A disease outbreak is a story we can really get into. The invisible micro-organism lodges itself inside a human host and travels undetected among the teeming masses—until it decides to reveal itself and bring humanity to its knees. The narrative is powerful. Other people, who should be sources of support, are suddenly threats. Scientists must bring to bear every ounce of expertise to achieve a narrow victory over their diminutive foe.
This is the case with the current outbreak of Ebola. What started as largely ignored cases this past March in Guinea has now captured the world’s attention. Previous epidemics (like SARS in 2003 or H5N1 in 2004) had much lower fatality rates than Ebola, yet created similar global concern. The rapid propagation of illness, the exotic disease profile and the parry and riposte with an opponent as skilled at survival as a virus is can be intoxicating for the news media. And although we must marshal resources to stem the tide of Ebola in West Africa, the story we now know so well might not be the most important one to tell.
Ebola is killing people, but its true power comes from poverty and political instability. There have been nearly a dozen outbreaks of Ebola since it was first identified in 1976. In the current instance, however, the virus has made its way to the urban areas of Guinea, Liberia and Sierra Leone. When the virus stays isolated in rural outposts, it is easier to contain. But once it makes its way to the cities, with their greater population density and more movement, the complexity of isolation and quarantine grows considerably.
With more people at risk, greater public cooperation is necessary. Yet the public in these countries has been conditioned to fear instruction from the government. Those in Liberia grew up under Charles Taylor, a convicted war criminal responsible for unspeakable crimes against Liberian citizens that verged on genocide. Those in Sierra Leone grew up during decades of coups and civil war, led by wannabe dictators who conscripted child soldiers. Survival required distrusting and evading the government. So when health workers in official uniforms want to round up family members and friends who are “sick,” it is easy to see why the public is not as cooperative as one would like. The virus thrives while the people live in fear. But we cannot ignore that it was people, not the virus, who originally sowed distrust.
There is another very simple reason why the outbreak in West Africa is more complicated than it ought to be. In the United States, we have about 24 physicians for every 10,000 people. In Guinea, there is one physician for the same number. In Sierra Leone, one physician must care for 50,000 people. And in Liberia, there are a few dozen doctors for the entire country of 4.4 million people. While in the United States epidemiologists track at-risk patients and set aside isolation rooms for those infected, the West African nations struggle to procure latex gloves for their health workers or bleach to disinfect beds upon which victims have died. Yes, the virus is deadly. But we cannot ignore the ways poverty magnifies its power.
In the United States, we isolate those who are sick, quarantine those who are at risk and practice “social distancing” when it is called for (as when schools or workplaces close for flu outbreaks). But what can be done when people live cheek-by-jowl in urban slums? Thousands are crammed onto the same hillside in corrugated tin structures, bumping against one another in every small act of life. Governments find it hard to access the areas to collect dead bodies, and families do not have anywhere to put them. Water and sanitation are not in place, so the necessary disinfection is a fantasy. A virus thrives in these conditions. But we cannot forget that we created them.
The Media Piles On
The media’s coverage of the Ebola outbreak has received criticism from all sides. I sympathize with them all. One critique decries the disproportional emphasis on the few Americans and Europeans who have the disease while treating the tens of thousands of West Africans as mere side stories. Another compares the few thousand deaths from Ebola against the millions who die from cardiovascular disease, diarrhea or H.I.V-AIDS. This argument suggests that if we lessen the coverage of Ebola, we will pay more attention to diseases that kill more people. But it is naïve to think this is a zero-sum game. If we talk less about Ebola, the gap will be filled with the escapades of Justin Bieber instead of ways to reduce hypertension.
There are also some myths about Ebola that will not die. For example, although it is deadly, it is not highly contagious. Epidemiologists give infectious diseases a number called an R0 (“r nought,” or basic reproduction number). It indicates how many people, on average, a person with the disease will subsequently infect. The number for measles can be as high as 18. For polio it is about 6, for influenza 2 or 3. But for Ebola the R0 is at most a 2. So while Ebola is deadly, it is not highly contagious.
In public health we often describe five determinants of health: genetics, personal behavior, medical care, physical environment and socioeconomic factors. The first three get most of the attention in health care, but the last two are far more powerful than we realize. In the United States, for example, zip code is a better predictor of your health status than your genetic code. That is because of the pervasive influence of social determinants on health. Your education level, employment status, social networks and neighborhood all shape your ability to realize a healthier life.
What if a child wants to exercise, for example, but the sidewalks are cracked, her shoes are falling apart and the parks are filled with broken equipment? Our instinct is to overlook the social and environmental influences on health and focus on personal behavior and medical care. We like to blame either the individual (typically for chronic diseases like diabetes or obesity) or the micro-organism (tuberculosis or Ebola). But we fail to appreciate how involved we all are—how responsible we all are—for the social conditions that foster disease along the way.
In the case of Ebola, it is impossible to imagine thousands of deaths in places where governments can be trusted, where living conditions are decent and where health systems are strong. I am not suggesting that every case of Ebola could be prevented if we rid the world of poverty (the new cases in well-equipped U.S. hospitals are proof enough of that). But it is disingenuous to ignore the humanly constructed social and physical environment when speaking of the ravages of Ebola.
By paying attention to these things, we can see the fault no longer rests solely with the virus. We are no longer just the victims. We also become responsible for its devastating toll on human life. This is much more difficult to accept. Suddenly the outbreak narrative becomes much less attractive, because it no longer has a tricky, microscopic virus as the villain. Humans become co-conspirators.
The outbreak of Ebola eventually will be stopped. It will extend for months longer than our attention span, but like previous instances of the disease, it will be extinguished. Yet the social conditions that allowed its spread will continue in every corner of the world. If we learn anything from Ebola, the lesson should not be related only to this particular disease, because another infectious disease is going to emerge in short order. Perhaps instead we can grow in appreciation for the many things that we can control and predict, the social conditions that we build and perpetuate as a human community.
If we are truly interested in stopping Ebola and other contagious diseases, we will look to more enduring yet uncomfortable truths about our responsibility for these events. Over the past century, human life expectancy has increased by over 30 years, primarily due to improving social determinants of health (less than 20 percent of the gain is due to better medical care). But the gains have been unevenly distributed. We have the ability to achieve even greater improvements in health and the widespread attention to Ebola presents an opportunity to do just that.
The real story is not about Ebola. It is about us. The sooner we admit that, the sooner we will realize our true power to stop these outbreaks before they begin. It might not make for a good news story, but it would lead to a happier ending for us all.
