Health, fitness and Food
A Tale of Two Africas
In 2000, the deadly Ebola virus struck Uganda. And like the current outbreak in West Africa, now the largest in history, Uganda was completely unprepared.
Combating it in a remote northern district under siege from a rebel insurgency, Ugandan health authorities failed to stem an initial outbreak. Frightened residents—many displaced by militants and living in congested camps—hid their ill relatives, infecting themselves as they wiped away the sweat and blood of the sick or as they prepared infectious bodies for burial. Patients fled hospitals, spreading the disease. Health-care workers ran away too.
Uganda defeated the epidemic several months later, but by then, 425 people contracted Ebola, and more than half of them had died. It was the largest Ebola outbreak on record—until this year.
Today, Uganda has a different Ebola story to tell. The East African nation has had four more occurrences with the disease, but none has proved as deadly as the first in 2000. Authorities from the nation’s president to village leaders exhort Ugandans to be on the lookout for people with symptoms. Health officials screen airline passengers and have stockpiled hospitals with supplies. Teams of veterinarians test wildlife for viruses like Ebola that can infect humans. Uganda has even sent doctors to West Africa to train medical staff there during the outbreak.
The contrast with the countries where Ebola is raging now—Liberia, Guinea and Sierra Leone—paints a picture of two Africas. One has built up a health and education system to shield itself against Ebola and other emergent disease threats. The other Africa is in chaos, its public health systems in shambles.
Uganda’s experience offers the world a timely lesson as the outbreak threatens to burst beyond West Africa. It isn’t only rich countries with sophisticated hospitals and expansive pharmaceutical industries that can squash outbreaks. Basic medical training, everyday vigilance and sustained political will go a long way. Propping up the health systems of poor nations with outside aid and workers—without passing on skills to locals—may provide a quick fix but won’t immunize them from the next outbreak, which could be even bigger.
Uganda’s three Ebola flare-ups since 2011 have fizzled out. There were a mere 18 cases of the disease. Eight people died. In one instance, a single case was isolated before the virus could spread.
Uganda is “really a model of what we want to see happen all over in low- and even middle-income countries in terms of better detection, response and prevention,” said Tom Frieden, director of the Centers for Disease Control and Prevention, which has set up a high-security laboratory and helped fund other health system upgrades in the country as part of a U.S. government global health security initiative.
By contrast, Ebola-stricken countries such as Sierra Leone and Liberia are unraveling. Hospitals, schools and businesses have closed. In Liberia, doctors have gone on strike for want of protective clothing and gloves. In one Liberian neighborhood, residents looted a transit center for suspected Ebola patients.
A security crisis is now emerging: Earlier this week, Liberian soldiers fired on a crowd of young men who were trying to force their way out of a quarantined neighborhood in the stricken capital of Monrovia.
Despite a rising death toll, many of Liberia’s residents are convinced that the virus is a government conspiracy. “It’s a rumor,” said Patrick Brandy, an electrician in Dolo Town, one of the nation’s hardest-hit communities. “I’ve never seen anybody die of Ebola. I’ve only heard of it. So it’s a rumor.”
With at least 2,615 cases spanning West African countries, including 1,427 deaths, the epidemic is more than six times as large as the 2000 outbreak in Uganda’s Gulu district. The World Health Organization says even that toll is “vastly” underestimated.
The West African epidemic illustrates the dangers that weak health systems in destitute, urbanized nations pose to the rest of the world—and the dangers of a tepid international response to their predicament. Like Uganda, the three West African nations are emerging from a past of war, dictatorship and corruption. But their wounds remain far more visible.
Until its first free election in 2010, Guinea was one of Africa’s worst-led nations, its civil service systematically disemboweled over 50 years of dictatorship. Liberia’s civil servants all but vanished too, fleeing in a 14-year-long civil war that erupted in 1989 and left 250,000 people dead after spilling into Sierra Leone and Guinea—the two fragile nations that now, not coincidentally, are also struggling to beat back Ebola.
Today, Sierra Leone has the lowest life expectancy on Earth, according to the World Bank. Guinea has the fewest number of hospital beds per person, according to a 2011 survey of 63 developing countries by the bank. Liberia has one doctor for every 71,428 people, the world’s second-lowest rate, according to the WHO. All three have barely any public health expertise.
Liberia’s Health Ministry spent months trying to persuade even senior government officials that Ebola was a real disease—not a scam perpetuated to draw aid money, as several officials suggested publicly. On a recent workday, Deputy Health Minister Tolbert Nyenswah was shouting with a secretary who brought in several stacks of papers in need of signatures.
“Only Ebola things I’m signing!” he yelled, adding to a reporter: “This is a public health catastrophe.”
It’s a public health threat to the rest of the world, too. Ebola has traditionally been a rural disease, infecting villagers who ate tainted bush meat or came into contact with bat droppings. They would then spread the infections to family members or health care workers who touched their bodily fluids.
The deadly virus emerged in a similar way this time. In December, the first known case was a 2-year-old who died in a village in Gueckedou, a rural prefecture in a forested area of Guinea near the borders with Liberia and Sierra Leone. The boy’s mother, sister and grandmother died shortly after.
By late March, Ebola cases were cropping up hundreds of miles away on the Atlantic coast in Conakry, Guinea’s congested capital, with a population of 1.7 million. The disease had also spread into Liberia, and then Sierra Leone, as nurses who treated the sick and villagers who attended their funerals all brought the virus into their homes and workplaces, sparking chain reactions.
It quickly became apparent how different this corner of Africa was from Uganda and other parts of Central Africa where Ebola has been striking sporadically since 1976.
Despite bad roads, West Africans are mobile; they travel long distances and carry the disease with them. In Uganda, just 16% of the population lives in cities, but that situation has become more the exception than the rule in Africa as economic growth picks up and more young people flood cities—and other countries—in search of work. In Guinea, 36% of the population lives in cites; in Liberia, it’s 49%, according to the World Bank. Many also hew to traditional rather than modern medicine, making them suspicious of doctors and health officials trying to stop Ebola’s spread.
In Guinea, officials recently have managed to turn a corner: Priests and imams recently convinced residents of 26 resistant villages to bring their sick to nearby clinics.
But Liberia and Sierra Leone are on an opposite trajectory. Governments there have simply cordoned off areas where the virus is spreading most. On Wednesday, Liberia’s government blocked all entry and exit from West Point, a densely packed neighborhood of tin-roof houses overhanging the ocean.
The scenario playing out in West Africa could become more common. The number of new emerging diseases is increasing every year, and about three-quarters of them originate in animals, according to EcoHealth Alliance, a nonprofit organization that researches the animal origins of emerging viruses. At the same time, about 80% of the WHO’s member states weren’t able to meet original deadlines for strengthening their public health systems enough to comply with international health regulations that require a capacity to detect and respond to disease events and to report outbreaks to the WHO.
While government agencies and relief organizations had been working on some projects in the three countries to stem diseases such as malaria and Lassa fever, none are as robust as investments in countries like Uganda or Nigeria where governments have embraced change.
The WHO is trying to corral emergency funds of $100 million in international aid to carry out an Ebola action plan—an effort that is likely to take several months, with money that would have been better spent preventing such events in the first place. A spokesman said the agency has reached about 40% of that need so far.
The World Bank is providing up to $200 million in emergency funding to the three countries. The CDC has deployed 62 staff who are traveling to remote villages to train health workers, setting up mobile labs to test for the Ebola virus, tracking down people who may have been in contact with Ebola patients and other tasks.
But doctors, epidemiologists and other staff are all still in short supply. “We have reached our limit in what we can do,” said Joanne Liu, international president of Doctors Without Borders, the nongovernmental group that is leading the effort to treat patients and is a veteran of multiple Ebola outbreaks. “We need the equivalent of the CDC from other countries to come in, and schools of tropical medicine that are used to working with hemorrhagic fevers. This is not happening right now.”
The epidemic is also testing the limits of the WHO, which has been managing multiple public health crises this year, from Ebola to a flare-up of Middle East Respiratory Syndrome this spring. “We are extremely stretched,” WHO Director-General Margaret Chan said earlier this month.
Despite its call for governments and other organizations to put more boots on the ground, the U.N. public health agency doesn’t have the authority to compel any to rush in. “It’s the coalition of the willing, not the coalition of ‘you have to,’ ” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota and a former government adviser on bioterrorism and public health preparedness. “There is really no incident commander on an international level.”
In the long term, the answer for African nations is to build up their own public health systems so that they can fight disease battles mostly on their own, global health experts say. Nigeria is one example: To fight its own Ebola outbreak, sparked by a traveler from Liberia who died in Lagos, the country tapped public health expertise it has developed in recent years, said Health Minister Onyebuchi Chukwu. Six analysts from its emergency program to eliminate polio have helped lead the Ebola response. So far, 14 people have been diagnosed with Ebola, of whom five died.
“These are countries that just came up from civil war, and we have to help them,” he said of Nigeria’s West African neighbors. “We can assist with training.” Nigeria runs a program set up by the U.S. CDC to train epidemiologists who track and help fight outbreaks, he said.
Before quashing Ebola, Uganda didn’t win all its battles against the disease either. When people began dying of a strange and virulent disease in a small Ugandan town in the northern Gulu district in October 2000, chaos erupted. The scourge quickly spread to other villages and through camps full of people displaced by the rebel insurgency, as people infected themselves at funerals or patients fled Ebola treatment centers.
The Gulu outbreak, and another big one in 2007, prompted the nation’s government to set up early warning systems and tools to fight an epidemic. Today, village health teams of between four to seven people monitor year-round for cases of diseases from hemorrhagic fevers to malaria, part of a push by President Yoweri Museveni to strengthen the country’s public health system at all levels. Authorities broadcast health messages on more than 200 radio stations across the country when an epidemic strikes, as well as television and places of worship. “Every time I appear for my weekly radio talk show, I remind my people” to look for symptoms of Ebola given the West African outbreak, said Moses Awany, deputy residence district commissioner for the Gulu district.
In 2010, the CDC set up a new high-security laboratory at the state-run Uganda Virus Research Institute, overlooking Lake Victoria, to test for viral hemorrhagic fevers such as Ebola and Marburg. The agency had collaborated for years with the Ugandan government on a big U.S. government HIV/AIDS relief program; now it also wanted to respond more quickly to other emerging infectious disease outbreaks in the region. Previously, samples from possible Ebola patients had to be shipped abroad—often to the U.S.—for testing. Today, “we can test in one day,” said Trevor Shoemaker, an epidemiologist in the U.S. agency’s viral special pathogens branch. That allows responders to pinpoint and get to the scene of an outbreak much more quickly, he said. “The time savings for us being in country is huge,” he said.
The agency tapped a system it had already built that collected blood samples for its HIV/AIDS program to collect samples to test for other diseases, including viral hemorrhagic fevers.
At the two-room lab Wednesday morning inside the gates of the institute, Stephen Balinandi leapt to his feet as a delivery man arrived with a square-shaped box. “Now that’s another sample from the airport,” he said, holding the door open for the delivery man.
A flood of suspected Ebola virus samples has poured in recently due to concern about the West African outbreak, Dr. Shoemaker said. While the lab normally receives five to 10 samples a month for testing, last week it got 10, including two from Rwanda, and three or four from an airport screening.
In an Ebola outbreak in 2012, CDC and Ugandan scientists set up a rapid diagnostic testing center in Luwero district, where cases were reported, gaining the ability to confirm cases quickly and enabling early diagnosis and treatment, Mr. Balinandi said. That helped stamp out the outbreak quickly; only six people were infected.
The CDC has also helped Uganda set up an emergency-operations center, a critical tool that it uses itself at its headquarters in Atlanta to monitor outbreaks and coordinate the response to them, said Dr. Frieden.
Uganda has a spottier record in its fight against HIV, with rates of infection rising after sharply declining in the 1990s. A Ugandan court earlier this month overturned a law signed by President Museveni in February that mandated life sentences for certain homosexual acts, which HIV advocates worried would make it harder to get people at risk to present themselves for testing and treatment.
The CDC investments in Uganda are paying off, said Dr. Frieden. “It’s exceeded far beyond our expectations,” he said. They are part of a larger U.S. government global health security project to help 30 countries upgrade their health systems. At least $40 million in existing funds are going toward the project in fiscal 2014 and another $40 million is included in President Barack Obama‘s fiscal 2015 budget request. “This is our No. 1 priority for global public health,” Dr. Frieden said.
The agency will now help build public-health systems in Guinea, Sierra Leone and Liberia as part of its work to control the outbreak there. “It’s in everybody’s interest in the U.S. and globally, and there is a real need for us to invest in the weakest links, the blind spots, the places where the next SARS or MERS or Ebola or H7 or H1N1 or the next HIV will emerge,” said Dr. Frieden of the global health security initiative. “There will be new health threats, and they will be very costly in terms of lives and economic impact. SARS cost the world $30 billion in just a few months. The current Ebola outbreak is going to devastate the economies in many West African countries.”
He added, “Imagine how different the world would be today if we’d found HIV a couple of decades before we did.”