The Poor and the Sick

The two deadliest outbreaks of this century can be traced to one thing: poverty. Cholera exploded in the Haitian countryside in October 2010, infecting more than 600,000 people and killing 8,600. Ebola surfaced this March in Guinea and has since spread to Liberia and Sierra Leone. As of mid-October, more than 8,000 have been infected and 4,000 have died, almost exclusively in West Africa.

At first glance, the two outbreaks couldn’t be less similar. Cholera moves quickly but it is a nineteenth-century disease, easily thwarted by modern water treatment systems and health care. It ravaged Haiti, but it has not spread beyond the developing world. Ebola, on the other hand, moves slowly and is not as easily treated. Further, it has reached the United States, earning it near-obsessive attention in U.S. news. As Greg Gonsalves, co-director of the Yale Global Health Justice Partnership wrote this month in Quartz, “Exotic infections for Americans, often from far away places, often Africa, strike fear into their hearts, but only once the pathogens have cleared customs.” Ebola has cleared customs in a way Haitian cholera never has. 

But a look at the long list of casualties reveals what the two diseases have in common. The right to health comes with a cover charge, and much of the world -- especially those in struggling states such as Haiti, Liberia, and Sierra Leone -- can’t pay it. In Haiti, cholera found its ideal host. The poorest country in the Western Hemisphere, Haiti lacks any system of modern water treatment. In the fall of 2010, United Nations peacekeeping troops from Nepal imported cholera to Haiti. They were stationed at a military base in rural Haiti, where their sewage was dumped, untreated, into Haiti’s waterways. As Paul S. Keim, a geneticist who studied the Haitian and Nepalese cholera strains, told The New York Times, in 2012, “It was like throwing a lighted match into a gasoline-filled room.”

Ebola arrived in similarly combustible terrain in West Africa. Violent conflicts in Liberia had left only 51 doctors to care for more than four million people. The country runs a deficit in medicine, supplies, facilities, and trained nurses and doctors. Guinea and Sierra Leone face similar constraints. 

To understand the impact these conditions had on the scale of the outbreak, consider a counterfactual: What would have happened had the outbreaks first surfaced in my hometown, Indianapolis, Indiana, instead of Haiti or West Africa? For one thing, it’s unlikely that cholera would have infected anyone at all. Rigorously enforced public health laws would have prevented filthy sewage disposal practices, and even if they hadn’t, effective sewage treatment would have eradicated the bacteria before it entered the drinking water. If anyone did somehow become infected, any emergency room would be prepared to offer the fluids and antibiotics that, when provided promptly, eliminate the infection in over 99 percent of cases.

As for Ebola, we know how the United States would respond. Those suspected of being infected would be isolated and provided care in a way that also protects health-care workers. All the while, at the state and federal levels, officials would implement a public health communication and response strategy. That two Dallas health-care workers were infected is worrisome, of course, but there is every reason to believe they will remain an anomaly. And the two cases pale in comparison to the 8,000 victims in West Africa, a number that is likely to keep growing. As Jim Yong Kim, president of the World Bank, and Paul Farmer, a professor at Harvard, wrote in an August op-ed in The Washington Post, “A functioning health system can stop Ebola transmission.” 

Yet functioning health systems have proved elusive for the world’s poor -- even though the right to health is codified in the Universal Declaration of Human Rights. And it is difficult to get richer countries to fight massive outbreaks that have not yet reached their borders. Diseases such as Ebola, which affect primarily the global poor, are unattractive targets for pharmaceutical companies looking to maximize profit. Government-funded research has its own budget limitations. According to Dr. Francis Collins, the director of the U.S. National Institutes of Health, an Ebola vaccine would already exist had the U.S. government not slashed research funding.

Public health experts have been quick to point out that poverty -- and the accompanying lack of health-care access -- is something far more likely to be endured by people of color. The United Nations has refused to admit its role in spreading cholera in Haiti, or to offer any reparations, a response that seems unthinkable had the outbreak occurred in Europe or the United States. In an interview with Public Radio International, Joia Mukherjee, a professor at Harvard Medical School and chief medical officer at the Boston-based nonprofit Partners in Health, blamed racism for the slow international response to the Ebola crisis. “I think it’s easy for the world -- the powerful world, who are largely non-African, non–people of color -- to ignore the suffering of poor black people.” The gold standard of care provided to white Americans and Europeans infected by Ebola, compared to the substandard treatment of West Africans, bears out her point.

Of course, Ebola’s arrival in the United States has already changed the international response to the outbreak. Efforts to create a vaccine have been fast-tracked, and nonprofits have launched community-based programs in West Africa to combat Ebola and other less sensational killers such as malaria and infectious diarrhea. 

But if the cholera outbreak serves as any indication, West Africans should not be too optimistic. This week marks four years since cholera surfaced in Haiti, and the anniversary will pass with no reparations for affected Haitians, no new water treatment system to prevent future outbreaks, and no guarantee that the disease will stop claiming victims. If Ebola is to be any different, the response must target the root of the problem: the deep-seated poverty that has allowed it to spread.