I wrote a story for National Geographic about the Ebola outbreak in the Democratic Republic of Congo (DRC). It was published yesterday, and you can read it here.

A few things are notable about this outbreak:

One question I didn’t get to answer in the story is the one I’m hearing : 

Is this outbreak the US’ fault?

It’s hard to hear this question without also hearing a subtext:

I’m angry that our current administration withdrew US support from the World Health Organization, killed the U.S. Agency for International Development, and hollowed out the CDC. Are those actions in some way responsible for this outbreak? 

To be clear, Ebola isn’t new to this part of the DRC. Although outbreaks of the virus are more common in the northwest part of the country, they’ve been bubbling up in the northeastern corridor since 2012 (mostly Zaire strain). In fact, the biggest and most lethal outbreak in the DRC’s history included the same province affected now, the Ituri province, in 2018-2020: Nearly 2,300 people died.

Still, the answer is complicated.

A few features make this area particularly susceptible to outbreaks:

Lots of opportunities for human contact with animal reservoirs of disease. Animal reservoirs are animals that live with a virus, often without getting sick. People may catch Ebola from these animals when they touch or eat ones they find sick or dead, or ones they hunt for food. Fruit bats are a common reservoir for Ebola, and their ideal habitats are dense, moist forests like the ones in Ituri province. When people eat fruit bats for meat — not uncommon in rural Africa – they can get infected with Ebola. 

Lots of opportunities for human transmission to other humans. Ebola is spread between humans by contact with body fluids, which happens pretty easily in overcrowded living situations where lots of people share sinks and toilets, and running water and soap are scarce. Ituri province has hundreds of thousands of people living in these kinds of situations. That’s partly because the area been mired in conflict for decades, and tens if not hundreds of thousands of people have had to leave their homes there due to violence, including in recent years. Many of these internally displaced people live in camps.

Additionally, the province is home to tons of mining camps. People who work in the mines are often migrant workers, and as in many places around the world, their housing is overcrowded. Here’s what IDP camps and living barracks at a copper/cobalt mine look like — the mining camps are better, but still conducive to spread. (Note that the mining camp photo is from pandemic times, which might’ve been somewhat different.)

Extremely limited access to health care, including laboratory testing. People in Ituri have had a really hard time accessing healthcare for a long time. There aren’t enough facilities and health care workers in the area, partly because health care workers are often targeted by the militias that operate in the region. (MSF had to actually close one of its hospitals nearby in 2020 due to repeated attacks.) That means people don’t go to get health care until they’re really, really sick — if they get health care at all — which creates more opportunities for transmission to the people around them.

Despite these massive vulnerabilities, previous Ebola outbreak responses in Ituri province were able to contain the spread. But not this time.

Without a doubt, some of what makes the current outbreak different is the fact a rare viral strain is involved. I’m not sure if that has anything to do with changes in US foreign aid, but I doubt it.

However, it seems totally possible that this curveball would’ve been easier to spot early and respond to quickly — although still a big challenge — if USAID in particular were still active in the area.

Nahid Bhadelia is an infectious disease doc at Boston University and founding director of BU’s Center on Emerging Infectious Diseases who has been on the ground for multiple Ebola outbreaks. When I talked to her for the Nat Geo story, she explained it this way:

Pulling out USAID led to higher levels of lots of different diseases in Ituri province, making Ebola harder to find than it used to be. Ebola has a lot of natural mimics in the tropics, including malaria and typhoid: All of these show up as fever, fatigue, and gastrointestinal distress in their early days. Finding Ebola is like picking a needle out of a haystack – it doesn’t turn up on standard testing, and you need to think of it to find it. 

When USAID had a presence in northeastern DRC, it ran a system that facilitated getting medicines into the pharmacies in the area. Without USAID, that’s not happening, according to infectious disease doctor-journalist Celine Gounder’s interview with epidemiologist Les Roberts. Less treatment for malaria and typhoid means more malaria and typhoid. “Then you've got a bigger haystack, and you're missing the needle,” Bhadelia told me.

Pulling out USAID led to higher levels of conflict, raising the risk of Ebola transmission and also making it harder to find than it used to be. The US uses aid money to convince countries to do (and not do) certain things. For years, USAID money given to Rwanda was likely inducing that nation to keep a militia it funds in the area, M23, on a short leash. When the aid money went away, so did the incentive to restrain that militia. (This is also detailed in Gounder’s Les Roberts interview, which also explains why Rwanda has that militia to begin with. Tl;dr: it uses it to smuggle and profit off the minerals in Ituri’s mines.)

Unbound, M23 seized several cities. Clinic prices tripled and facilities stopped providing free treatment for pregnant women and children. Escalating conflict followed, leading to more hospitals stopping services in the region, as infectious disease researcher Alain Casseus recently explained. Less health care access means more people dying at home, which means more transmission and less detection.

It’s already hard to diagnose Bundibugyo in this part of the DRC: Because the GeneXpert machines used in the local labs don’t detect this strain, samples would need to be sent to the national lab a thousand miles away in Kinshasa to even be tested for Bundibugyo. That’s a long way for a sample to travel: If it was collected by inexpert or nervous hands — far more likely in a region where health care workers have fled due to violence, also Ebola is fucking scary — the sample could be inadequate, or could be damaged during travel. 

A recent publication in Science found shutting down USAID led to rising violence in lots of regions, not just East Africa.

Pulling out USAID removes the well-oiled response machine that existed in the area, making an outbreak harder to stop than it used to be. In the outbreak responses Bhadelia has been part of, there was a “nice rhythm” that enabled trust and rapid deployment of boots on the ground, facilitated largely by USAID. The agency paid and organized teams of people who knew what to do, how to run and understand lab tests, how to contact-trace and run teams to do village-to-village education and provide help. US funds also helped get supplies needed to run Ebola treatment centers where they needed to be, as Casseus writes: “The unglamorous reality of outbreak response is that an ETC needs gloves, gowns, body bags, chlorine, fuel for generators, and reliable transport... every single day and in volumes that can only be sustained by an industrial supply chain. USAID was that supply chain.”

The US State Department just announced millions in emergency funding to respond to this outbreak, and the CDC is deploying teams to help. Money is good, but responses are built on relationships and trust – and many of those were disrupted when USAID’s funds and people got pulled out of the area.

So yeah, dismantling USAID made this outbreak worse, and will likely make it last longer, than it would have otherwise.

The US government isn’t done sitting on its own balls. On May 18, CDC not-exactly-Acting-Director Jay Bhattacharya signed a travel ban restricting people from entering the US if they’ve been in the outbreak zone in the past 3 weeks. Travel bans don’t work, and in fact usually make it more likely infected people will sneak in undetected, and affected countries will be less transparent in gathering and reporting data on new cases to avoid the economic effects of exclusion from worldwide trade and travel patterns.

I know a lot less about how the disrupted relationship with WHO and the decimation of CDC are playing out in the outbreak and the response. As things unfold, I’m sure we’ll all learn more.

Since you read this far, you get a little media literacy treat: 

Why did I write so little about all of this in my Nat Geo story? 

For starters, I was assigned 900 words, and most of that needed to be focused on other topics. But it’s worth noting that National Geographic is part of the Disney Corporation, and Disney is directly in the US government’s sights. According to the only Democratic member of the Federal Communication Commission, the Trump administration is targeting Disney with a “sustained, coordinated campaign of censorship and control.” 

Nat Geo has been intentionally apolitical for some time, and it’s not like they’re tiptoeing around the White House just for this story. All I can say is that the aid withdrawals and the travel bans didn’t make it into the final draft.

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