Understanding Ebola in West Africa Through Laurie Garrett's Lens on Kikwit

The WHO announced yesterday that the decline in Ebola cases which has been occurring has halted. This is ominous news as it highlights the very real fact that unless every Ebola case is run down, a new transmission chain can commence, reigniting the epidemic in West Africa. 

To understand why the West African Ebola epidemic is so recalcitrant to the public health measures that have been employed to stop all the prior instances of Ebola, it is instructive to examine prior outbreaks. After the 1st outbreak of the most virulent Zaire strain of the virus in 1976, the next biggest outbreak of this strain (present outbreak excluded) was in Kikwit (DRC) in 1995.  This--once considered large--300+ person 1995 Ebola outbreak has many lessons for today, as presented in a book published in late 2014 by Laurie Garrett. Ebola: Story of an Outbreak, extracted from Garrett's Betrayal of Trust: The Collapse of Global Public Health (with a new introduction focused on the West African outbreak), provides an in depth view of the Kikwit outbreak highlighting the struggles that physicians, many of whom are now everyday names in infectious diseases now (e.g. Ali Khan, Pierre Rollin, David Heymann), encountered in trying to extinguish this outbreak.

Many of the incidents described presage what occurred in West Africa: distrust of government authorities, belief in a mystical origin (which includes a special hippopotamus), graft, corruption, and intense press coverage. The lesson I found most instructive is that after the outbreak abated, within a couple of years, public health infrastructure and public health behaviors had again eroded to dangerously low levels. Such a devolution illustrates that resources infused from outside are effective in the short term, but are not sustainable without actual acceptance from the local population as a rapid regression to the mean takes place. For example, safe burial practices ceased, the etiology of Ebola was placed back in the supernatural realm, and an ambulance became a limo for a local government thug. This regression to the mean is occurring even more rapidly in West Africa where, while the disease still rages, lax public health practices by local populations have given rise to a shadow--and open--epidemic that continues to burn.

 As someone who was captivated by Garrett's The Coming Plague and who also enjoyed I Heard The Sirens Scream, I highly recommend this book as an important guidepost to understanding the challenges faced in West Africa.