Infectious Diseases

The recent designation of Ebola as a “public health emergency of international concern” by the World Health Organization (WHO) is a positive development in efforts to contain the disease. The decision highlights the importance of containing the disease to an international audience; the WHO’s designation is being widely carried by the international media.  It will likely unlock badly needed international assistance, though WHO is careful to say that designation is not a fundraising strategy. The WHO states that it has received only $49 million in donations since February, about half of the amount it needs. Representative Karen Bass, the top Democrat on the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations, welcomed the designation. In June, she introduced legislation to expand the amount and type of resources the U.S. is authorized to commit to fighting Ebola. Meanwhile, the pharmaceutical giant Merck has donated 195,000 doses of the apparently effective vaccine. Much more is needed, but it takes a year to produce the vaccine. There is a second vaccine, developed by Johnson and Johnson, which the WHO would like to use, but the Congolese authorities have not authorized it because of residual popular suspicion of all vaccines that has led to attacks on health workers. According to the New York Times, there are ongoing discussions between the WHO and Congolese authorities.  The WHO moved because the disease has been present for twelve months and continues to spread, most recently to Goma, a city of more than two million people on the border with Rwanda and near Uganda, raising the possibility that the disease could spread internationally. Congolese officials are reportedly concerned that international hysteria could lead to travel and trade restrictions. Given the hysteria in the United States (among other places) during the 2014 Ebola outbreak in West Africa, with calls for such restrictions, those officials’ concerns are not misplaced. Fear of disease can translate into a political cause that is easily exploitable for domestic political purposes in many countries. Thus far, the eastern Congo Ebola outbreak has infected 2,512 people, with 1,676 deaths in the twelve months of the outbreak. The eastern Congo is riddled with competition among militias for, among other things, access to minerals, resources, and tax revenue amid a breakdown of governmental and societal structures. Many people in the affected region do not trust the government in Kinshasa; anybody apparently associated with it, including health workers, can be at risk of violence. As recently as last week, two health workers were murdered in their homes.   

The Ebola vaccine is proving highly effective, but distrust of health workers, skepticism of the disease’s existence or provenance, and attacks on medical facilities are stymying progress. Popular suspicion of government authority is an old song in sub-Saharan Africa. Governments are often seen as exploiters that operate for the benefit of a tiny elite, deliver few services, and levy arbitrary taxes. In Nigeria, for example, critics will say that they still live in a “colonial state,” with the British having been replaced by a tiny, local elite. In general, anti-government suspicion tends to intensify the further the distance from the capital. In many cases, that distrust is not without good reason. But the current Ebola outbreak in the eastern provinces of the Democratic Republic of Congo illustrates the devastating practical consequences of that suspicion for disease control, especially when it is fanned by misinformation spread by social media. A study published in the highly respected British medical journal, The Lancet, reports the findings of a survey in the Ebola-affected parts of the eastern Congo. Less than a third of responders trusted official authorities. More than a quarter believed that Ebola was not real. Ignorance and social-media-fanned misinformation led to a reluctance to seek health care, to accept the Ebola vaccine, and to practice preventive behaviors.  The New Humanitarian explores the specific factors in parts of the eastern Congo that make so many prone to accept social media false information. North Kivu province has a long history of grievances against any government authority. Ostensibly because of the Ebola outbreak, the Kabila government postponed—until after the new president was sworn in—national elections in Ebola-affected areas, further fueling suspicion. There are more than one hundred militant groups fighting the government and each other in the area. Many who accept the reality of the disease believe it is being used by the far-away Kinshasa government to kill them. Efforts to counter Ebola are well-funded by the international community, in contrast to poor indigenous medical facilities. The disparity causes resentment. A consequence of such factors is that victims of the disease do not seek treatment.  On April 28, the authorities in Goma (the largest city in the region) confirmed 27 new cases of Ebola, bringing the total for the week to 126 cases. That time period established a new record since the outbreak started in August 2018. So, Ebola is far from being under control. The tragedy is that the disease can be controlled through vaccines and prevention, and even recovery is increasingly possible. Ebola is a governance issue as well as a medical one.   

Cyclone Idai devastated parts of Malawi, Mozambique, and Zimbabwe this month and dissipated last week. Recovery in the affected countries is starting, but there is still a long way to go. The death toll continues to mount. As of March 24, according to media, it at least 446 in Mozambique, 259 in Zimbabwe, and 56 in Malawi. Local authorities caution that it is likely to go much higher. According to Mozambique Environment Minister Celso Correia, progress is being made to restore basic services in Beira, a major port city that bore the brunt of the storm. Electricity has been restored to water treatment facilities, the port, and to the vital rail lines, as well as some parts of the city. The main road that connects Beira to the rest of the country is expected to open early this week, facilitating the arrival of food and medicine to the city and to its environs. Beira’s population is more than half a million. Its port and rail line connects interior Mozambique and landlocked Zimbabwe and Malawi to the sea. Restoration of the railway is essential for the delivery of international humanitarian assistance to those landlocked countries. The minister’s chief concern now appears to be disease: “We’ll have cholera for sure,” he said, and malaria is “unavoidable,” given the flooding and standing water. The authorities have established a cholera center in Beira, though as yet there are no reported cases. There is also likely to be an outbreak of typhoid, and because of the damage to transportation links and disruption of markets, a food shortage. The deputy director of the UN’s humanitarian operation, Sebastian Rhodes Stampa, reports that two large field hospitals and a water purification system are expected soon. Drones are also being used as part of an extensive effort to access humanitarian needs in central Mozambique. But UN Secretary General Antonio Guterres cautioned that “far greater international support is needed.” The region is the breadbasket of Mozambique; according to the World Food Program, this puts each affected country at risk of food insecurity in some cases on par with that faced in Yemen, Syria, and South Sudan.  

A case of Ebola, the deadly hemorrhagic fever with terrifying symptoms, has been found in the second-largest city in eastern Democratic Republic of Congo (DRC). The city, Bunia, has a population of almost one million. The disease has already been identified in Butembo and Beni, the former with a population slightly larger than Bunia, the latter slightly smaller. The disease is now urban and rural in eastern Congo. The director of the United States Centers for Disease Control and Prevention (CDC), Dr. Robert Redfield Jr., recently returned from the region. According to him, the disease is not under control and could last for another year. He expressed concern that stocks of Ebola vaccine could become depleted, which many observers conclude has kept the epidemic from becoming worse. Merck is developing the vaccine, which at this stage is not licensed and cannot be sold. It has donated over 133,000 doses and more than 87,000 have received it.  According to the World Health Organization (WHO), this Ebola outbreak is second only to the one in West Africa from 2014 to 2016, which killed some 11,000. As of March 13, WHO estimates that there have been 932 cases and 587 deaths in the affected parts of eastern Congo since the outbreak began in August 2018. Concern is that the disease could spread to eastern Congo’s neighbors, including Rwanda, Uganda, and South Sudan. National borders are porous with little regulation of the movement of people from one country to another in the region. Dr. Redfield says that his agency is prepared to do more, but its personnel cannot go into the epicenter of the disease because of a breakdown in security. (The U.S. Department of State determines where and when it is safe enough for federal employees to work outside the United States.) Eastern Congo has long been a war zone, with various militia groups active. A consequence has been intense suspicion among local people of outsiders. In February, there were two attacks on treatment centers that forced Doctors Without Borders (MSF) to close its facilities. It is not clear who the attackers are, but MSF and WHO officials have expressed concern about local community hostility to outsiders. Further complicating treatment, the disease is relatively new in the area and carries considerable stigma; protocols for containing the disease interfere with some traditional burial practices, for example. Centers for the treatment of routine diseases may also facilitate the spread of the disease because its victims are not necessarily segregated from other patients, again because of lack of familiarity with the disease. Some thirty percent of the victims have been children, and one hypothesis is that they were infected by the disease when they were taken to clinics for the treatment of routine childhood diseases. 

Measles cases have spiked as a growing number of anti-vaxxers, opting out of immunizations for their kids, threaten decades of progress toward eliminating the disease.

For the first time in recorded history, bacteria, viruses, and other plagues and pestilence do not cause the majority of deaths or disabilities in any region of the world. Curbing infectious diseases has extended lives and prevented child deaths in poor societies, but also brought new and unexpected challenges—like rising youth unemployment, overcrowded and underbuilt cities, and surging rates of premature chronic diseases—that many nations are unprepared to handle. In Plagues and the Paradox of Progress, Thomas J. Bollyky traces the rise and fall of infectious disease in human history and the challenges and opportunities that unprecedented health achievements pose for our future.

Health and infectious diseases have shaped the history of urbanization, but it is cities that will define the future of global health.

Voices from the Field features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This piece is authored by Gary M. Cohen and Dr. Daniela Ligiero.

During its fifteen years, PEPFAR has become one of the most important global health initiatives ever launched. However, its influence is fading, threatening the global fight against HIV/AIDS as the struggle against the pandemic faces a turning point.

Toyin Saraki is the founder and president of Africa’s premier maternal and children’s health charity, the Wellbeing Foundation Africa, and a long-standing advocate for universal immunization in her native Nigeria. Polio, a vicious disease that primarily affects children and leaves them severely disabled, reared its ugly head once again in Nigeria last year, two years since it was last detected in the region. Up to this point, global polio eradication efforts had managed to defeat polio in all but two countries—Afghanistan and Pakistan. Its reemergence speaks volumes to Nigeria’s inability to continue to deliver the most basic health care, begging the question: why does universal immunization remain unfulfilled?  This Tuesday was World Polio Day, and it is worth reflecting on the mistakes made and the challenges ahead in tackling this disease. Eradication is finally within our grasp, and we would be remiss to let this opportunity slip through our hands. To understand polio’s reemergence, it is important to understand the landscape in which it occurred, my native Nigeria. In 2016, four new cases of polio were reported, three of which were in Borno state, at the heart of Nigeria’s conflict ridden northeast. The reappearance of polio in this region is no coincidence—Boko Haram has wrought immense destruction to the Lake Chad basin, destroying an estimated 75 percent of basic infrastructure in northeastern Nigeria. Vaccines typically require cool conditions in order to maintain their potency. In the hot, dry, and remote northeast, this is near impossible with the destruction of so much infrastructure and frequent power outages. As a result, swathes of Nigeria’s most vulnerable children have been denied access to this cheap and simple preventative measure.    Another hurdle to universal immunization is the inadequate monitoring systems that track which immunizations people have received and ensure that a patient’s vaccinations are up-to-date. Nigeria suffers a severe lack of personal health records, rendering health statistics a product of mere guess work. In the absence of effective recordkeeping, it is nearly impossible to hold people that need vaccines accountable. In this sense, polio’s return to Nigeria is merely a symptom of a much larger failure in Nigeria’s public health system. Personal health records would serve to ensure access and delivery of vaccines. They would also put everyone in the system, and create impetus for improvement in healthcare as a response to accurate monitoring of health outcomes.   In 1990, polio coverage in Nigeria was 55 percent. By 1999, it had plummeted to 19 percent. Although polio coverage rebounded and was almost universal at the time of last year’s outbreak—polio coverage reached 90 percent in high-risk states—this remains suboptimal, and alludes to a striking lack of government commitment to the cause.    One solution to the problems facing polio immunization, as well as that of other preventable diseases, is the implementation of universal primary healthcare. Primary healthcare forms the cornerstone of basic health provision and, when present, is typically the area of healthcare responsible for immunizing local populations. What’s more, in many remote regions in Nigeria, which have the lowest immunization levels nationally, primary health is commonly the only form of healthcare access. It must therefore be prioritized, to give all people access to basic healthcare provisions, including crucial vaccinations.   For universal primary healthcare to be implemented in Nigeria, more needs to be given towards Nigeria’s failing healthcare system. In 2001, all members of the African Union pledged 15 percent of national spending to healthcare in the Abuja Declaration. Ironically, Abuja has not met this commitment, only spending a third of the pledged 15 percent on health care.  Fortunately, since the new polio cases were reported in 2016, there has been a renewed immunization drive. The international community and Nigerian government is set to vaccinate as many as 30 million children against polio. This drive must be sustained, and there is no room for complacency.   Investment in health infrastructure and reliable electricity are vital for remote areas, followed by the implementation of universal primary healthcare and adequate record-keeping. Yet none of this will be possible in the absence of greater commitment to the cause.   We know how to prevent polio, but children in my native Nigeria continue to be denied access to this basic but necessary vaccination. The reemergence of polio is tragic, but we should use it as an impetus to address the shortcomings of Nigerian healthcare. Greater government commitment to the sector is critical to preventing future outbreaks of illnesses like polio, protecting Nigerians of today and of the future.