Ebola in urban slums: the elephant in the room

A host of factors has been cited as causes of the current Ebola virus disease (EVD) epidemic in west Africa: local cultural practices, poverty, inadequate health infrastructure, and the region’s recent strife-filled history. These factors alone, however, cannot completely explain the epidemic’s uncontrolled nature. There is an “elephant in the room” in the international discourse concerning this epidemic: urban informal human settlements or slums.
The UN defines slums as settlements with inadequate access to safe water, sanitation, and other infrastructure; poor structural housing quality; overcrowding; and insecure residential status.1 These conditions are the perfect breeding ground for EVD. Previously reported outbreaks of EVD occurred in rural and geographically isolated communities.2—6 The presumed introduction of the virus to the slums of Kenema and Freetown in Sierra Leone has undoubtedly augmented its spread.7 Sierra Leone is urbanising at a rate of 3% each year, and in 2005 more than 97% of its urban population lived in slums.8
The West Point slum in Monrovia, Liberia, has been a flashpoint for that country’s epidemic. The community’s poor health infrastructure, lack of health education, and inadequate government-enforced quarantine have all contributed to the disease’s spread. WHO has reported that the bodies of West Point EVD victims were being thrown into an adjacent river in a desperate attempt to stem the disease and deal with the overwhelming death toll.9 This inhumane situation is another simple means for the disease’s transmission to new areas.
Slum residents can be a highly mobile population. Limited economic opportunities force slum residents to migrate, clandestinely and often illegally, to new cities and countries. This type of migration subverts anti-EVD screening measures and presents an imminent threat to other informal communities and the rest of the world.
The primary factor contributing to slum dwellers’ disproportionate disease burden—their invisibility and neglect—also makes them an ideal vehicle for the epidemic. EVD is only the beginning and only one disease; even if we are to control the current epidemic, the future introduction of this and other highly contagious and virulent microbes to and from global slums is inevitable. It is not sufficient just to talk about poverty, lack of health-care access, cultural practices, etc. It will be impossible to stem this epidemic and prevent future epidemics of emerging diseases without addressing the underlying structural and socioeconomic determinants of disease unique to slums. Experts and politicians must acknowledge their existence now and divert resources towards improving the conditions of urban slums.
We declare no competing interests.


1 United Nations Human Settlements Program. The challenge of slums: global report on human settlements 2003.http://mirror.unhabitat.org/pmss/listItemDetails.aspx?publicationID=1156. (accessed Oct 27, 2014).
2 WHO/International Study Team. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978; 56: 271-293. PubMed
3 Borchert M, Mutyaba I, Van Kerkhove MD, et al. Ebola haemorrhagic fever outbreak in Masindi District, Uganda: outbreak description and lessons learned. BMC Infect Dis 2011; 11: 357. CrossRef | PubMed
4 Roddy P, Howard N, Van Kerkhove MD, et al. Clinical manifestations and case management of Ebola haemorrhagic fever caused by a newly identified virus strain, Bundibugyo, Uganda, 2007—2008. PLoS One 2012; 7: e52986. CrossRef | PubMed
5 Bwaka MA, Bonnet MJ, Calain P, et al. Ebola hemorrhagic fever in Kikwit, Democratic Republic of the Congo: clinical observations in 103 patients. J Infect Dis 1999; 179 (suppl 1): S1-S7. PubMed
6 Ndambi R, Akamituna P, Bonnet MJ, et al. Epidemiologic and clinical aspects of the Ebola virus epidemic in Mosango, Democratic Republic of the Congo, 1995. J Infect Dis 1999; 179 (suppl 1): S8-10. PubMed
7 Gire SK, Goba A, Andersen KG, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 2014; 345: 1369-1372. CrossRef | PubMed
8 United Nations Human Settlements Program. The state of the world’s cities 2006/2007.http://mirror.unhabitat.org/pmss/listItemDetails.aspx?publicationID=2101. (accessed Oct 27, 2014).
9 WHO. Why the Ebola outbreak has been underestimated: situation assessment 22 August 2014.http://www.who.int/mediacentre/news/ebola/22-august-2014/en/. (accessed Oct 27, 2014).
a Division of Epidemiology, University of California—Berkeley, Berkeley, CA 94720, USA
b Division of Infectious Diseases and Vaccinology, University of California—Berkeley, Berkeley, CA 94720, USA
The Lancet Global Health, Early Online Publication, 30 October 2014

Um pensamento sobre “Ebola in urban slums: the elephant in the room

  1. I think relevant as well to talk about the « African doctors » brain drain phenomenon that is happening since the 1980’s, mostly due to the budget cuts in the public sector implemented by the international financial institutions (as it has been called in french; PAS (Plans d’Ajustement Structurel). Health systems in Africa since then suffer from a serious lack of investment from the states.
    It appears nowadays that the 3 countries most affected by the Ebola Virus Disease (Libéria, Sierra Leone, Guinée) are facing an important shortage of medical staff.
    For example, for every 10’000 inhabitants, there is an average of 1 doctor in Guinée, and less than 0,5 in Sierra Leone and Libéria. Where as the average for the countries part of the European Union varies around 34 doctors !
    Doctors are often overworked and discouraged which results in exodus from the South to Northern countries, and mostly to United States where it was estimated in 2008 that 26% of their doctors were formed abroad. In fact, United States and european countries have a high responsibility in this exodus for not beeing able to train enough medical staff. They can not keep deploring the lack of doctors in Africa and at the same time not do anything to stop the brain drain phenomenon.
    Sierra Leone and Libéria have an expatriation rate of doctors of 50% ! Strikes were carried out in Libéria to claim for better work conditions and many patients left the health centers because the equipment is inadequate and the risk of contamination is high.
    It seems that the shortage of medical staff in Africa is a problem that Northern countries should tackle in order to improve the general situation.

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