I lived in Liberia for six months in 2009. I was in the capital, Monrovia, to train lawyers, and thankfully did not have much cause to access the country's limited and under-resourced health services, apart from the occasional malaria test. Ebola was a non-issue then, although easily preventable diseases still stalked the native population. And while poverty, lack of infrastructure and uneasy race relations were quotidian concerns, for a nation that was barely half a decade out from a brutal civil war (remember blood diamonds?), things seemed relatively stable.
Five years later, the situation has worsened dramatically. The World Health Organization (WHO) stated over the weekend that the death toll from Ebola had passed 2,000 people. Approximately half those deaths are in Liberia, and the WHO estimates that the disease will take at least six months to contain and could eventually claim the lives of 20,000 people. This is a shocking statistic, although its impact is largely muffled because the outbreak is taking place in poor, benighted Africa, where the antics of Boko Haram, ethnic unrest in South Sudan, and smouldering tensions in Mali are all competing for newspaper headlines. With Putin on the march and the Islamic State wreaking havoc in the Middle East, the attention of world leaders is elsewhere and the donor community is besieged by requests to help the Syrians, Ukrainians and Palestinians. When chaos reigns on every front, it can be hard to focus.
Here's what we are all missing, though: Ebola outranks everything else. Perhaps not in terms of fatalities (although the nearly 200,000 killed in Syria's civil war proves that overwhelming casualties alone will not prompt external action), but in terms of its potentially devastating impact far beyond the realm of public health. Left unaddressed, this virus has the power to undermine not only national health services, but food security, oil production, and international relations. If you think I'm being alarmist, you haven't been paying attention.
Let's start with public health in poor countries: even before Ebola decimated the population of trained medical professionals in Liberia, it is estimated that there were only 150 doctors in the whole country, or approximately one doctor for every 25,000 citizens. Such extreme under-representation meant that even without the spectre of agonizing death from a mysterious virus with no known cure, Liberia was already a very dangerous country to get sick or be injured in. Without access to adequate medical care, typhoid, malaria and dengue fever were routinely fatal. But car crashes, child birth or even just stepping on a rusty nail were fatal as well--if complications arose and you couldn't get to a hospital, which you probably couldn't, if you lived outside a major city and it was the rainy season. There are a lot less than 150 doctors left in Liberia now, which means that even routine medical conditions just became much more fraught.
If it seems a stretch to connect public health with food security, the common thread is ineffective governmental preparation in the face of potential crises. Panic regarding Ebola's potential transmission in densely-populated neighbourhoods led Liberia's government to unexpectedly quarantine large parts of Monrovia's West Point slum. While isolation of affected persons is very much recommended in preventing Ebola's spread, the WHO has stressed that quarantines only work with the consent of the population, which the government never sought (nor received). In any event, there were no contingencies in place to deal with the effects of cutting off people from their livelihoods. Travel restrictions are affecting food production and distribution, leading to an increased reliance on aid agencies to provide rations (who will in turn need to further rely on donors to pay for supplies). And prolonged restrictions on free movement could eventually lead to an increase in food prices, prompting additional urban unrest. Citizens that are already suspicious of their government's motives don't need very many excuses to riot.
Outside of immediate, personal concerns regarding food and medical care, Ebola could disrupt oil production in Nigeria, the continent's largest exporter. There is thought to be a cluster of cases developing in Port Harcourt, home of Nigeria's two largest oil refineries. The cases can be directly linked to a Liberian man who travelled to Nigeria while suffering from symptoms of Ebola and later died in Lagos, the capital. It is not difficult to imagine the knock-on effects that might occur if oil workers--who often live in close quarters with communal bathrooms--were to contract the disease. While national and international medical authorities appear to have the situation in Port Harcourt under control for now, this hypothesis is well within the realm of possibility.
But it is perhaps in the area of international relations that Ebola poses the biggest threat. The virus has already caused Cameroon, Ivory Coast, and South Africa to impose a complete travel ban on nationals from Guinea, Sierra Leone and Liberia. This will not only affect commercial links between these nations, but will undoubtedly raise diplomatic hackles. Airlines and shipping companies are also suspending services to affected countries, which the WHO points out only makes it more difficult for external aid to reach those in need. In parallel to all these practical considerations, rumours about the existence of a 'cure' is fostering antagonism against the United States, which successfully treated two of its affected nationals with Zmapp, an experimental drug that was in short supply.
Zmapp is not a miracle remedy; a Spanish priest and a Liberian doctor treated with the drug both still succumbed to Ebola. And there is no conclusive proof that the two American aid workers who recovered did so because of Zmapp. But a 50% success rate is better than nothing, and the US has just signed a $25 million contract with Zmapp's creator to manufacture more of the drug. The WHO is also exploring other possibilities, including Avigan--an as-yet unproven flu drug being developed in Japan.
Neither Zmapp nor Avigan has been clinically tested on humans, and the international community should be wary of using vulnerable African populations as a testing ground. Questions of informed consent and drug safety should be foremost in everyone's mind--there is a real danger that a zealous pursuit of an effective Ebola treatment will be used to hide incomplete research and/or rank profiteering. Governments desperate to demonstrate their effectiveness in fighting this plague cannot necessarily be trusted to value their citizens' lives above their own political longevity. International relations will be further strained by concerns about the ethics of access to such potentially promising treatments--who has it, who can get it, and how much it will cost. Even with the most altruistic of intentions, external geo-political influences are sure to be a factor.
Public health emergencies often occur in the place least likely to be able to manage them, and western Africa was poorly prepared for the latest outbreak of Ebola. However, as much as an overwhelmed world might fervently hope that it will remain an African problem, its impact will be felt far beyond the borders of Liberia and its neighbours. Ebola outranks everything else on a crowded global agenda today, and the quicker we acknowledge this, the more effectively it can be contained.