Negligent global response to Ebola reflects geopolitical inequality in health
International mobilization in response to epidemics varies according to the virus’s geographic reach, highlighting neglect of public health crises that affect vulnerable populations
When an outbreak remains confined to African countries, the international response — political attention and the deployment of supplies, professionals and international funding — tends to be slower and more neglectful — Photo: bhossfeld/Pixabay
When an Ebola outbreak remains confined to African countries, the international community’s response — political attention and the deployment of supplies, professionals and financial resources — tends to be slower and more neglectful. The situation changes when the disease comes to be seen as a “threat to international security”, particularly when there is a risk of spread beyond the African continent and into the Global North. One example was the large number of cases in West Africa in 2014: cases were also recorded in the United States, Spain, the United Kingdom and Italy.
“This discussion takes on greater relevance in light of the recent epidemic situation in the Democratic Republic of the Congo (DRC), in Central Africa, which has once again recorded Ebola cases, while circulation of the Bundibugyo strain was also identified in Uganda”, said professor Deisy de Freitas Lima Ventura of USP’s School of Public Health (FSP), who supervised the research.
The DRC officially declared the Ebola outbreak caused by the Bundibugyo variant on May 15. According to data from the European Centre for Disease Prevention and Control (ECDC), as of September 22 the country had reported a total of 7,773 confirmed cases, including 3,759 related deaths (data through September 21). A total of 839 patients were hospitalized in isolation as of that date. This represents an increase of 40 new confirmed cases and 27 deaths since the previous report, dated September 21.
This is considered the second deadliest event in the history of the Congo — and one of the fastest-moving.
“The outbreak risks being underestimated by the global community as long as it is seen only as a local problem affecting African countries, as occurred in 2018, without posing a direct threat to developed nations”, Deisy Ventura told Jornal da USP
The study resulted in the article Negligência e saúde global: o caso do surto de ebola na República Democrática do Congo em 2018 (Neglect and global health: the case of the 2018 Ebola outbreak in the Democratic Republic of the Congo), published in the journal Interface – Comunicação, Saúde, Educação, whose first author is Brazilian researcher Ramiro Januário dos Santos Neto, who holds a Master’s degree in Human Rights from the Law School (FD) and a PhD from the Graduate Program in Global Health and Sustainability at the School of Public Health (FSP), both at USP.
He defended his dissertation at FSP, addressing how the international community handled and responded to the 2014 and 2018 episodes, while also detailing the process by which the World Health Organization (WHO) declares a Public Health Emergency of International Concern (PHEIC).
The investigation is grounded in the fields of Critical Security Studies and Global Health and uses the concept of securitization, which describes the process by which a public health problem comes to be treated as a security threat.
Within this framework, “risk perception and the political interests of the most influential countries can determine which crises receive priority on the international agenda”, the researcher stated in the article.
When an epidemic becomes an international threat
Originating in Guinea and spreading rapidly through Liberia and Sierra Leone, the 2014 outbreak — caused by the Zaire ebolavirus strain — resulted in around 11,000 deaths. The initial response by multilateral organizations such as WHO was delayed. The political stance of Global North nations changed radically as the virus crossed oceans and infected people in the United States, Spain and the United Kingdom.
Given the risk of contagion in the Global North, the health crisis was rapidly reframed as a defense issue. In August 2014, WHO declared a Public Health Emergency of International Concern (PHEIC). The following month, the UN Security Council adopted the historic Resolution 2177, framing the epidemic as a “threat to international peace and security.”
The measure triggered a massive financial and military mobilization led by powers such as the United States, France and the United Kingdom, driven by fears of global economic destabilization. “Developed countries sent substantial financial resources, troops and emergency medical teams”, said professor Deisy Ventura.
Invisible tragedy in the Congo in 2018
Four years later, the provinces of North Kivu and Ituri in the Democratic Republic of the Congo became the epicenter of the second-largest Ebola epidemic in history, with 3,470 cases and 2,299 deaths. Efforts to fight the disease faced the worst possible setting — a civil-war zone marked by armed conflict, mass displacement of refugees and distrust among local communities.
Deisy Ventura said that “the political and social situation in the Democratic Republic of the Congo also contributed to an insufficient international response to the outbreak that occurred in 2018”. For much of its course, the cases remained concentrated in an African region marked by conflict.
According to the researcher, “there is a relationship between social vulnerability, political instability and international neglect: local conditions made it more difficult to control the epidemic, while the perception that the problem was restricted to a Global South population contributed to delaying international mobilization”, she reported.
According to Ramiro dos Santos Neto, in the article, “despite the severity of the situation, the international reaction to the 2018 outbreak was different from 2014. The response was marked by hesitation, delays in releasing resources and neglect”, he reported. There was also a delay in WHO’s declaration of a Public Health Emergency of International Concern (PHEIC) and less direct engagement by global powers.
The WHO Emergency Committee declined to classify the situation as a PHEIC three times, arguing that the global epidemiological risk remained “low” even amid a regional collapse. The highest alert was activated only in July 2019 — nearly a year after the outbreak began — when the virus crossed the border into Uganda, an East African country.
Without fear that the disease would affect the West, the UN Security Council did not securitize the crisis, and international relief efforts foundered amid chronic underfunding and shortages of professionals. “Without an imminent risk of contagion in high-income developed countries, the emergency was treated as a ‘regional problem’, exposing the asymmetry in global health prioritization”, said the professor.
Outbreak history
Ebola was first identified in 1976, with simultaneous cases in what was then Zaire, now the Democratic Republic of the Congo, and in South Sudan.
Between 1976 and 2022, 35 outbreaks of the disease were recorded on the African continent: 15 in the DRC, six in Uganda, four in the Republic of the Congo, four in Gabon, three in South Sudan, two in Guinea and one in Côte d’Ivoire.
The disease is caused by viruses of the genus Ebolavirus and has a high case-fatality rate. Transmission occurs mainly through direct contact with the blood and other body fluids of infected people or with infected animals.
Despite advances in the development of vaccines and treatments, access to technologies and supplies remains unequal. According to Deisy Ventura, the concentration of production and health technologies in developed countries also affects the capacity to respond to epidemics. “Despite the development of vaccines and treatments, access to these resources is still marked by intellectual property barriers and by the concentration of technologies and supplies in the United States”, she said.
The researchers’ analysis therefore raises one of the challenges of global health: if international mobilization depends on the perception that an epidemic may reach wealthy countries, crises that remain confined to vulnerable populations risk receiving less attention precisely when their local impacts are most severe.
The article Neglect and global health: the case of the 2018 Ebola outbreak in the Democratic Republic of the Congo, published in the journal Interface – Comunicação, Saúde, Educação is available online.
More information: email deisy.ventura@usp.br, contact Deisy de Freitas Lima Ventura; and email secom.sydney@itamaraty.gov.br, contact Ramiro Januário dos Santos Neto
English version: Nexus Traduções, edited by Denis Pacheco
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