What is Ebola? How is it contracted? How is the disease highlighting the prejudices and shortcomings of the international community? In what ways is it undermining West African values and practices. Yohannes Woldemariam reflects on these questions and more.
WHAT EBOLA IS AND IS NOT
What is Ebola and how is it different from other transmitted diseases? It is a viral disease. According to the New York times: ‘One is not likely to contract Ebola just by being in proximity with someone who has the virus; it is not airborne, like the flu or respiratory viruses such as SARS. Ebola spreads through direct contact with bodily fluids. If an infected person’s blood or vomit gets in another person’s eyes, nose or mouth, the infection may be transmitted. The virus can survive on surfaces, so any object contaminated with bodily fluids, like a latex glove or a hypodermic needle, may spread the disease’. [i">
This characteristic of the disease forces the swift isolation and pariah status of the victims, along with those not showing symptoms who are from the affected or suspected areas. Furthermore, the epidemic can be confused with other diseases, the symptoms of which closely resemble symptoms of Ebola. Even the elites of Africa attending the US-Africa Leaders Summit in Washington D.C. were not immune from suspicion of infection. They had to be screened before being allowed to set foot in the country. [ii">
AFFECTED COUNTRIES AND THE CURRENT CHALLENGE
The most affected countries in Africa are Liberia – most recent deaths have occurred there – Guinea, Sierra Leone, and most recently the Democratic Republic of the Congo. Nigeria has also reported over a dozen deaths and many more infected. To make matters worse, doctors in Nigeria are on strike. Nigerian President Goodluck Jonathan fired 16,000 resident doctors for striking while in the midst of an epidemic [iii">. The World Health Organisation (WHO) determined that the East African country of Kenya is at high risk for Ebola because the country is a hub for air travel to many West African countries [iv">. In a knee-jerk reaction and bowing to international pressure, Kenya’s airlines have stopped all flights to the affected countries [v">. South Africa has followed suit by similarly banning flights.
However, Kenya is not the only major hub; so are Ethiopia, South Africa, and several other countries in Africa. Why has the international community decided that Ethiopia, for example, is not a similar risk? It is the hub for organisations like the African Union (AU), and Ethiopian Airlines makes frequent flights to West Africa and many other African countries. [vi"> Such a reaction demonstrates the contradictory and incoherent nature of the response by those who should know better and provide effective leadership.
Are these countries prepared for Ebola? I honestly doubt it. The public health system in most of Africa is dysfunctional, in many cases almost non-existent.
Ethiopia claims to have established a special hospital for potential Ebola cases. Yet the health care system in Ethiopia is one of the worst in the world. In her recent trip to the country, Amy Walters of (National Public Radio) NPR discovered that even the country’s best hospital, Tikur Anbesa, has inadequate equipment, facilities, and medical personnel [vii">. The doctor/patient ratio in the country suffers from a chronic brain-drain due to the exodus of doctors who complain of low salaries to Western countries. On top of that, 85% of Ethiopians never see doctors at all [viii">. The picture is more or less similar in most African countries.
It is encouraging that the WHO at least belatedly declared Ebola an International Public Health Emergency [ix">. Also, the US. health authorities have acknowledged that Ebola’s spread beyond West Africa is ‘inevitable’, and the medical charity Doctors Without Borders/ Médecins Sans Frontières (MSF) warned that the deadly virus was now ‘out of control’ with more than 60 outbreak hot-spots [x">. MSF is urging the WHO to give better leadership in the fight against Ebola. Frankly, MSF appears to be the first to realise the gravity of the situation. This could be due to the WHO, as a specialised UN agency, being constrained by bureaucracy and politics. MSF is an independent NGO with a fearless record of speaking out, often being the first in and the last to leave in many humanitarian interventions.
Ebola is spreading much faster than is generally acknowledged publicly, and the death rate is much higher than the 1300 or so reported as of 25 August [xi">. Part of the reason can be that the borders in Africa are very porous. Borders have in response been strengthened by African governments. But is cordoning off the affected areas the right or ethical approach? The reaction resembles the scenario in Foucault’s ‘Discipline and Punish’ of how plague-struck towns were treated in medieval Europe [xii">. Will we see the same now done to the unfortunate inhabitants of Ebola stricken areas? Certainly, the international air travel ban and increased border security point in that direction.
CLASH OF CULTURES AND EBOLA
Not only is Ebola killing Africans; it also threatens to undermine dearly held social structures and values. Touching, washing and arranging bodies for burial are integral to African cultures. There are secret societies of women who perform burial rituals for women and men who perform similar rituals for men. It is a form of emotional violence for loved ones to be prevented from these long held traditions and have strangers wearing masks and space suits take away the bodies. The trauma of being denied the traditional closure can be psychologically devastating to surviving relatives.
Moreover, most of Africa is a very sensorial culture. Not greeting people by shaking hands and in some cases by kissing on the cheek is considered rude. Embracing people through hugging and touching is the norm. Therefore, Ebola strikes at the heart of African values and social structures: civility, liveliness, respect for elders, the strength of the family unit and the sense of duty. Traditional funerals, which involve washing and touching the corpse, are now forbidden. There are reports that relatives of the deceased have run away from home in fear of infection. They let medical teams come to collect and dispose of the body. The initial resistance and respect for tradition is wearing out, and people are now suddenly in survival mode. Ironically, people who are ill with other deadly ailments like malaria are refraining from seeking hospital care because of a perception that hospitals are transmitting agents for Ebola. Even worse, a quarantine center for suspected Ebola patients in the Liberian capital of Monrovia has been attacked and looted by protesters. According to a government official, ‘the protesters were unhappy that patients were being brought in from other parts of the capital’.[xiii">
This whole thing reminds me of a book I read many years ago: Albert Camus’s The Plague. Camus’s novel chronicles the effects of an evil pestilence on an Algerian town called Oran. The book is the journal of a doctor who describes and analyses the epidemic with thorough scientific detachment in an attempt to make sense of human mortality and the circumstances beyond human control that isolate individuals yet curiously unite even the most personally and philosophically disparate within the towns and villages. Camus’s message is that there’s no constant except that we are all in it together despite the panic and hysteria and isolation.
INTERNATIONAL REACTION AND THE WAY FORWARD
According to the WHO, air travel is low risk for transmitting the disease [xiv">. Yet, we’re now witnessing extreme hysteria, and countries like the UAE and British Airways are suspending flights to the affected countries. Germany has asked its nationals to leave the affected countries. Korean Airlines has suspended flights to Kenya. The International Olympic Committee (IOC) has ruled that athletes from affected countries will not be allowed to compete in combat sports or in the pool. Brazilian executives have cancelled a visit to Namibia over fears about Ebola, despite the center of the outbreak being almost 3,000 miles away [xix">. The panic about the unknown and unseen contagion can do as much damage as the disease itself (AIDS comes to mind). Unlike AIDS, so far it seems that Ebola cannot be spread by asymptomatic people. That being said, we may find that the virus changes over time to include strains that can be transmitted by people without symptoms. This eventuality could be quite worrisome. Oddly, sometimes viruses get too smart for their own good and end up killing their hosts (the fruit bat in cases of Ebola) so efficiently that their spread dissipates on its own. This seems to have happened with other Ebola outbreaks, but earlier Ebola cases occurred in geographically limited areas or isolated villages.
The international community is being rather slow and reluctant in responding constructively to Ebola. In the short run, a much more aggressive campaign which would also be as sensitive as possible to long held burial rituals is urgently needed. What that might be, given poor countries with a dismal health care system to begin with, is the real quandary. There certainly needs to be a more efficient system of transporting volunteer doctors and health care professionals to affected areas with the necessary preventive equipment.
Experimental drugs that might help need to be available and delivered in a timely manner. In an unprecedented move, the WHO has determined that under the circumstances, it is ethical to use the new drug Zmapp with patient consent [xv">. Japan is also offering Avigan – used to treat new and re-emerging influenza viruses – as a possible treatment for Ebola [xvi">. Despite the fact that these drugs are merely experimental and no clinical trials have been conducted, lives could be saved. Especially in the case of victims who may not survive, they could be used in the remote chance that they might help.
The Nigerian trauma doctor, Ola Orekunrin, suggests leapfrogging and working around the infrastructural problems of African healthcare. She advocates efficient use of existing resources, the creative use of mobile phone technology, and telemedicine [xvii">. Education is also key as ‘some of those in infected areas were not seeking medical treatment as they thought the disease was the work of sorcerers’ [xx">. Technology, schools, word of mouth, and music by popular musicians could be used to raise public awareness and improve early warning systems. Anthropologists versed in the cultures of the affected communities can also help as a bridge in easing the shock that comes with the intrusiveness of modern medicine.
According to Laurie Garrett, a Pulitzer Prize winner for her writings on Ebola: ‘As terrifying as Ebola is, the virus has been controlled in the past, and can be again. The current crisis, which threatens an 11-nation region of Africa that includes the continent’s giant, Nigeria, is not a biological or medical one so much as it is political. The three nations in Ebola’s thrall need technical support from outsiders but will not succeed in stopping the virus until each nation’s leaders embrace effective governance’. [xviii">
Garrett is urging a political mobilisation, transcending borders on a massive scale, to stop this epidemic. Garrett doesn’t believe airport screenings are effective. She urges nations to exert a focused political will to deal with Ebola on a massively coordinated scale at the regional and international levels. Short of that, we could be looking at a pandemic catastrophe.
In the long run, global actors also need to invest in healthcare infrastructure and research into tropical pathogens in Africa. Ebola has been known since 1976. Why has vaccine been so elusive? By all knowledgeable accounts, the Ebola virus is not as smart as the HIV virus. Increased funding for research and finding a cure or vaccine is not only about altruism but also a matter of enlightened self-interest. Investing in the health care of Africans is cheaper than the inevitable disruption to lives, trade and transportation.
It is myopic to assume that a disease like Ebola or any tropical pathogen can be contained in Africa for long. In medicine as in many aspects of life, the ‘us’ versus ‘them’ mentality is pervasive. However, the Ebola virus is not discriminating. It may eventually find its way to the affluent world.
[x"> Ebola: WHO declares the epidemic as global emergency; US health authorities had admitted that Ebola’s spread beyond West Africa was inevitable. Even medical charity Doctors Without Borders had warned that the deadly virus was now ‘out of control’ with more than 60 outbreak hotspots.’ Money Life 8 Aug. 2014.
* Yohannes Woldemariam teaches international relations at Fort Lewis College in Colorado, USA.
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