6 o’clock in the morning, shortly after the sun spills over the horizon, the city of Kikwit doesn’t so much wake up as ignite. Loud music ...
By late morning, I am away from the bustle, on a quiet, exposed hilltop some five miles down a pothole-ridden road. As I walk, desiccated shrubs crunch underfoot and butterflies flit past. The only shade is cast by two lines of trees, which mark the edges of a site where more than 200 people are buried, their bodies piled into three mass graves, each about 15 feet wide and 70 feet long. Nearby, a large blue sign says in memory of the victims of the ebola epidemic in may 1995. The sign is partly obscured by overgrown grass, just as the memory itself has been occluded by time. The ordeal that Kikwit suffered has been crowded out by the continual eruption of deadly diseases elsewhere in the Congo, and around the globe.
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Emery Mikolo, a 55-year-old Congolese man with a wide, angular face, walks with me. Mikolo survived his own encounter with Ebola in 1995. As he looks at the resting place of those who didn’t, his solemn demeanor cracks a bit. In the Congo, when people die, their bodies are meant to be cleaned by their families. They should be dressed, caressed, kissed, and embraced. These intense rituals of love and community were corrupted by Ebola, which harnessed them to spread through entire families. Eventually, of necessity, they were eliminated entirely. Until Ebola, “no one had ever taken bodies and thrown them together like sacks of manioc,” Mikolo tells me.
The Congo—and the world—first learned about Ebola in 1976, when a mystery illness emerged in the northern village of Yambuku. Jean-Jacques Muyembe, then the country’s only virologist, collected blood samples from some of the first patients and carried them back to Kinshasa in delicate test tubes, which bounced on his lap as he trundled down undulating roads. From those samples, which were shipped to the Centers for Disease Control and Prevention in Atlanta, scientists identified the virus. It took the name Ebola from a river near Yambuku. And, having been discovered, it largely vanished for almost 20 years.
In 1995, it reemerged in Kikwit, about 500 miles to the southwest. The first victim was 35-year-old Gaspard Menga, who worked in the surrounding forest raising crops and making charcoal. In Kikongo, the predominant local dialect, his surname means “blood.” He checked into Kikwit General Hospital in January and died from what doctors took to be shigellosis—a diarrheal disease caused by bacteria. It was only in May, after the simmering outbreak had flared into something disastrous, after wards had filled with screams and vomit, after graves had filled with bodies, after Muyembe had arrived on the scene and again sent samples abroad for testing, that everyone realized Ebola was back. By the time the epidemic abated, 317 people had been infected and 245 had died. The horrors of Kikwit, documented by foreign journalists, catapulted Ebola into international infamy. Since then, Ebola has returned to the Congo on six more occasions; the most recent outbreak, which began in Bikoro and then spread to Mbandaka, a provincial capital, is still ongoing at the time of this writing.
The ordeal Kikwit suffered has been crowded out by the continual eruption of deadly diseases elsewhere in the Congo.
Unlike airborne viruses such as influenza, Ebola spreads only through contact with infected bodily fluids. Even so, it is capable of incredible devastation, as West Africa learned in 2014, when, in the largest outbreak to date, more than 28,000 people were infected and upwards of 11,000 died. Despite the relative difficulty of transmission, Ebola still shut down health systems, crushed economies, and fomented fear. With each outbreak, it reveals the vulnerabilities in our infrastructure and our psyches that a more contagious pathogen might one day exploit.
FROM OUR JULY/AUGUST 2018 ISSUE
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These include forgetfulness. In the 23 years since 1995, new generations who have never experienced the horrors of Ebola have been born in Kikwit. Protective equipment to shield doctors and nurses from contaminated blood has vanished, even as the virus has continued to emerge in other corners of the country. The city’s population has tripled. New neighborhoods have sprung up. In one of them, I walk through a market, gazing at delectable displays of peppers, eggplants, avocados, and goat meat. Pieces of salted fish sell for 300 Congolese francs—about the equivalent of an American quarter. Juicy white grubs go for 1,000. And the biggest delicacy of all goes for 13,000—a roasted monkey, its charred face preserved in a deathly grimace.
The monkey surprises me. Mikolo is surprised to see only one. Usually, he says, these stalls are heaving with monkeys, bats, and other bushmeat, but rains the night before must have stranded any hunters in the eastern forests. As I look around the market, I picture it as an ecological magnet, drawing in all the varied animals that dwell within the forest—and all the viruses that dwell within them.
The Congo is one of the most biodiverse countries in the world. It was here that HIV bubbled into a pandemic, eventually detected half a world away, in California. It was here that monkeypox was first documented in people. The country has seen outbreaks of Marburg virus, Crimean-Congo hemorrhagic fever, chikungunya virus, yellow fever. These are all zoonotic diseases, which originate in animals and spill over into humans. Wherever people push into wildlife-rich habitats, the potential for such spillover is high. Sub-Saharan Africa’s population will more than double during the next three decades, and urban centers will extend farther into wilderness, bringing large groups of immunologically naive people into contact with the pathogens that skulk in animal reservoirs—Lassa fever from rats, monkeypox from primates and rodents, Ebola from God-knows-what in who-knows-where.
Survivors of the Kikwit Ebola epidemic (from left): Emilienne Luzolo, Shimene Mukungu, and Emery Mikolo in 1995. Mikolo, the first of the three to be infected, later donated his antibody-rich blood to Luzolo and Mukungu. (Emery Mikolo)
On average, in one corner of the world or another, a new infectious disease has emerged every year for the past 30 years: mers, Nipah, Hendra, and many more. Researchers estimate that birds and mammals harbor anywhere from 631,000 to 827,000 unknown viruses that could potentially leap into humans. Valiant efforts are under way to identify them all, and scan for them in places like poultry farms and bushmeat markets, where animals and people are most likely to encounter each other. Still, we likely won’t ever be able to predict which will spill over next; even long-known viruses like Zika, which was discovered in 1947, can suddenly develop into unforeseen epidemics.
The Congo, ironically, has a good history of containing its diseases, partly because travel is so challenging. Most of the country is covered by thick forest, crisscrossed by just 1,700 miles of road. Large distances and poor travel infrastructure limited the spread of Ebola outbreaks in years past.
But that is changing. A 340-mile road, flanked by deep valleys, connects Kikwit to Kinshasa. In 1995, that road was so badly maintained that the journey took more than a week. “You’d have to dig yourself out every couple of minutes,” Mikolo says. Now the road is beautifully paved for most of its length, and can be traversed in just eight hours. Twelve million people live in Kinshasa—three times the combined population of the capitals affected by the 2014 West African outbreak. About eight international flights depart daily from the city’s airport.
If Ebola hit Kikwit today, “it would arrive here easily,” Muyembe tells me in his office at the National Institute for Biomedical Research, in Kinshasa. “Patients will leave Kikwit to seek better treatment, and Kinshasa will be contaminated immediately. And then from here to Belgium? Or the U.S.?” He laughs, morbidly.
“What can you do to stop that?,” I ask.
“Nothing.”
One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.
Humanity seems to need such reminders often. In 1948, shortly after the first flu vaccine was created and penicillin became the first mass-produced antibiotic, U.S. Secretary of State George Marshall reportedly claimed that the conquest of infectious disease was imminent. In 1962, after the second polio vaccine was formulated, the Nobel Prize–winning virologist Sir Frank Macfarlane Burnet asserted, “To write about infectious diseases is almost to write of something that has passed into history.”
Hindsight has not been kind to these proclamations. Despite advances in antibiotics and vaccines, and the successful eradication of smallpox, Homo sapiens is still locked in the same epic battle with viruses and other pathogens that we’ve been fighting since the beginning of our history. When cities first arose, diseases laid them low, a process repeated over and over for millennia. When Europeans colonized the Americas, smallpox followed. When soldiers fought in the first global war, influenza hitched a ride, and found new opportunities in the unprecedented scale of the conflict. Down through the centuries, diseases have always excelled at exploiting flux.
The White House is now home to an inattentive, conspiracy-minded president. We should not underestimate what that could mean.
Humanity is now in the midst of its fastest-ever period of change. There were almost 2 billion people alive in 1918; there are now 7.6 billion, and they have migrated rapidly into cities, which since 2008 have been home to more than half of all human beings. In these dense throngs, pathogens can more easily spread and more quickly evolve resistance to drugs. Not coincidentally, the total number of outbreaks per decade has more than tripled since the 1980s.
Globalization compounds the risk: Airplanes now carry almost 10 times as many passengers around the world as they did four decades ago. In the ’80s, HIV showed how potent new diseases can be, by launching a slow-moving pandemic that has since claimed about 35 million lives. In 2003, another newly discovered virus, sars, spread decidedly more quickly. A Chinese seafood seller hospitalized in Guangzhou passed it to dozens of doctors and nurses, one of whom traveled to Hong Kong for a wedding. In a single night, he infected at least 16 others, who then carried the virus to Canada, Singapore, and Vietnam. Within six months, sars had reached 29 countries and infected more than 8,000 people. This is a new epoch of disease, when geographic barriers disappear and threats that once would have been local go global.
Last year, with the centennial of the 1918 flu looming, I started looking into whether America is prepared for the next pandemic. I fully expected that the answer would be no. What I found, after talking with dozens of experts, was more complicated—reassuring in some ways, but even more worrying than I’d imagined in others. Certainly, medicine has advanced considerably during the past century. The United States has nationwide vaccination programs, advanced hospitals, the latest diagnostic tests. In the National Institutes of Health, it has the world’s largest biomedical research establishment, and in the CDC, arguably the world’s strongest public-health agency. America is as ready to face down new diseases as any country in the world.
Yet even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”
Perhaps most important, the U.S. is prone to the same forgetfulness and shortsightedness that befall all nations, rich and poor—and the myopia has worsened considerably in recent years. Public-health programs are low on money; hospitals are stretched perilously thin; crucial funding is being slashed. And while we tend to think of science when we think of pandemic response, the worse the situation, the more the defense depends on political leadership.
When Ebola flared in 2014, the science-minded President Barack Obama calmly and quickly took the reins. The White House is now home to a president who is neither calm nor science-minded. We should not underestimate what that may mean if risk becomes reality.
A containment vessel for infected patients (Jonno Rattman)
Bill Gates, whose foundation has studied pandemic risks closely, is not a man given to alarmism. But when I spoke with him upon my return from Kikwit, he described simulations showing that a severe flu pandemic, for instance, could kill more than 33 million people worldwide in just 250 days. That possibility, and the world’s continued inability to adequately prepare for it, is one of the few things that shake Gates’s trademark optimism and challenge his narrative of global progress. “This is a rare case of me being the bearer of bad news,” he told me. “Boy, do we not have our act together.”
Preparing for a pandemic ultimately boils down to real people and tangible things: A busy doctor who raises an eyebrow when a patient presents with an unfamiliar fever. A nurse who takes a travel history. A hospital wing in which patients can be isolated. A warehouse where protective masks are stockpiled. A factory that churns out vaccines. A line on a budget. A vote in Congress. “It’s like a chain—one weak link and the whole thing falls apart,” says Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. “You need no weak links.”
Among all known pandemic threats, influenza is widely regarded as the most dangerous. Its various strains are constantly changing, sometimes through subtle mutations in their genes, and sometimes through dramatic reshuffles. Even in nonpandemic years, when new viruses aren’t sweeping the world, the more familiar strains kill up to 500,000 people around the globe. Their ever-changing nature explains why the flu vaccine needs to be updated annually. It’s why a disease that is sometimes little worse than a bad cold can transform into a mass-murdering monster. And it’s why flu is the disease the U.S. has invested the most in tracking. An expansive surveillance network constantly scans for new flu viruses, collating alerts raised by doctors and results from lab tests, and channeling it all to the CDC, the spider at the center of a thrumming worldwide web.
Yet just 10 years ago, the virus that the world is most prepared for caught almost everyone off guard. In the early 2000s, the CDC was focused mostly on Asia, where H5N1—the type of flu deemed most likely to cause the next pandemic—was running wild among poultry and waterfowl. But while experts fretted about H5N1 in birds in the East, new strains of H1N1 were evolving within pigs in the West. One of those swine strains jumped into humans in Mexico, launching outbreaks there and in the U.S. in early 2009. The surveillance web picked it up only in mid-April of that year, when the CDC tested samples from two California children who had recently fallen ill.
One of the most sophisticated disease-detecting networks in the world had been blindsided by a virus that had sprung up in its backyard, circulated for months, and snuck into the country unnoticed. “We joked that the influenza virus is listening in on our conference calls,” says Daniel Jernigan, who directs the CDC’s Influenza Division. “It tends to do whatever we’re least expecting.”
https://www.theatlantic.com/magazine/archive/2018/07/when-the-next-plague-hits/561734/
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