In the wake of the recent Ebola outbreak, public health officials in this country are quick to assure the American public that there is no cause for panic. Ebola, we are told, can be contained in this country. We have some of the best medical facilities and personnel in the world, and our public health system is robust.
The same, however, cannot be said of West Africa. Ebola has the capacity to do incalculable damage in developing countries with inadequate medical facilities and compromised public health systems. If it is not adequately contained, Ebola could destroy whole economies and undo much of the progress that has been made in reducing poverty and improving public health. Unless the world commits thousands of health workers and provides the West African governments with the necessary logistics and food aid, the region could suffer one of the greatest humanitarian disasters of our time.
Ebola, if it is not stopped soon, is likely to have a cascading effect. Unless medical personnel in these countries are given the proper training and equipment, many doctors and nurses could die, leaving the populace to care for itself. Unless more is done to educate the general public, many -- if not most -- of the caregivers, many of them mothers, could also die. Panic, both informed and ill-informed, will ensue and lead to the disruption of agriculture, commerce, and civil order. Relief workers in some areas are already being physically assaulted, even killed, making the task of caring for the afflicted potentially more hazardous than it already is.
Two months ago John Campbell, the former U.S. Ambassador to Nigeria, cautioned the Council on Foreign Relations that:
"Guinea, Sierra Leone, and Liberia are very, very weak states" that have been weakened by protracted conflict. The greatest danger, he warned, is that the growing urban density in these countries puts them at heightened risk, as people from the villages are moving to "urban slums where the transmission of disease, any disease, becomes easier than in villages where the population density is very low."
Laurie Garrett, the author of The Coming Plague, is warning that we "just don't get it." She has been saying that now for two decades. Developing regions, including many countries in sub-Saharan Africa, have long been at risk of contagion. Vastly underfunded and severely compromised by conflict and the spread of HIV/AIDS, public health systems in many countries have not been able to keep up with the needs of a rapidly growing population. And when it comes to the transmission of disease, population growth, density, and distribution matter.
Writing nearly two decades ago for Foreign Affairs, Garrett cautioned that "Population expansion raises the statistical probability that pathogens will be transmitted, whether from person to person or vector -- insect, rodent, or other -- to person." She went on to warn that while high population density "does not doom a nation to epidemics... [but] the areas in which density is increasing most are not those capable of providing such infrastructure support. They are rather the poorest on earth."
The public health crisis that now threatens to envelope West Africa was not unforeseen. Many more experts than Laurie Garrett have been sounding the alarm.
In 1992, the U.S. Institute of Medicine published Emerging Diseases, a landmark report, which noted that increases in the size, density, and distribution of human populations "can facilitate the spread of infectious agents" and that "changes in the distribution of populations can bring people into contact with new pathogenic organisms or with vectors that transmit those organisms." The report warned that:
In many parts of the world, urban population growth has been accompanied by overcrowding, poor hygiene, inadequate sanitation (including wastewater disposal), and insufficient supplies of clean water. Urban development, with its attendant construction, emergence of slum areas and shanty towns, and infrastructure needs (e.g., water treatment and waste disposal facilities), has also caused ecological damage. These factors have created conditions under which certain disease-causing organisms and the vectors that carry them have thrived.
Ebola is just one of many threats to densely populated areas with inadequate public health systems, and climate change, by facilitating the spread of malaria and dengue fever, may further tax the ability of developing countries to cope with emerging public health threats. Thanks to America's PEPFAR initiative and the Millennium Development Goals, significant progress has been made in the fight against AIDS, but public health systems in many developing nations remain ill-prepared for another epidemic, whether it takes the form of bird flu, Ebola, or an entirely new contagion. With the populations of many of the poorest developing countries doubling every 35 years, the challenge of improving public health systems becomes formidable.
The immediate task before us is the containment of the Ebola outbreak. For the moment, little else matters. But we still must confront the larger challenge. We must make the repair of public health systems in developing countries a global priority. We must ensure that the poorest of countries are able to meet the essential health care needs of their citizens, including family planning and reproductive health services. There are an estimated 222 million women in the developing world who want to avoid a pregnancy, but who are not using a modern method of contraception. Providing them with family planning services and information will reduce maternal and infant mortality and help to relieve the pressure on beleaguered public health systems, as would the training of more nurses and doctors and the expansion of medical facilities.
It is good and noble that the people of the world will respond when confronted with a potential humanitarian disaster like Ebola, but it would be so much greater if we had acted in time to prevent its initial outbreak. Shame on us for not acting sooner against a known threat of this terrible magnitude, but we still have an opportunity to address the larger public health threat and prevent future tragedies.
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