Fighting the ghost

It’s a typical day on the shores of Lake Edward, nestled between the grassy savannah of Uganda’s Queen Elizabeth National Park on one side and the rolling hills of the Democratic Republic of the Congo (Congo) on the other. Fishermen unfurl their nets to check for tears and knots, before sorting the day’s catch of tilapia and catfish. A marabou stork, with its characteristic wrinkly red head and bulbous neck, wades expectantly through the reeds: if it loiters long enough, the men chuck the scavenger bird a scrap of guts or a fish head. In the lake, just metres from the row of beached boats, a rock shifts ever so slightly, sending a ring of ripples through the water. Slowly, a hippo rises. First its nostrils emerge, then its eyes and finally its whole head, jaw agape in a giant yawn.

Bwambale Julies, 34, is a fisherman and a local school teacher. He’s lived in this community that hugs the lake’s edge all his life and every morning he heads out in a small wooden boat. Like most, he sells some of the fish he catches and uses the rest to feed his family. “It’s a big worry for us out there; every day of course you know there’s a risk it could get you,” he says gesturing to the vast, flat expanse of water. But he’s not talking about one of the shape-shifting pods of hidden hippos lurking in the lake. It’s something far harder to spot coming: Ebola, among the world’s most deadly viruses. “It’s like a ghost. You can’t see it, but it’s there. It can inhabit you and come home with you and spread to your wife and children without ever being seen, not until it’s too late,” says Julies.

In eastern Congo, just a few miles from this landing site, health workers are battling to contain the second largest outbreak of the Ebola virus to date. Since August 2018, more than 3,400 people in eastern Congo have been infected and 2,200 killed by this cruel disease, which has an incubation period of 21 days. Its victims can take up to two weeks to die, mostly from internal bleeding and organ failure.

For those working on Lake Edward it’s a constant, lurking menace. The latest World Health Organization (WHO) map charting the virus ‘hotspots’ shows a cluster of red dots nestled worryingly close to the lake and along Uganda’s border. Ebola has a mortality rate of up to 90 percent and spreads through close contact – WHO guidelines recommend against sharing foods or even hugging. Here, the Ugandan and Congolese fisherman share nets, boats and handshakes while out on the water. Fish traders from both sides of the border come to work at the landing station’s small marketplace. Bodas, the local name for motorbike taxis, flit back and forth between the two countries; drivers often squeeze on as many as four pillion passengers.

In a bid to keep the virus at bay the Ugandan authorities have put up screening centres along the landlocked country’s 545-mile border with Congo. At the landing site I visited, Kyanzi Nasur Tsiha, 68, sits behind a wooden desk in a small blue tarpaulin tent. Those arriving at the lake shore must use the sanitiser dispenser to clean their hands outside Tsiha’s makeshift office, before entering to have their temperature taken. A fever is one of the early symptoms of Ebola. I scrub up and take a seat and Tsiha points the non-contact thermometer at my temple. My temperature is fine. Screening points such as this one appear to be having a positive impact: so far, Uganda has only had four confirmed cases of the disease during this outbreak, all of whom were Congolese travellers.

Yet fear that the virus could slip into the country undetected and spread is ever-present. Every day up to 50,000 people cross at official border posts to study, work and visit family. At these, travellers are checked for fever and, if one is present, taken for further testing. But many locals also use the network of unpoliced ‘mouse paths’ or ‘panyas’ – the name in Kiswahili for the small dirt-track backroads through the bushland and forests. Still more come and go unnoticed by boat; between them Lake Edward and, further to the north, Lake Albert straddle around one-third of the two countries’ borders.

“We have to be constantly vigilant, because every person is a potential case. We try to check everyone, but of course maybe some people try to avoid coming here or take the route where there is no screening station,” says Tsiha. “They are frightened that we are trying to catch people: to hurt them, not help them. People believe a lot of things about Ebola here. Some believe it is a weapon of foreigners or political enemies, others think it’s black magic.” He pauses and sighs heavily. “There’s a lot of misinformation, mistrust. Most of all they are afraid.”

The Black River

The story of Ebola begins in 1976, when scientists working at the Institute of Tropical Medicine in Antwerp received an unusual package: a shiny blue metal thermos flask brought from Zaire, now the Democratic Republic of the Congo, in a passenger’s hand-luggage. Inside, nestled amid some melting ice cubes, were glass vials containing blood samples. Accompanying the delivery was a brief handwritten note from a Belgian doctor requesting help with a diagnosis. The blood, he wrote, belonged to a Flemish nun who had been struck down by a mysterious illness. Its symptoms included fever, diarrhoea, vomiting and bleeding. One of the vials had cracked, leaking blood into the slushy ice mix. Unaware of the danger, the scientists began conducting routine antibody tests on the samples. Yellow fever, Lassa fever and several other candidate diseases all yielded negative results.

It wasn’t until several days later, when the researchers placed a secondary cell line sample under the microscope, that they realised the risks they had taken in handling the nun’s blood. Made visible by the magnifying lens was a worm-like structure measuring 14,000 nanometres, huge by virus standards, that bore a striking resemblance to Marburg – a haemorrhagic virus named after the German town where seven scientists died in 1967 after being infected by monkeys imported from Uganda. The discovery meant that the Antwerp laboratory, which lacked the specialist equipment required to handle haemorrhagic viruses, was forced to hand over the remaining samples to the Centers for Disease Control (CDC) in the United States. They did, however, get one of their scientists a spot on a field mission of international experts that was sent out to investigate the source of the virus, deep in Congo’s equatorial rainforest.

Microbiologist Peter Piot, who co-discovered the Ebola virus in Zaire in 1976. Photo: Getty Images

In his autobiography, No Time to Lose: A Life in Pursuit of Deadly Viruses, Peter Piot, who later went on to be director general of the UN HIV/Aids programme, recalls feeling like “Tintin, the boy hero, in some kind of comic book thriller” as he boarded the flight to Kinshasa. Aged just 27, he was equipped with little more than a pair of motorcycle goggles, borrowed from a colleague to protect his eyes, and instructions on how to catch bats – his boss believed the flying creatures carried the virus and wanted him to bring some home for testing. Piot, a self-described “greenhorn” who had never been to Africa, resolved to make good use of the former and ignore the latter – he was, he admits, terrified of bats.

By the time the team boarded the flight to Yambuku, a remote village some 620 miles north of Congo’s capital, the gravity of the situation was starting to sink in. Three missionaries – two nuns and a priest – had succumbed to the illness and dozens more people in local communities were reported to be showing symptoms. The Congolese authorities had imposed martial law on the region. The crew of the C-130 military aircraft, charged with transporting the team of scientists, were petrified. They had heard rumours of birds falling from the sky above the quarantine zone and bodies piled high on the roads of Yambuku. When they reached their destination, the pilot left the plane’s engines running and remained locked in the cockpit as the researchers unloaded their equipment. As the plane hastily took off again, Piot recalls the pilot’s farewell shouted down to the researchers below: “Adieu” – a goodbye that implies you won’t be seeing the person again in the foreseeable future.

The atmosphere on the ground was equally grim. Upon arrival, the team found terrified missionaries holed up in a guesthouse next to the church in a self-imposed quarantine. Outside, nailed to a palm tree, was a sign reading: “Anybody who passes this fence will die”. Inside, a group of sobbing nuns was praying. Undeterred, the researchers turned ‘virus detectives’ set about soothing the sisters, then eliciting from them as much information as possible. In notebooks they scribbled down details and sketched out theories. Confirmed deaths included nine missionary hospital staff and 39 people from the 60 families living at the mission. The local school’s headmaster who had recently eaten monkey and bat, considered delicacies, was identified as a possible ‘Patient Zero’ and the food as a potential source of the disease. They noted down one of the sister’s observations that something strange must be happening at funerals as mourners seemed to be getting sick en masse.

In the week that followed, they toured the surrounding area. Village elders helped them identify the sick. In hut after hut they were greeted with the same grim spectre: lethargic, glassy-eyed people who were bleeding from their orifices and clearly on the brink of death. Interviewing family members and, when possible, the patients, the scientists concluded that the virus was passed on through contact with the highly contagious bodily fluids of the sick. This explained its rapid spread among family members, who cared for ill relatives, and at burials where local traditions often brought mourners into direct contact with the deceased’s body.

They also unearthed another rather more unsettling chain of transmission. Nearly twice as many women as men had contracted the virus. Most were clustered in the 18-to-25 age group and pregnant. The link between these victims: the Yambuku missionary hospital’s antenatal clinic. A brief search through the medical ward’s stockroom confirmed the scientists’ suspicions. Just five glass syringes, rinsed in lukewarm water at the end of each day, were being used to give vitamin shots to expectant mothers. The well-meaning but ill-informed nuns had unintentionally spread the virus to scores of patients.

A WHO nurse handles a bottle containing the Ebola vaccine at the launch of a vaccination campaign in the Congolese town of Mbandak in May 2018. Photo: Junior D Kannah/AFP via Getty Images

Back in Kinshasa, over a half gallon bottle of bourbon, the scientists came to the task of naming the virus. Not wanting to stigmatise the villagers they opted against calling it the ‘Yambuku virus’. “Geographical finger-pointing” had, one of the team recalled, caused no end of problems for the villagers from Lassa in Nigeria, the namesake of Lassa fever. Instead, the researchers turned to a “not-so-very-big” map of Zaire pinned to the wall and found the Ebola River. The vaguer reference point seemed “suitably ominous” – in Lingala ‘ebola’ meant ‘dark’ or ‘black’. Although a later, closer examination of a larger map would reveal the river was much further away than they initially realised from the outbreak hotspot, the name stuck.

The official credit for ‘finding’ Ebola would ultimately go to the Atlanta-based CDC, which subjected the nun’s blood to further testing. Piot and his fellow scientists’ early expedition to Yambuku, however, provided much of the early epidemiological information about Ebola’s spread which, at least in part, helped limit the death toll of the first-known outbreak to 280. Looking back, Piot describes his role on the team of scientists “cobbled together to fight a virus that none of us yet understood” as a giddy experience. The allure of being part of the discovery was, he writes, “almost like light drunkenness – with tingles”.

The vaccine and the Valley of Death

Despite the researchers’ initial excitement, the discovery of Ebola garnered little attention beyond academics specialising in tropical diseases. Over the decades that followed, outbreaks of the virus came and went almost unnoticed. According to WHO data, between 1976 and 2012, some 1,600 people in Sudan, Congo, Uganda and Gabon were killed by the virus.

When Steven Jones, who now heads the School of Public Health at the University of Saskatchewan, applied for a position researching Ebola at a Canadian laboratory in 1999 he had no idea that the job location, Winnipeg, was the “windiest and rainiest city in the world”. But he’d never been much of a forward-thinker. As he’s fond of telling students who ask how he planned his career: “I didn’t!” After completing his PhD in biomedical science Jones first worked on an oral vaccine for farmed salmonid fish, before stumbling into research on “agents of concern” – a name given to pathogens that were deemed a security threat.

Steven Jones, head of the School of Public Health at the University of Saskatchewan

The move was well timed. After 9/11 and the Bush administration’s declaration of the War on Terror, bioterrorism research was in vogue and money was readily available. Still, as Jones would find when he moved to Winnipeg, Ebola remained an extremely “niche area”, far less trendy than anthrax or the bubonic plague, which were better known among policy-makers and attracted more investment. At that time almost everyone who worked on Ebola “knew each other personally – we could fit in a reasonably sized room,” he says.

Much like Jones’s career trajectory, the Winnipeg lab’s discovery of rVSV-ZEBOV – the vaccine that would eventually go on to be used against Ebola in Congo – was part stroke of luck and part hard work. Initially, the team wasn’t working on a vaccine but on trying to determine why the virus wreaked such havoc in the immune systems of humans and some animals. In particular, they were working to disprove a theory that a glycoprotein within Ebola was the cause.

The scientists used a livestock virus, called vesicular stomatitis virus, or VSV, which had been adapted for use as a vaccine delivery system and could be engineered to deliver specific genes from viruses. Mice injected with the gene that triggers production of the Ebola glycoprotein showed no ill effects, confirming the scientists’ suspicions. Almost as an afterthought, they exposed the mice to the complete Ebola virus, a move that should have killed them. To their surprise, the mice were fine. Repeat experiments, this time using monkeys, produced the same results: the primates also survived what should have been lethal doses of Ebola and Marburg, both members of the filovirus family. The team had inadvertently discovered a vaccine.

Drumming up money to develop the drug proved harder, however. The Winnipeg team applied for funding to put the vaccine through further trials but were repeatedly shot down. The questions were always the same, says Jones: “Who would ever use an Ebola vaccine? Why would anyone make one?” For the next decade-and-a-half, rVSV-ZEBOV (short for ‘recombinant vesicular stomatitis virus-Zaire Ebola virus’) languished in what vaccine researchers darkly call the ‘Valley of Death’ or, as Jones puts it, the place “where good ideas die”.

Seeing a vaccine through trials to drug licensing is typically a $1 billion endeavour and the death toll from Marburg and Ebola was, at that time, relatively low. Pharmaceutical companies simply weren’t interested in conducting expensive clinical trials of a drug that would have poor countries as its main market. In business terms it made no sense. But, as Jones discovered, in human terms the delay turned out to be devastating.

In 2003, scientists from the Winnipeg research team were deployed to Angola, where an outbreak of Marburg, a sister virus to Ebola, had struck a maternity ward. The Canadian scientists took vials of rVSV-ZEBOV with them to use in case of a needle-stick injury. Marburg’s mortality rate is high, up to 90 percent, and Jones says if he’d been exposed he would have used the untested vaccine “in a heartbeat, because you’re probably going to die if you don’t do something”. But although the vials offered the scientists some peace of mind about their own welfare, Canadian law meant that, because the drug had not undergone human tests, they could only inject themselves with it and not distribute it. Unable to use the vaccine, the researchers could only watch as whole families were wiped out by the haemorrhagic disease.

Among the victims was a chubby two-year old boy who had just come down with a fever when Jones was about to travel home. Two days later, when he stepped off the plane in Canada, Jones got the news that the toddler had died. “It was heartbreaking, to know you had something that could make all the difference, but you couldn’t use it,” he tells me.

The world wakes up

And then, in late 2013, an Ebola outbreak struck Guinea. It began like most others, with a single victim: two-year-old Emile Ouamouno, who was thought to have caught the virus playing near a fruit-bat-infested tree in a small forest village. The toddler’s death was shortly followed by those of his sister, mother and grandmother, then by a traditional healer who had treated the family. From there the virus spread exponentially out to the nearby villages and towns, then to cities.

By May 2014, it was hopping borders across West Africa: first Liberia, then Sierra Leone and on to Nigeria. Over the course of two years, 28,637 people were infected and 11,315 killed by the virus. News crews broadcast the horror straight into living rooms across the world: the bodies piled in the streets of Sierra Leone, the health workers in spacesuit gear, the distraught families who waited outside the Ebola treatment centres, the sick who bled from their eyes and ears before dying in lonely isolation units. The public were horrified, politicians were panicked. A little-known disease that affected far-flung corners of Africa looked like it could turn into a global pandemic.

The scale of the outbreak, which dwarfed all the previous ones combined, proved a game-changer. In August 2014, the WHO declared the upsurge in cases a “global health emergency”. Money poured in to fight Ebola – in 2014 and 2015 some $652 million was invested in Ebola research, much of it provided by Western governments. Meanwhile, the sale of rVSV-ZEBOV from New Link, the small company that owned the drug licence, to Merck, a much larger pharmaceutical organisation with experience developing VSV-based vaccines and running trials, was hastily pushed through under international supervision. There was widespread consensus that something had to be done. There was less agreement, however, on what that should be.

In particular, the question of how to run trials of rVSV-ZEBOV – later known as V920 and then by the brand name Ervebo – and other candidate vaccines, sparked fierce debate. While pharmaceutical companies favoured a randomised-control trial design, the gold standard of scientific testing, humanitarian organisations like Médecins Sans Frontières (MSF) pushed for a ring-vaccination approach. Denying the inoculation to a control group, or giving them a placebo, might produce faster, more scientifically rigorous results, but ring vaccinating – an approach in which you vaccinate all known contacts and contacts of contacts of infection ‘cases’ – was more ethical and had, they argued, proven successful in eradicating smallpox.

They also insisted that small-scale studies to ensure the vaccines’ basic safety in humans be carried out first. Ultimately the humanitarians, who were running the Ebola treatment centres that housed the would-be test subjects, won the day.

Although the drug trials progressed at breakneck speed, in the end they still proved to be too little too late for Africa in 2014. By the time the experiments started in earnest, traditional containment methods were already bringing the outbreak to a close, and the number of new cases were dwindling. Studies in Guinea and Liberia were both brought to an early end due to an insufficient number of cases. Still, data had been gleaned that indicated the vaccine worked in humans. It was valuable progress. In 2018, when Ebola struck again, this time in Congo, widespread trials started almost immediately. Yet, as the scientists would find out, having a vaccine is one thing – stopping an outbreak with it is another.

Dancing with the pygmies

To describe eastern Congo as poor and war-torn doesn’t do the situation justice. Last year, the Kivu Security Tracker project recorded more than 130 armed groups fighting in the region. Between June 2017 and 2019 the NGO, which maps violence in the region, confirmed 3,316 abductions, 24 mass rapes with a total of 100 victims and 1,879 people killed in conflict. The per capita rate of civilian conflict deaths of 8.38 per 100,000 makes it among the most dangerous places in the world; the comparable figure for Borno State in Nigeria – the heartland of the Boko Haram insurgency – is 6.87 and for all of Yemen 4.13.

A girl receives the Ebola vaccine in Goma, eastern Congo, in November 2019. Photo: Pamela Tulizo/AFP via Getty Images

The conflict has destroyed the region’s social fabric. “If people don’t trust their own neighbours because of this terrible war, how are they meant to trust you? That’s how you have to see it, from their perspective,” says Julienne Anoko. For much of the last decade Anoko has worked in healthcare in places that most people are trying to avoid. She was in Madagascar during an outbreak of the bubonic plague and Cape Verde in the midst of the Zika epidemic. Now, she’s just started her second stint for the WHO in North Kivu, the epicentre of the latest outbreak of Ebola in eastern Congo.

A Sorbonne-trained anthropologist from Cameroon, her approach to disease outbreaks is different from the medical model. While scientists focus on numbers – transmission rates, mortality figures, prevention efficacy – Anoko is working with the individuals who make up those stats. Her work takes her to some of the most isolated places in the region. Much of it centres on trying to find ways to “build bridges” between communities that are more used to visiting traditional healers than a health centre (often a long walk away) and more likely to believe in “black magic and superstitions” than vaccination.

The environment Anoko works in is hostile and mistrustful towards those responding to the Ebola outbreak. Fear of outsiders here is deeply entrenched – and with good reason. Since Belgium’s King Leopold carved the country out of Central Africa in the late 19th century its rainforests have been ransacked for rubber, its people exploited for slave labour and its soil plundered for diamonds, gold and, most recently, cobalt, a metal used in the production of smartphones. Despite being one of the most resource rich countries in the world, its people are among the poorest – the World Bank found around three-quarters of the population live on less than $1.90 per day.

Health workers, too, have played a role in Congo’s bloody past. In his book Congo: The Epic History of a People, David Van Reybrouk describes how between 1900 and 1940 Belgium carried out a heavy-handed campaign to counter an outbreak of sleeping sickness – a disease spread by tsetse fly and propagated by colonial policies that pushed people from traditional lands into fly-infested areas. Colonial authorities forcibly relocated villages and introduced a ‘medical passport’ with a health certification to travel a distance of more than 20 miles. In north-eastern Zaire, an area that overlaps with the current Ebola outbreak, doctors screened entire villages in search of people with swollen glands, an early symptom of sleeping sickness. Those thought to be infected, although many would have felt healthy at the time, were taken under duress to be isolated in ‘lazarettes’ that “resembled leper colonies”. The sick were then used as guinea pigs for experimental treatments including atoxyl, a derivative of arsenic, which more often rendered them blind than cured. As a result, people came to believe that the camps were places where “colonial officials intentionally infected [people] with the sickness” prompting the outbreak of riots.

In this context, Congolese suspicions of Ebola responders are not surprising. As Van Reybrouck notes, just two generations ago: “The state: that was the men with microscopes who frowned gravely as they looked at your blood. The state: that was the gleaming hypodermic needle that slid into your arm and injected some kind of mysterious poison. The state literally got under your skin. Not only was your countryside colonised, but so was your body and your self-image.”

Echoes of the past continue to reverberate into the conflict-ridden and impoverished present. In 2019, the WHO recorded 300 attacks on Ebola treatment centres in Congo, killing six and wounding at least 70. Anoko’s childhood friend, Richard Valery Mouzoko Kiboung, a Cameroonian epidemiologist, was among those killed. Despite this, she remains undaunted. Every day in the field she patiently notes down peoples’ frustrations and fears: Ebola has been brought by outsiders to kill us. Ebola is made up to make us leave our homes. In the treatment centres people are being injected with Ebola, nobody leaves there alive. The government is infecting us with Ebola to get money from foreigners, they tell her. She never walks away from them, even though she knows the rumours are not true. “Listening is the key, people are the key, this can be a type of medicine too,” she tells me.

Her task is not easy. Congo is a patchwork of different ethnic groups, tribes and traditions – an estimated 215 languages are spoken in the country. Each place she visits is different and so too must be her responses. Recently, she was given the task of visiting a community of pygmies that had, thus far, rejected health workers’ pleas to be vaccinated. “They were very tense, very suspicious of this vaccine; they didn’t want it at all,” she explains. Her job was to persuade them otherwise.

On arrival, however, Anoko didn’t launch into an explanation of the drug’s benefits; in fact she didn’t mention it all. Instead, she presented the village elders with bags of salt and cartons of palm wine – gifts that travellers visiting the community had traditionally brought as tokens of peace and friendship. “It broke the ice and we sat down to talk,” she says. Still she didn’t mention Ebola – not until it was raised by the elders.  When they did so, it “turned out they were actually quite worried, quite fearful; they understood it could kill them,” Anoko explains.

During the conversation she noticed something intriguing: the pygmies never called the virus by name, referring to it only as ‘The Monster’. It could be an opening, she thought, a chance for her to frame the vaccine in ways that worked for everyone. “You have to name this thing – you have to name your enemy before you fight it. Let’s name it, face it and fight it together,” she told them. The elders looked at her and nodded. Her reasoning made sense. They asked for drums to be fetched. For the next two hours they swayed to the pounding, rhythmic beats, performing a local traditional dance to ward off unseen evils. Anoko joined them. That time dancing together, playing the drums together, created “a bridge” she says. “After that they asked for the vaccine. They were convinced.”

Anoko can reel off a list of stories like this one. In a Guinea marketplace, she overheard locals trading gossip about Ebola at a popular food joint over lunch. Instead of confronting those spreading misinformation, she waited until everyone had finished and then had a quiet word with the food vendor. The stall owner, who was well liked in the community, became a valuable way for health workers to pass on accurate information to locals about the crisis and counter rumours.

In another Congolese village, she discovered that an unfilled grave was the cause of tensions between the community and health workers. The body of a local leader who had died at an Ebola treatment centre had not been returned and the villagers saw the empty hole, already dug in preparation for his funeral, as an inauspicious sign. Anoko was not able to return the body – he’d already been given a safe burial by health workers – but she was able to find a solution. A goat, a vat of palm oil and 50 kilograms of rice were, at Anoko’s behest, purchased for the villagers. Instead of a body, they buried a symbolic banana leaf and held a send-off party in the elder’s honour. The health workers were allowed to return to the community.

Refusing the vaccine

Finding ways to mesh modern science and traditional beliefs, however, is only part of the problem.

At a border crossing in Mpondwe in Uganda, cargo trucks kick up a gigantic plume of dirt as they edge closer to the custom points. Shopkeepers selling everything from mounds of used shoes to counterfeit Levi’s jeans bellow to be heard over the ghetto blasters that blare out the latest Congolese rap. Roadside fruit-sellers swat flies away from stacks of fresh pineapples and piles of papayas, and a man barbecuing goats’ heads along with their still-hoofed legs wafts the thick smoke away from his watering eyes. Women with children strapped to their breasts somehow also manage to balance their shopping – anything from a jerrycan of petrol to a basket full of eggs – atop their heads, as they weave through the chaos.

Down a backstreet a group of Congolese traders, here for the market day, are taking respite from the midday heat. All are from Beni, a trading town close to the border with a population of around 200,000 that has been a hotspot in the recent outbreak of Ebola. Around half of this group tell me they have refused offers of the Ebola vaccine from health workers. Bwambale Lawrence, 24, is among them. “What’s the motive behind Ebola? That’s the biggest question. That’s what disturbs people, that’s why people are suspicious of this vaccine,” he says with passion. “We have war, we have many other diseases. People are dying from Aids, cancer, malnutrition. Why the concern over Ebola? There are many other diseases killing people, but the international community is quiet.” The others nod in agreement.

“Madam, you have to understand, people in Congo die in large numbers and nobody cares, nobody helps us,” chimes in one of them. “So, we want to know why all these foreigners have so much money to come here now?”

Their questions have no easy answers, and they’re only too familiar to John Johnson, programme lead for MSF’s Ebola vaccination programme. Currently, he says, they’ve only been able to vaccinate around half of the ‘contacts’ of Ebola patients as many are untraceable or go underground when attempts are made to reach them. It’s a number well below what is needed for a ring-vaccination approach, as is currently being deployed in Congo, to successfully eradicate a virus from a population.

John Johnson, programme lead of MSF’s Ebola vaccination project

“You have this situation with many international actors coming for a few sick people in the middle of a conflict zone,” he explains. “On top of that there are strange protective measures that are put in place, plastic protective suits, isolation centres that people can’t enter to see the sick, burials have to be carried out differently. What we hear from people over and over again is that we’re responding because we want to protect ourselves. We’re not there because they’re sick, but because we’re afraid that people are going to come to Europe or the United States,” he tells me. “And they’re not wrong.”

As Johnson points out, while Ebola has made headlines worldwide, far less attention has been given to Congo’s measles crisis. In the last year alone, 6,000 people, more than three-quarters of them children, died of the virus, for which a vaccine has been available since 1967, nine years before Ebola was even discovered. In August 2019, MSF posted a plea for donations to support a measles vaccination campaign, stating that it had raised less than a quarter of the $8.9 million needed, and contrasting it with “the Ebola epidemic in the east of the country, which attracts multiple organisations and hundreds of millions of dollars in funding”.

The difference in donors’ readiness to give is, at least in part, a result of how the viruses are viewed. Unlike measles, Ebola is seen as a potential bioterrorism threat: as a result, much of the funding for Ebola research and response has come from the deep pockets of security budgets, not public health funds. In 2014, during the West Africa outbreak, the US Department of Defense alone contributed $402.8 million from its budget to fighting Ebola, including $72 million for vaccine research and ‘cooperative threat reduction’. Meanwhile, its Canadian counterpart contributed at least $7 million to the development of rVSV-ZEBOV.

A cure for Congo

Ebola and measles, however, do have one thing in common: they are both signs of a problem that runs much deeper. Less than half of Congo’s population have access to clean water and only 20 percent have access to basic, safely managed sanitation services. Public health services are dilapidated: an article in The Journal of Nursing describes how state-run hospital wards are “sorely lacking” in basic equipment and often “filthy” because cleaners’ wages can’t be paid, and cites maternity wards that have no beds or mattresses. Like the well-intentioned nuns at the mission hospital whom Piot encountered in 1976, health professionals working in these conditions are as likely to spread disease as they are to cure it. Meanwhile, food insecurity affects 70 percent of Congo’s population, with one in four children suffering from malnutrition – a situation that drastically increases the likelihood of zoonotic diseases, like Ebola, spreading from infected bushmeat into the human population.

People exit the Mpondwe Health Screening Facility as they cross the border from Uganda into the DRC, June 2019. Photo: Issac Kasamani/AFP via Getty Images

It is first-hand knowledge of conditions like these, in Liberia and Sierra Leone, that has left Jones with “mixed feelings” about rVSV-ZEBOV. He’s pleased that the vaccine has finally been “pushed over the line” – it got approved by the European Commission in November 2019 and by the US Food and Drug Administration in December 2019. Yet, he also knows from hard experience that science alone isn’t the cure. “I used to be pretty self-satisfied, making a vaccine and being part of this excellent team. As a biomedical scientist this is the pinnacle. But when you get on the ground you realise that, in common with many, many other diseases in the developing world, this is a disease that is caused by poverty rather than the virus,” he says. “People in London, New York, Washington and Geneva, who are very bright and are trying to do the right thing, are often developing programmes which are not deliverable or sustainable in the African healthcare context.”

It’s not for lack of money being spent. Countering Ebola is costly. In West Africa international donors spent $6 billion in 2014 to 2015, and in Congo another $734 million has been pledged following the start of the current outbreak in 2018. And with more outbreaks likely in the future – Ebola is endemic to Central Africa – a more long-term solution is desperately needed. While GAVI – a public-private partnership focused on vaccination programmes in developing nations – has signed a noteworthy advance purchase agreement worth $178 million with Merck, the 500,000 doses it will secure are, in real-terms, a rather small amount. More than 260,000 vaccinations given so far have failed to stop the current outbreak and Congo’s population is 81.3 million, meaning a full-scale inoculation programme in the country, let alone the broader region, is unlikely in the foreseeable future.

Indeed, once GAVI’s stockpile is exhausted it’s far from guaranteed that Congolese people will have access to an Ebola vaccine at all. Big pharmaceutical companies have legal obligations to their shareholders to return profits, but none to help the developing world. And there’s a risk that in the future Merck could put rVSV-ZEBOV into a price bracket that orientates the vaccine at travellers visiting Africa, rather than being part of a routine inoculation package for Africans. In 2018, Merck prematurely pulled out of a long-term agreement with Unicef and GAVI to supply RotaTeq – a vaccine against rotavirus, which kills around 200,000 young children annually – to West Africa at $3.50 per dose. Despite citing “supply constraints” as the reason, the company still sent stock to China, where it can fetch up to $40 – a more than tenfold price hike.

“An expensive vaccine that is paid for by outsiders and gets flown into a place where there aren’t public healthcare basics like primary healthcare centres and refrigeration to maintain cold-chain supply for it just isn’t sustainable,” points out Sonia Shah, author of The Body Hunters: Testing New Drugs on the World’s Poorest Patients. Moreover, large support packages that rapidly disappear once a crisis ends, or a vaccine promised as a panacea that never arrives, can “backfire terribly” and have a long-term “degrading effect on trust,” she says. “We see this now with Ebola outbreaks, where healthcare workers are getting murdered or blockaded… It comes down to this deep bedrock of mistrust that exists: What are the intentions of these white people in white coats? Why are they over here? What are they doing?”

Back at Mpondwe market, the Congolese traders might well agree. They’re done with lunch and are getting ready to go back to work. As they go, Lawrence leaves me with a parting shot. “Scientists might have invented a cure for Ebola,” he says, “but it’s not a cure for Congo – tell them that’s what we need.”

 

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