Opinion

Farah Stockman

Ebola outbreak begs the question: Are cities hazardous to health?

People shop on Sept. 6 in Monrovia’s West Point slum.

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People shop on Sept. 6 in Monrovia’s West Point slum.

In August of 1976, a teacher in a remote region of what was then called Zaire went touring in the forest with his friends. On the way home, he bought a dead monkey, bush meat he thought his family would eat. He didn’t eat it, but he touched it, and that turned out to be a fatal mistake; he developed a fever and abdominal pains. Two weeks later, he was dead. Then the patients and medical staff at the hospital where he’d gone for treatment began to die. Eleven out of 17 doctors and nurses passed away so quickly that the hospital shut down. Health officials realized they had a plague on their hands that had never been witnessed before. They named it after a nearby river: Ebola.

Since then, the world has seen at least 10 Ebola outbreaks. Until recently, the largest one killed 425, in Uganda. But for the most part, health officials stamped out the virus quickly. In 1976, it took just four months to get rid of Ebola, even though no one even knew what it was. So why is today’s epidemic in Liberia still spreading, six months after the first reported case?

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The answer lies in the fact that nearly a third of all Liberians live in Monrovia, the capital city.

Since Ebola springs from contact with forest animals — monkeys and fruit bats — it is has always cropped up in isolated places that were easy to quarantine. In 1976, Ebola’s first victims came from villages, where people struggled to afford bus fare, let alone a flight. It was easy for epidemiologists to track down all the people the “index case” had contact with.

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But today, Ebola spreads in slums, where people have flocked from all over the country to find jobs. They can return to their rural villages just as easily, carrying the virus.

In 1976, doctors went door to door, explaining in the native tongue why loved ones shouldn’t be touched at their funerals, why their blankets must be burned. Local people, who’d experienced smallpox, understood. They kept the sick in make-shift structures outside their villages, and sent survivors of the illness, who’d built up antibodies, to care for them.

But in Monrovia’s overcrowded slums, there’s no room to isolate the sick.

EDITORIAL: International response is better late than never

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Ebola might seem like that rare instance where city life — civilization, if you will — is hazardous to your health. Most of us assume that urbanization represents an improvement over hunter-gatherers in the forest or farmers in the countryside.

But some anthropologists argue the opposite.

Mark Cohen, author of the 1989 book “Health and the Rise of Civilization,” studied the skeletal remains of ancient people, and concluded that hunter-gathers were taller, better fed, and healthier than their more “civilized” counterparts. That’s because cities were rife with infectious disease, poor sanitation, and malnutrition.

In the year 542, about 10,000 people a day were said to have died from the bubonic plague in Constantinople. In the 1600s, in London, about 66 percent of all deaths could be attributed to infectious diseases, including a form of tuberculosis called “The King’s Evil,” according to the book “Yellow Fever, Black Goddess: The Coevolution of People and Plagues.”

While it is true that the wealthy benefited greatly from cities, which brought luxuries that had never been experienced before, the living conditions of poor city dwellers was often far worse than their rural ancestors.

This is the situation today for the shantytowns of Monrovia. Residents have the worst of both worlds: They left the safety of their farms, but the benefits of the modern city — water treatment plants, sewage systems, medicine — remain elusive.

THE PODIUM: Rebuilding Liberia’s health care infrastructure

It’s important to remember that Ebola is not a death sentence. Three American doctors have recovered from the disease. Blood transfusions, rehydration, and nutrition can help a healthy body defeat it. So many people in Liberia are dying of Ebola today for the same reason they are dying of tuberculosis and diarrhea: They live in overcrowded cities that lack sanitation, and much else.

Almost one out of every nine children in Liberia die before their fifth birthday, for reasons that have nothing to do with the virus we are talking so much about. The leading cause of death in Liberia is not Ebola. It’s malaria, followed by acute respiratory infections.

We should fight Ebola, and cure Ebola, if we can. But we should also remember that Ebola is not the biggest problem plaguing Liberia’s cities.

Farah Stockman can be reached at fstockman@globe.com. Follow her on Twitter @fstockman.
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