, uprooting communities and breaking down social cohesion.
Unsurprisingly the epidemic in west Africa has spread quickly to cities such as Freetown. This process was accelerated not only by the links between the countryside and the cities created by mass migration in the wake of civil wars, but also by the continent-wide increase in the mobility of labour, brought about by the global spread of capitalism. New arrivals into the shanty towns are huddled together in overcrowded accommodation. Moreover, the disproportionate adult deaths caused by those wars brought about a change in the extended family structure, with fewer and fewer adults caring for an ever-larger number of children and the elderly. The family, so to speak, was drawn closer together in the face of an increasingly hostile and unfamiliar world. This added to the overcrowding, and the increasing suspicion of outsiders. Hovering above these dramatic social changes is climate change and forest-logging. Together they altered the habitat of the fruit bat - which, as a result of mass poverty, became a convenient source of protein for humans. The stage was set for a ‘perfect storm’.
Most diseases have a social dimension, and infectious diseases are essentially defined by social interactions.2 Viewed from this angle, the current epidemic of Ebola in the region can be laid at the feet of the social upheavals, disruptions and breakdowns brought about by the global spread of capitalism and its latest offspring, neoliberal capitalism.
Back in March the charity, Médecins Sans Frontières, warned that the Ebola epidemic was about to get out of control and called for immediate action. Its cries fell on deaf ears. It was something happening in ‘far-off countries of which we know little’, and which are not high on the list of capital’s global priorities. Public opinion in the US only moved when two nurses became infected by a visiting Liberian. The United Nations target of $1 billion to combat the epidemic has still not been reached.
One explanation given for the meagre international response is the danger to healthcare workers, and the fact that over 200 have already died as a result of being infected while treating victims. Yet a leading doctor from MSF, in a debate broadcast live on Aljazeera TV on October 15, reminded us that MSF has over 3,000 healthcare workers battling Ebola and has suffered very few casualties. She pointed out that the enforcement of strict adherence to its guidelines was behind this success, which was achieved even in the difficult environments in which MSF has been forced to work.
As to the development of a treatment regime that can see off such epidemics, that is clearly a long way off. The sporadic and localised nature of Ebola outbreaks has meant that it has remained below the radar for all but a few dedicated virologists, etc. Such a disease in a poverty-stricken part of the world was never going to induce drug company investment in treatment or vaccine development. Yet for a disease that produces natural immunity in survivors, the chance of an effective vaccine is excellent - unlike HIV, which easily escapes the infected individual’s immune surveillance. Both research for treatment and vaccination for such rare diseases falls on the state sector - not very likely at a time of global depression.
Yet the US military has the capacity to provide both the field hospitals and the personnel to provide health education and to isolate infected individuals.3 Cuba has shown how even a small country can mobilise resources to deal with this deadly epidemic. Pressure should be placed on rich countries to provide the personnel, to repair and boost the meagre local infrastructure and to come up with the necessary funds to control and push back the epidemic, both directly and through such effective organs as MSF.
2. See ‘Threat of social breakdown’ Weekly Worker October 16 2014.
3. See www.bmj.com/content/bmj/349/bmj.g6151.full.pdf.