Ebola in DRC – The Reality and the Media Hype

We are to believe, according to some public health voices and media, that the Ebola outbreak in Ituri in the Democratic Republic of Congo (DRC) is a threat to us all. This is a bit of a pattern, and it is a story full of obvious flaws.

So, when really good public health analysis is published – once common but now rare – it is worth highlighting. Every journalist interested in understanding the current Ebola outbreak should read this contextual note on the French HAP Open Science website. It is what public health looks like when truth and good outcomes are the sole criteria.

The Polycrisis Narrative

Hot on the heels of COVID-19, in which humans may have fiddled with a virus and then used the Nature Medicine journal to pretend otherwise, we have endured one existential threat after another. Mpox, avian flu, Marburg virus and Hantavirus between them have not totalled 1,000 deaths together over the entire period. Mpox is perhaps the worst, with about 500 deaths across two separate “public health emergencies of international concern”, mostly due to malnutrition in, once again, DRC. But DRC loses 70,000 children to malaria every year, so Mpox was really our problem rather than theirs.

The narrative of polycrisis foisted on an ever-more sceptical public has wrecked the integrity of international public health. Under its current model, global health priorities are largely determined by a few very wealthy individuals with limited public health understanding, or corporations with direct vested interests in certain outcomes. Public health journals are financially beholden to these, as are mainstream media, and can only reflect the hype.

The story is all about the necessity for more money to enable experts to rescue both ourselves and the people of affected regions. Highly paid consultants and pharmaceuticals from Western corporations become essential to save populations apparently helpless without our urgent largesse. This is historically ridiculous, it is ignorant, it is stupid and the note by Villa and co-authors of the Ituri Collective explains why in very clear and coherent terms.

What is Ebola?

Ebola virus was first identified 50 years ago in DRC, and since then has caused intermittent outbreaks, mostly small. It has presumably done this throughout human history, which means hundreds of thousands of years in this area. The largest, in 2014, was in West Africa and killed about 11,000 people over a year. Spread by close and direct contact with body fluids from a sick person, it kills about 30% of presenting cases with a severe febrile illness and systemic bleeding (‘haemorrhagic fever’). Illness is therefore relatively obvious, as commonly is the path of transmission.

Ebola virus presence has been detected at low frequency in many animal species in Central and West Africa. Its main animal host, if it has one, is not clear, but evidence is found in bats, rodents, non-human primates, pigs and species such as the small duiker antelope. And, of course, occasionally in humans. Transmission from animals to humans is called a ‘spillover’ of a pathogen or disease, and it happens a lot. Influenza is a common example, as are brucellosis and Hantavirus. What matters is whether it then establishes transmission between humans, and that depends on many factors.

Critically for understanding the current hype: why did transmission become established in Ituri province in DRC to cause the current outbreak?

Why Did This Outbreak Happen?

Viall and colleagues explain the reasons why this outbreak could be sustained, as summarised below. Unfortunately, the media have ignored these factors in most reporting. But they are common to many such occurrences in African populations.

Ituri is a province in North East DRC with a population of about seven million people. It has several ethnic groups, a lot of gold mining and a lot of poverty. There have been major armed insurgencies for several years, including two main factions – one (the Allied Democratic Forces) affiliated with the Islamic State terrorist group. Active military responses come from the DRC armed forces and, in the past, those of neighbouring Uganda. Atrocities against the civilians trying to survive within this context are common, and there are several large camps of people displaced from their homes by the armed groups. Groups such as the ADF have a gruesome reputation.

Health services are limited in rural areas, and most services must be paid for. However, few people in rural areas have much money – it being hard to accumulate and hard to keep. As a result, there is generally poor healthcare access. Together with high malnutrition, an HIV prevalence of over 5% and even plague, this makes it likely that small outbreaks are missed and larger ones picked up late.

There is also a reported deep distrust of many healthcare activities, particularly regarding outbreak responses. People have dignity and self-respect and a good general knowledge – including active radio networks – and cultural memories of the disgusting actions of European colonisers not so long ago, for which DRC is particularly renowned. People in such areas will know that the foreign consultants who come to help often earn more per month than they will earn in 10 years, and that the CEO of the International Rescue Committee, for example, earns more than a million pounds per year. Any self-respecting person would start to question and distrust such a model of disease management.

Recent memories of Ebola and Covid vaccine trials perceived as rich people experimenting on poorer local people, and alleged sexual abuse by personnel in past Ebola outbreaks, have further coloured opinions of external ‘assistance’. The reports of tent burnings during this outbreak seem less surprising in this context. We get angry with injustice too.

Lastly, local funerary practices involve people – particularly women – spending a lot of time tending the bodies of the dead. This is common in countries outside the West, where dead people’s bodies are not simply packaged off by professionals and often never seen again. It is probably a better practice in general. But it is a disaster for Ebola, as it exposes those involved to a high risk of infection, followed by a high mortality.

All the above is very important for three reasons.

1. It explains why an initial spillover had a chance of becoming a significant event (though as yet still only a thousand suspected cases, 100 confirmed, in a province of seven million), and it explains why numbers will rise further before they fall, with some scattered cases turning up in neighbouring provinces and crossing the nearby national border.
2. It tells us why this disease will not take hold in Europe or North America (or to any significant extent in nearby and more stable countries like Kenya or Rwanda, for that matter). It also highlights the ridiculous over-reaction of the United States closing all visa applications in the DRC capital Kinshasa – 1,800 miles away – and in neighbouring Uganda and South Sudan.
3. It provides a guide to the best way to respond, which would not be to parachute in a lot more highly paid foreign consultants and vaccines and force a pharmaceutical fix on a population with low trust and even more pressing problems to deal with.

The Ituri Collective article then gives a clear series of recommendations, which are essentially a list of the way such outbreaks used to be dealt with before non-public health entities rewrote public health policy in their own interests:

• Work with communities and employ local people – with plenty of unemployed youth available – rather than bringing in outsiders. This includes negotiating safe funerary practices that reduce the risk of spread but address local customary needs.
• Concentrate on local health systems and expertise in the response, leaving long-term capacity rather than temporary emergency care.
• Be transparent about past excesses and the money made from outbreaks, rather than dismissing local concerns (and hiding behind inventions such as ‘infodemics’).

This may sound wishy-washy to someone steeped in CNN or BBC-promoted predictions of global spread, but Ebola is actually a local problem. Even the largest outbreak in history, in West Africa in 2014, killed only as many as die globally every three days from tuberculosis, and never maintained transmission beyond three poorly-resourced countries.

Rushing vaccines to ring-vaccinate an area can help if it is small and clearly defined, but all previous outbreaks – despite the hype – were declining before vaccines could have had a major effect. Local people can manage Ebola, with respectful help, when provided with appropriate knowledge and when valid reasons for distrust are addressed. They have done so ever since it was identified 50 years ago, and did so before even then.

Reducing the Problem, or Profiting From it?

The most important lesson from the current outbreak, and all previous ones, is the impact of poverty on disease risk. This is not new, but it is also not newsworthy. The DRC is rich in resources that we covet – many of these, such as rare earths for batteries and solar panels. In order to extract them as cheaply as possible, we support child labour and widespread civil unrest that prevents the retention of value locally and regionally. This is a choice – a low-carbon economy, as it is currently being promoted, requires the exploitation and impoverishment of a great many people. This is the cost of Western virtue.

The end result in Ituri and similar regions is massive insecurity, displacement, poverty, malaria, plague, HIV and Ebola. As a crucible for outbreak development, it is proving increasingly attractive to Pharma, and it supports a very large, highly salaried international health workforce. Both benefit from the fuelling of foreign wars, poverty and dependency. Their incentives do not align with strengthening the capacity and independence of local health systems, or with policies that would reduce the need for continued aid and an NGO industry run by obscenely paid executives.

The outbreak industry thrives on making ordinary people in the West think this is all about rapidly evolving pathogens from which only greater diversion of public funds and clever Pharma can save us. Such centralised responses will further expand the underlying inequalities that are the very basis of the problem.

But as the Ituri Collective’s summary shows, there are still voices of reason, and we still hold the knowledge of better ways of acting. Please read their article and think about why it is so different from the hype we are daily subjected to. And remember that a hundred, a thousand or several thousand cases in Ituri is still not their greatest threat – and not ours. Then perhaps we can begin to address some of the deeper problems that underlie it.

Dr David Bell is a clinical and public health physician with a PhD in population health and background in internal medicine, modelling and epidemiology of infectious disease. Previously, he was programme head for malaria and acute febrile disease at FIND in Geneva and coordinating malaria diagnostics strategy with the World Health Organisation. He is a Senior Scholar at the Brownstone Institute.