BUKAVU, Congo—The World Health Organization last month declared the ongoing Ebola outbreak in the Congo a “Public Health Emergency of International Concern.” This is only the fifth time in history that this kind of declaration has been made by the WHO. Others include recent outbreaks of swine flu, the Zika virus, and the previous—and largest ever—outbreak of Ebola in 2014, which originated in West Africa and killed more than 11,000 people.
The current outbreak began just over a year ago, with initial cases turning up in remote villages in the northeast of the Congo but soon enough spreading to larger regional cities. Since then, an estimated 1,600 people have died from the virus. But it is not death tolls that spur the WHO to declare an emergency of “international concern.” Rather, it is the potential for a particular public health risk to shift from a localized problem to an international hazard. The Congo declaration was made after a case of the virus was confirmed in Goma, a busy city that borders Rwanda and that is a base for international travel in and out of the east of the country. Last week, a second death from the virus was confirmed in the city. Despite the best efforts of health officials to trace the virus, it is clearly capable of spreading to other urban areas of the Congo—and potentially beyond—before it is contained.
A declaration of a “Public Health Emergency of International Concern” is intended to reduce the international spread of a disease, and it enables a number of practical functions toward that goal. Primarily, it requires the country in which a disease originates to share critical information for transnational risk assessment and puts an onus on that state to implement recommendations that are formulated by an international emergency committee. In this case, the Congo was already sharing information and accepting international intervention prior to the emergency declaration, meaning that, effectively, the purpose of the declaration has been to spur a coordinated international response—particularly, by soliciting more funding.
While the emergency designation has certainly brought attention to the current crisis in the Congo, it also brings up new questions. Who does a declaration of “emergency” really protect when it comes to treating and containing an Ebola outbreak?
I am an anthropologist, and I have spent July conducting research in the east of the Congo, in the areas where the U.S. Department of State suggests “Do Not Travel … due to crime, Ebola, and kidnapping.” Unlike international travelers, people who actually live in the eastern Congo do not have the opportunity to heed such precautions. My research focuses on the ways that local people eke out a sense of ordinary life within such everyday insecurity. When the WHO declared that the Ebola outbreak constituted a public health emergency, I was interested to know how these locals interpret the current situation. Did it make them feel more secure, or did it make them more fearful about the extent of the virus? How do they intend to prevent infection? Is Ebola even an important concern?
On the morning after the WHO declaration, I met with women living in Ibanda, one of the poorest sections of the city of Bukavu. Like Goma, Bukavu is a large city that straddles the Rwanda-Congo border. Overnight, the WHO declaration had transformed Bukavu from a bustling urban center to a ticking time bomb, a latent reservoir of potential Ebola infection just waiting to surface. Under the assumption that the virus could already be incubating amongst people living in the city, well-meaning colleagues from various public health nongovernmental organizations instructed me, “Do not shake people’s hands.” The virus spreads through physical contact.
One of the first questions I asked these women was whether they were concerned about the potential for Ebola to spread into Bukavu. “Of course,” one woman, Joselyne, told me. I asked her what she was planning to do, if the virus were to spread. She responded, “What can we do? We barely know whether we will have food to eat at night. How can we worry about that problem? We do not even have food to put in our bellies.”
Joselyne’s concern about the immediate problem of poverty rather than the potential problem of Ebola reveals an interesting—and overlooked—dynamic about the current health crisis in the Congo. Given that poverty leads both directly and indirectly to the deaths of far more people in this part of Africa than Ebola, why is the virus a focal point of attention? Why is the underlying poverty that defines so many people’s lives treated as business as usual? Is it because poverty, unlike Ebola, is not transmissible to the West?
In following Joselyne’s lead and posing these kinds of questions, I do not mean to downplay the deadly destruction that Ebola wreaks in the communities most directly affected. There is no alternate way to spin Ebola. It is a painful and highly infectious virus that kills about half of the people who contract it. Those in the midst of treatment often spend their last hours in the terrifying loneliness of an isolation ward, separated from the soothing presence of friends and family.
But what Joselyne and other Congolese people I spoke with are suggesting is that, perhaps, the framing of a health crisis as an “international emergency” does not always reflect the interests of those who are most vulnerable to it. In fact, in this case, the emergency framing may do more harm to them than good.
Although the designation of a public health situation as a “Public Health Emergency of International Concern” may prevent the transmission of a virus across national borders, it has very real—and very negative—consequences for the local people who are most at risk of contraction. Declarations of international emergency tend to impede activities that stimulate local economies. They discourage visitors and tourists to the area. More importantly, these kinds of warnings reduce international trade, which many local people rely on to survive. These situations only make locals more vulnerable to ill health. Their isolation reflects international interests, but comes at a high cost for them.
These concerns about the negative impact of closing national borders in the wake of an international emergency were made apparent last week, after Rwanda attempted to close its border with the Congo at the Goma entry point, where an estimated 50,000 people cross between countries each day. The effects were immediate and disastrous: Local people who cross the border for business or education felt panicked and confused, the prices of food in both countries skyrocketed, and international aid workers could not get into the Congo to provide important humanitarian assistance.
In fairness, the WHO was initially reluctant to declare the situation in the Congo an emergency precisely because of the economic concerns I describe above. Yet, in the global media, discussions about Ebola rarely emphasize the role of poverty. Instead, much of the focus has been on the ways that conflict in the affected regions has made treating and containing the virus a security threat as much as a public health issue, or the resistance of locals in rural areas to heeding or believing the guidance of health professionals, with deadly results.
Those are real concerns. However, highlighting them only sensationalizes the most shocking aspects of the outbreak. When global commentary of the outbreak continually focuses on the sensational, it becomes all too easy to view the Congo through Joseph Conrad’s Heart of Darkness lens. In doing so, international audiences become dehumanized from the very human impact of the outbreak on Congolese people’s lives.
Poverty may be more banal than violence, but it is just as important a factor in complicating how Ebola is treated. Poverty leads to densely populated housing and poor sanitation, which increase the spread of infectious diseases. Poverty prevents people from getting adequate nutrition, which helps fight off and lessen the potentially deadly effects of infectious illnesses. Poverty forces people into contagion zones to work, because if it comes to the decision between starving to death and potentially contracting a deadly virus, many people will choose to risk death with a full belly.
When it comes to Ebola, we ignore the risks of poverty at our own peril, and especially at the peril of those within the contagion zone. We need to take seriously the concerns of Congolese people, like Joselyne, whose poverty directs her attention to the possibility of whether she and her family will eat that night, rather than whether they will contract Ebola. If not, we remain complicit in a system of global relations that continues to privilege the lives of the advantaged few over the lives and concerns of ordinary people in Africa.