It was 65°F outside and Yusia was freezing. The cold and the damp of the Sudanese rainy season clung to his bones as he biked to work, the pumping of his legs over the sodden ground making thuck thuck sounds as the mud tried to suck up the wheels of his bike, coating his calves with flecks of mud in the process. For 10 miles the sharp morning air stung Yusia’s cheeks as he pedaled though the frigid, waterlogged dawn to the town of Nzara, where heworked as a tallyman at a cotton factory. When he reached the factory, Yusia went into his office next to the storeroom and set to work, maybe hoping that a little industry would take his mind off his chill until it got warmer outside. So Yusia sat at his desk, next to his officemate Bullen, and began taking inventory of the number of cotton bales lying within the guano-stained walls of the company storeroom so they could be hauled away to wherever they were going.
As the day progressed and the weather got warmer, Yusia somehow felt even colder than he had that morning. In addition, he had developed a splitting headache and began having pronounced muscle pains in his chest, neck and back. By the time his workday was through and he had returned home, things had taken a turn for the worse. Over the course of the next few days new ailments began popping up with undue speed, as he developed small ulcers on the inside of his cheeks, a raging sore throat and lost all color and vitality from his face. Before long, Yusia started suffering from severe abdominal pains, vomiting and diarrhea and, after finally being taken by his brother to a local hospital, bouts of profuse bleeding from his nose and mouth. Six days after being admitted to the hospital, Yusia died. However, the disease that killed him did not.
Within a week, both Yusia’s brother and his officemate Bullen began showing similar symptoms. Yusia’s brother managed to survive, but Bullen wasn’t so lucky. Neither was Bullen’s wife, who died shortly after her husband and another co-worker, Paul, a social butterfly and bachelor who was attended to by many (mostly female) friends during his fatal illness. One of these friends was a man named Samir, who caught the virus from Paul and was taken to the a hospital 80 miles away in the city of Maridi. Once in the hospital, the virus amplified tremendously, using the frequent contact with hospital visitors and nurses to spread with previously unseen efficiency among the local population. By the time the rainy season had officially ended in November, 213 people in Maridi had been infected, almost 4 times as many as were infected in Nzara where the virus first found a human host. The virus eventually petered out by the end of the year, but the damage had been done. Ebola had been formally introduced to world.
Or, at least the virus that we now know as Ebola was introduced. In the early summer of 1976, the members of the World Health Organization and the International Study Team they were working with in what is now the South Sudan had yet to give the illness a name. It wasn’t until later that year when researchers were investigating a similar, even more deadly outbreak near the Ebola River in northern Zaire (now the Democratic Republic of the Congo) that the virus got its moniker. That outbreak, which is believed to have been brought directly to Zaire by someone infected in the Sudan, took place almost exclusively at a Mission Hospital in the town of Yambuku, where more than 90% of the 318 people infected with Ebola would pass away.
It is not mere coincidence that both of these outbreaks took place in and around modern hospitals. Recent studies suggest that the Ebola virus, or some ancient ancestor thereof, has been around for at least 18 million years in rodents and other mammals, like the bats that roosted in the rafters of the cotton factory where Yusia worked. And, while zoonosis—the process by which infectious diseases are transmitted between species—is extremely rare, it is naïve to believe that this ancient virus only learned how to infect humans within the last 40 years. The cause for Ebola’s recent rise to dubious international prominence has very little to due with changes in the disease itself and is almost entirely attributable to changes in the world that existed around the disease.
For instance, ever since its first recorded outbreak, Ebola has popped up sporadically and with varying strength and severity across the African continent. Some of these outbreaks ended up infecting only 20 or 30 people while others, like the epidemic currently enveloping West Africa, have infected tens of thousands. Regardless of the number of infections they caused, each and every one of these outbreaks has been a descendent of the strain of Ebola that was first identified in 1976 and, while the virus has mutated over the years, these mutations have little or no effect on its virulence. What has changed in the past 150 years in places like the South Sudan and Liberia is the introduction of industrialization and modern medicine into their daily existence. Ironically enough, the advances and efforts of western medicine have resulted in some of the largest and deadliest epidemics in human history.
Before looking at the ways in which the industrialization and modernization of Sub-Saharan Africa have caused the current outbreak, it would be useful to look at the history of a slightly different and far more deadly disease whose “discovery” came after Ebola’s, but has caused the deaths of over 39 million people since it was identified: AIDS. In 1981, five years after the formal discovery of Ebola, a group of doctors in Los Angeles treated five gay men in their late 20s and early-to-mid 30s who had been suffering from Pneumocystis carinii Pneumonia, a rare infection that had previously only appeared in immunosuppressed patients who suffered from protein malnutrition, acute lymphocytic leukemia, or in patients receiving corticosteroid therapy.
The presenting symptoms were so bizarre that the doctors decided to publish the case reports in the CDC’s Morbidity and Mortality Weekly Report, a decision that we now know, in retrospect, to be the first published report on the HIV/AIDS epidemic. Over the course of the next decade, the estimated number of people infected with HIV had grown from a couple hundred to anywhere between 9 and 11 million. Today, the number of people living with HIV across the globe is a staggering 35 million. However, for the purposes of this article and in order for us to effectively look at the ways in which our experience with HIV can help explain the most recent Ebola outbreak in West Africa, we must go back and not forward, decades before AIDS was officially identified.
HIV is a very patient disease and its patience is the primary reason why it is so deadly. As best we can tell, the first known person to contract the Ebola virus, or Patient Zero, was a two year old boy from southern Guinea named Emile. Having passed away on the 28th of December, it’s fair to say that Emile likely contracted Ebola some time in mid-December of 2013, roughly 10 months ago. On the other hand, the Patient Zero for HIV was in all likelihood a hunter living in or around what is now southeastern Cameroon in 1921 who cut himself while hunting chimpanzees and handling their meat, providing an avenue for the disease the jump species. This was almost certainly not the first time that an African man had been cut and infected with SIV (Simian Immunodeficiency Virus) and, at any time in the past, it would have petered out of its own accord after possibly infecting members of Patient Zero’s family and community. However, the recent impact of European colonialism and the growing urbanization and industrialization that it brought with it to the African Continent had greatly expanded the travel radiuses of many Africans who had previously lived within very self-contained tribal communities.
It is most likely that our Patient Zero was one of the 127,500 Africans from that particular region to work on the construction of a massive railroad that ran from the French Congolese capital of Brazzaville to the port city of Pointe-Noire. The men who worked on this railroad were paid next to nothing and were forced to live in poorly maintained camps near their worksites, which ran through the Mayombe portion of the Congo Rainforest. Conditions would prove to be deadly, with dysentery, pneumonia and other febrile illnesses killing thousands of workers. After being exposed by journalists for their inhumane treatment of the railroad workers, the French began sending in doctors to inspect the camps and improve the overall health of the workforce, a goal that was achieved through the re-use of syringes and needles in the treatment of tropical disease. All you need is for Patient Zero to be diagnosed with some sort of tropical illness and treated for it and pretty soon you have an unsterilized, HIV-tainted syringe that’s being used to treat hundreds of men and further transmission of the virus would be pretty much unavoidable.
Shortly after that, HIV’s spread throughout Central Africa began to pick up speed as the administration of literally millions of injections by colonial doctors and nurses to treat a variety of tropical diseases in Cameroon and French Equatorial Africa ranging from Sleeping Sickness and Syphilis to Yaws and Leprosy likely facilitated further spread of the virus. From there, it was only a matter of time until transmission reached a level where it became inevitable that at least a few of these men would make their way to major cities like Brazzaville and Leopoldville (Kinshasa) and infect a free woman and initiate a chain of sexual transmission. Once it had found its way into those major cities it spread slowly until the Congo won their independence in 1960, triggering a protracted civil war and ushering in widespread unemployment and poverty that contributed to the rise of more high risk forms of prostitution and wider transmission of HIV. In the years following independence, HIV transmission rates skyrocketed and eventually, in the mid-to-late 1960s, a Haitian who had been living briefly in the Congo contracted HIV and brought it back to Haiti, which acted as a springboard to the global AIDS pandemic.
A disease of 1 does not become a disease of 35 million by dint of coincidence and bad luck. A disease of 1 becomes a disease of 35 million because it is ideally suited for the time in which it lives. AIDS is a cosmopolitan disease born out of a once localized virus. A disease that might as well have been designed specifically to operate within the confines of a globalized world. AIDS is patient, but it is also quiet and covert. It sits inside you for years, watching your viral load slowly rise and waiting for the opportunity to shuffle off its mortal coils out of your body and into someone else’s. AIDS is a hitchhiker; the end result of a retroviral bur that latches softly onto a man’s leg and travels halfway across the earth and back with him before he even notices it’s there.
Don’t bank on the Pollyanna projections of politicians and the Joint United Nations Programme on HIV/AIDS that the an AIDS-free generation is on the horizon. AIDS was around 28 years ago when I was born and it will almost certainly still be around whenever the universe sees fit for me to die. We’re well into the 21st Century and roughly 3.6 million people are still dying every year from diarrhea, typhoid, cholera and dysentery—diseases that are all preventable through something as simple as access to clean water—so hopefully you’ll forgive me in not sharing in their optimism. Amazing strides have been made since the turn of the century and a 38% decline in new infections and a 33% drop in AIDS-related deaths shows the truly remarkable progress that has been made in the fight against HIV/AIDS, but those numbers belie the fact that there are more people living with HIV/AIDS today than at any time in history and fail to take into account the effect that climate change and geopolitical/economic instability will have on access to treatment in the future.
The Ebola virus does not share HIV’s predisposition to longevity. Ebola may be intractable, but it is also impatient and all of those things which make the virus such a darling in our fear-driven mass media and help to foment panic in the general population are the very things that make it highly improbable that it will gain traction in the “developed world”. Like HIV, Ebola can only be spread through the exchange of blood or certain bodily fluids from an infected person to the mucous membranes or broken skin of someone who is not infected. But unlike HIV, Ebola is devoid of artifice or tact and, where HIV stealthily infects by cover of darkness, Ebola comes out in broad daylight with guns blazing. The external bleeding and the violent vomiting and the bloody diarrhea of Ebola is terrifying, but it also signals in no uncertain terms the arrival of the virus in the host’s body and the potential for infection. Couple this laissez faire approach to transmission with the fact that Ebola has a very limited shelf life and is not always fatal and you’re left with a virus that is eminently manageable with the use of stringent sterilization procedures and proper public health measures.
The reasons why this latest outbreak of Ebola has been so catastrophic in comparison to outbreaks past has much more to do with the nations in which it has flourished than it does any demonstrable change in the virus itself. The three countries where the epidemic has really taken hold—Liberia, Guinea and Sierra Leone—are some of the poorest, least developed nations on earth, ranking 175th, 179th and 183rd out of the 187 countries included in the UN’s Human Development Index. All three nations have been embroiled in civil wars and subject to coups d’etat at least once over the past 30 years and have struggled mightily with dictatorships and corrupt governments. As a result, there is virtually no healthcare system in place in all of these countries and any sort of coordinated public health response is impossible considering they have neither the infrastructure or the capital to orchestrate one. In Liberia and Sierra Leone, resources are so scarce that there are only 15 doctors for every 1 million citizens. You can’t even monitor a population’s cholesterol with a ration of 15 doctors per 1 million citizens, much less stem the tide of a deadly hemorrhagic fever.
However, while these West African nations lack the proper infrastructure to combat Ebola, all of the trappings and unintended consequences of colonialism and industrial development have created an optimal environment in which the virus can thrive. 100 years ago, a 2 year old boy in a small Guinean town could be infected with the Ebola virus and whatever tragedy that ensued would remain where started. The virus might reach the 2nd or 3rd generation of hosts, but after that it would run out of people to infect and die out. That’s not the case today. Today, there are railroads and highways and hospitals and metropolises in West Africa that provide Ebola with a blueprint for propagation in much the same way that urbanization and western medicine first enabled the spread of HIV in Central Africa almost a century ago. Knowing what we do now, it is the obligation of the entire global community to step up and provide aide to these West African nations as they struggle to contain Ebola; not because we’re terrified that it might spread in our homeland, but because we have compassion and love for the people already beset by this pestilence in theirs.