Overnight, U.S. Ambassador Deborah Malac later told her colleagues in government, the fog of despair that had settled over Monrovia seemed to lift. The arrival of the world’s most powerful military was what Malac called the “hope multiplier” at a turning point in the fight against Ebola. Soon, the number of new cases began to decline, and within half a year, the worst Ebola outbreak in recorded history was under control, thanks both to the thousands of brave Liberians, Guineans and Sierra Leoneans who put themselves in harm’s way to save their countries, and to the thousands of international aid workers who poured in from Western and African nations. It seemed like a model for fighting future epidemics.
But another Ebola outbreak rages today, and it’s not in Liberia, home of the only foreign capital named after an American president. The new epidemic is in the eastern part of Congo, where about 3,250 people have been infected and more than 2,100 have died; the numbers are probably far higher, as families hide their sick and bury their dead in secret to avoid stigma and ostracism. Two new treatments using the virus’s antibodies against it have shown promise, but supplies are limited and experiments are still ongoing. (More than 220,000 people at risk of catching the virus have received a new vaccine that has so far proved effective.)
The region is plagued by a maelstrom of violence that no president would ever dare to test with American troops. In Congo’s North Kivu province, ethnic violence and militant groups have forced 1 million people out of their homes. The World Health Organization has recorded nearly 200 attacks on health-care workers, United Nations forces and Ebola treatment facilities. In February, Doctors Without Borders, a group known for operating in war zones across the world, pulled staff out of the epicenter of the current outbreak, the twin cities of Katwa and Butembo, for fear of their safety. The State Department won’t allow American first responders from the Centers for Disease Control and Prevention (CDC) or the U.S. Agency for International Development into the area, for the same reason. The region is completely beyond Washington’s reach.
This time, in other words, the U.S. Army is not coming. And it may never ride to the rescue again.
The Liberia triumph seemed like a template on which future responses to public health emergencies could be based. In truth, it was an outlier. “We were able to divide the load between three Western countries. That’s like a coalition-building fantasy game,” Ron Klain, the White House Ebola coordinator who oversaw America’s response, told me when I reported a book about the event. “That’s never going to happen again. The disease broke out in one of the few countries on Earth where the arrival of 3,000 U.S. troops was seen as a happy event, was seen as a blessed event.”
The outbreak today offers a better look at global pandemics to come — ones that begin in regions where international public health workers are unable to move freely to contain the spread of a virus, where the U.S. Army would not be welcomed with open arms. “The most likely places where this is going to happen are not places where you can send the 101st Airborne without fighting their way in,” Klain says.
Conflict zones around the world have become the loci of some of the deadliest outbreaks we face today. In Yemen, a vicious civil war has led to a widespread cholera epidemic that is infecting about 10,000 people every week, according to World Health Organization statistics. The proxy battle there, between the nation’s Saudi-backed government and the Iran-backed Houthi rebels, makes the failed state inhospitable to all but the bravest emergency medical workers.
Hundreds of people in Myanmar have been afflicted with schistosomiasis, an acute disease caused by parasitic worms in freshwater snails. Last year, thousands of members of the ethnic Rohingya minority were struck by diphtheria. Western governments have spent recent years criticizing ethnic-cleansing efforts against this group, making aid workers from developed nations unwelcome. Myanmar’s government has blocked international aid workers and humanitarian assistance from accessing Rohingya refugee camps.
Polio, a disease that once was near eradication, has broken out this year in Afghanistan and Pakistan; more cases have already been reported this year than in the entirety of 2018. The actual case count could be up to 1,000 times higher, says former CDC director Tom Frieden, because the region is so unstable after years of war and militant control that strict medical surveillance is impossible. And the United States is not especially welcome in either nation: Afghans are trying to get U.S. troops out, and American agencies once used a fake vaccination campaign as a cover to spy on Osama bin Laden in Pakistan, making aid workers there especially suspect.
In Venezuela, a nation that eradicated malaria more than half a century ago, the breakdown of the health-care system amid economic and political turmoil has led to a resurgence of the mosquito-borne virus. Doctors Without Borders has treated more than 162,000 people there for malaria since 2018. The United States currently has no diplomatic relations with Venezuela and does not recognize its president, Nicolas Maduro, as the rightful leader. (If “the U.S. intends to invade us, they will have a Vietnam worse than they can imagine,” Maduro said in January.)
The future of disease eradication won’t be in friendly territory. “If you look at Yemen, you look at Somalia, you look at Syria, you look at what’s going on in Myanmar, they are countries under siege or failed states,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “This is what we need to expect.” Or as Michael Ryan, executive director of the World Health Organization’s Health Emergencies Program, said about Congo, “We’re trying to deal with the most dangerous virus in the world in the most dangerous place in the world.”
Public health is about using civic institutions to wage campaigns against those diseases. But in many of the sickest nations, those civic institutions are collapsing, and the international and nongovernmental organizations dedicated to propping up health systems are stretched to a breaking point. “Whenever you have disruption of the social order, that’s when you have outbreaks,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “The malaria in Venezuela is [happening because] the health-care system is essentially in disarray right now, the economic situation is in disarray.”
The Ebola outbreak in Congo is an example of what happens when a populace does not trust institutions. When the virus began circulating last August, the health responders who descended on the city of Beni, and later Butembo and Katwa, found a population that deeply distrusted outsiders. Their government in far-off Kinshasa had never shown an interest in bettering their lives, so why would it now? Up to half the new Ebola cases in Congo are occurring in people who do not appear on lists of those who have come into contact with a patient, an indication that many victims are avoiding health-care workers trying to track the virus’s spread.
In Congo, Afghanistan and beyond, public health officials worry that the breakdown of institutional authority and the accompanying isolationist turn against national or international institutions will have profound effects that aren’t yet clear. “A lot of the basic premises of an open, globalist, diplomatically oriented world are just no longer the operating principles, and we don’t know what the new operating principles are,” says Prabhjot Singh, former director of the Arnhold Institute for Global Health at the Icahn School of Medicine.
But one thing is clear: The spread of preventable diseases — Ebola, polio, malaria, measles — is not something the United States will always be able or welcome to fight.
Read more from Outlook: