“These woods are where silence has come to lick its wounds.” – Samantha Hunt
In 1994, Ebola, a lethal virus that had been silent for fifteen years, awoke. Two separate outbreaks would shatter this silence, but one of these was unique, the likes of which has not been seen since.
Though the last known Ebola outbreak that affected humans had occurred in 1979 in Sudan, in 1989, Reston virus, a species of Ebolavirus, emerged in laboratory macaques in Virginia that had been imported from the Philippines. The lethal virus caused hemorrhagic fever symptoms in macaques, but was determined to be nonpathogenic to humans. The virus was a new type of Ebola; similar outbreaks would take place in Alice, Texas and again in Reston, Virginia in 1990, and in Sienna, Italy in 1992. The Reston outbreaks would later be dramatized in Richard Preston’s 1995 best-selling book, The Hot Zone, which captures the tension of an Ebola outbreak in a dense urban area, followed by the relief experienced after it was found to be harmless to humans.
The world once again took notice of human cases of Ebola in December 1994, when it reemerged from its fifteen-year slumber in Gabon. As with most mysterious febrile illnesses, the cases of hemorrhagic fever were initially assumed to be yellow fever. The epidemic took place in early December 1994 and was declared over on February 17, 1995; 52 cases were confirmed, 31 died from the virus. The outbreak originated near gold mining encampments near Makoukou, just 75 miles west of the border with Republic of Congo, and 160 miles north of the capitol city of Franceville. The causative virus was identified as Ebola Zaire on December 14, 1994.
However, unbeknownst to investigators in Gabon, the virus had already reemerged elsewhere a month prior. On November 16, 1994, a chimpanzee in the Taï Forest National Park, Côte d’Ivoire was discovered dead by a primate behavior researcher, and was dissected on the spot. The researcher developed dengue-like symptoms on November 24th, and was hospitalized in Abidjan on the 26th after developing further symptoms and not responding to anti-malarials. On December 1, she was evacuated to Switzerland for further treatment and monitoring, and would eventually make a full recovery after 6 weeks of illness.
The cause of infection was determined to be from the handling of the infectious blood and/or tissues from the necropsy of the dead chimpanzee. It was determined to be new species of Ebola, though not until February 1995, months after the Gabon outbreak identification. It was named Ebola Côte d’Ivoire (though its name was changed in 2002 to Ebola Taï Forest to conform with new naming conventions), and it was unlike any Ebolavirus that had been seen prior, or that has been seen since.
First, the infected researcher is the only known case of Ebola Taï Forest, ever. This is especially interesting given the timing of the infection, after a fifteen-year period of Ebola quiescence. The four other known species of Ebola have each had multiple outbreaks, but 1994 Taï Forest was a unique event.
Second, similar to the first outbreak of Ebola in 1976–which had since been discovered to be two separate outbreaks of non-concurrent, differing species of Ebola (Zaire and Sudan)[i]–the Ebola Taï Forest case happened within a month of the Ebola Zaire outbreak in Gabon. This is also interesting in the context of the fifteen-year period of Ebola going undetected.
Third, the Taï Forest outbreak is the first time that a human Ebola case had emerged outside of the central African area known as the Congo River Basin. In fact, prior to 2014 it was the only time Ebola emerged outside of this region; it would be twenty years before Ebola would be discovered in West Africa again, and it would be under much different, catastrophic circumstances. However, the emergence from the Taï Forest is not inconceivable, given the environmental similarities to the tropical rainforests within Ebola’s known zone of endemicity in the Congo River Basin. The possibility exists that Ebola Taï Forest is a viral relic of times long ago, when the rainforests of Côte d’Ivoire and Central Africa were one and the same, stretching from coastal West Africa with the Congo River Basin.
Fourth, the Taï Forest case was the first documented human Ebola infection associated with naturally infected nonhuman primates in Africa. This discovery would shift research toward transmission of Ebola between primates and humans for years to come. Today, epizootic Ebola transmission research is focused mostly on bats, but Ebola is still a significant issue for primates: recent research indicates that up to a third of the world’s chimpanzee and gorilla populations have been wiped out by Ebola.
Finally, the Taï Forest case, though unrecognized as such, is the first Ebola outbreak in what can be viewed as the modern era of Ebola; since 1994, an average of one Ebola outbreak has taken place every year. The questions remain, decades after the Taï Forest outbreak: What has precipitated this frequency of outbreaks, particularly after the fifteen-year lull? Why have we not seen Ebola Taï Forest again? When Ebola emerges again, will we be ready, or will it emerge someplace new?
[i] Cox NJ, McCormick JB, Johnson KM, Kiley MP. Evidence for two subtypes of Ebola virus based on oligonucleotide mapping of RNA. J Infect Dis. 1983;147:272–275.
On October 20, 2017, a team of human rights lawyers and activists were jailed in Dar-es-Salaam, Tanzania – a clear violation of Tanzanian and international human rights obligations.
The initial arrests came on Oct. 17 after a consultation they were holding was raided by the Tanzanian police. Thirteen people were arrested. After authorities initially released all but one of them on bail, all are back in custody today after their bail was revoked.
The group was preparing strategic litigation against the government of Tanzania for violating the right to health of Tanzanians by eliminating and outlawing key programs to fight HIV. These human rights leaders are accused of “promoting homosexuality.” Those arrested include attorney Sibongile Ndashe, executive director of the Initiative for Strategic Litigation in Africa (ISLA), an O’Neill Institute partner organization. Activists from Community Health Education Services and Advocacy, a Tanzanian NGO, are also being held.
The detaining of thirteen attorneys and their clients, including nationals of Tanzania and South Africa, brings recent Tanzania’s targeting of civil society to unprecedented new heights. The detention of human rights attorneys and leading public health and community leaders is not only a severe violation of their rights, but also raises the level of threat to human rights defenders in the country – another step backwards for human rights. If a South African legal organization supporting local clients in litigation could be arrested on spurious charges, what human rights defender in Tanzania is not at risk? It is critical that this action not stand.
We strongly urge the government to release the detainees, discontinue the legal proceedings against them, return passports to the foreign nationals who have been arrested and restore their freedom of movement. The government should also ensure and affirm access to legal representation and support, as ISLA sought to provide, without intimidation. We’ve reached out to our partners to show our support and commitment to challenging this action.
Oscar A. Cabrera
O’Neill Institute for National & Global Health Law
Matthew M. Kavanagh
Director, Global Health Policy & Governance Initiative
O’Neill Institute for National & Global Health Law
More and more, technology is becoming a part of our everyday lives. Increases in technology can have both positive and negative impacts. We now live in a world where we can order anything, including food and car services on our phones. Recently, ride share programs such as Uber and Lyft are partnering with medical providers to help ensure patients have reliable transport to their health care appointments.
Technology has long been used in the medical profession. Today, almost all patient files are computerized and many doctors have switched to tablets or computers to input patient data. This can ensure faster diagnosis as well as increased efficiency and help to coordinate care among health care professionals.
One of the major barriers for many people accessing medical services, particularly the elderly or people with disabilities, is a lack of reliable and safe transportation. A 2013 analysis of 25 studies, found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access. One study reported that people who rely on buses were twice as likely to skip appointments compared to people who use cars.
Health care providers offer other alternatives to assist with transportation for non-emergency services. This includes volunteer drivers who work with health care providers to schedule pick-ups for patients. However, this usually requires scheduling ahead of time, which is ineffective when a patient forgets to book in advance or an unexpected or unscheduled appointment arises. Alternatively, patients sometimes call 911 for non-emergency services when they need transportation for a non-emergency medical appointment. This is not cost effective and can divert resources away from people that need it.
For patients living in cities, relying on public transportation for medical appointments can take hours. Additionally, in many cities, public transportation is not easily accessible for the elderly or people with disabilities. Sometimes, public transportation or even contracted transportation provider services are not reliable and can leave people waiting outside in extreme temperatures for long periods of time, causing potentially dangerous situations. Alternatively, car services such as Uber and Lyft can arrive in as little as 2 minutes and are able to provide door-to-door service.
When getting to a medical appointment is a hassle, patients are likely to miss the visit. This can lead to undiagnosed conditions or worsening health, which can lead to an overall increase in health care costs, for both individuals and providers. Out-of-pocket transportation costs for patients can vary. Medicaid patients are covered for transportation costs of non-emergency medical visits, however reimbursement rates vary by state. Traditional Medicare does not cover non-emergency medical transportation, however, there are some private Medicare Advantage plans that may offer such benefits.
To help alleviate some of the stress of finding transportation for health care visits, some hospitals and medical providers are utilizing services such as Uber and Lyft, and sometimes these costs are covered by Medicaid or insurance. Such partnerships between car service companies and medical providers are emerging all over the US.
MedStar Health, a nonprofit health care system in Maryland and Washington, DC, began a partnership with Uber in January 2016. The program allows patients to access Uber while on the hospital’s website and set up alerts and reminders for upcoming appointments. This program is available for patients that already have an Uber account. For Medicaid patients who do not have an account with Uber, the hospital’s patient advocate services can assist with arranging the ride.
Recently, National MedTrans Network, a national transportation system provider that provides non-emergency medical rides for patients and providers, has expanded its services through in New York, Nevada, and California in a partnership with Lyft.
There are other programs in place that will make transporting patients obsolete. The idea of an Uber for Healthcare app is gaining momentum and has attracted large name investors such as Lionel Richie and Ashton Kutcher. One such app is called Heal and allows users to input their location, medical symptoms, personal information, insurance and credit card information, choose an appointment time, and then request a doctor who is guaranteed to arrive with an hour. Such a house call costs around $99.
While these partnerships are fairly new, many people predict that this is just the start of what could be a very big program. In fact, dozens of startups use Uber as a template for bringing on-demand convenience to the market and there has been an influx of investment in such programs. It will be interesting to see what the future holds.
This post was written by Brenna Gautam and Rebecca Reingold.
Earlier this month, on October 3, the U.S. House of Representatives passed H.R. 36, the “Pain-Capable Unborn Child Protection Act.” Under H.R. 36, it is a crime for any person to perform an abortion if the probable post-fertilization age of the fetus is 20 weeks or more.
This federal ban on virtually all abortions 20 weeks after fertilization marks a departure from the U.S. Supreme Court’s abortion-related jurisprudence and flies in the face of both international and comparative law standards.
I grew up in Brooklyn, New York in the 1980s. I saw a lot of things many children not raised in a big city never experience. One of the things I remember is seeing some of my neighbors – who had previously been vibrant people who chatted with my parents in the building lobby or waved to me while I stood at the school bus stop – become shells of their former selves caused by, according to my 10-year old comprehension, some mysterious illness. I would overhear my parents talking about them, but they were skillful to not reveal details in front of me and my sister. One night, one of my neighbors rang our doorbell. My parents were busy, so I answered the door as I often did. In front of me was my friend’s uncle. He was one of those “cool uncles” who would crack jokes with us, smoked cigarettes, wore a leather jacket (again, it was the 80s), and would sometimes hook us up with money for the ice cream truck . However, that night he appeared sweaty and anxious with bloodshot eyes. “Hey, where’s your mom?” he asked. All of a sudden, my father appeared and practically knocked me to the ground away from the door.
– “Hey, Mr. B, can I get a few dollars?”
– “No. You have to go. Do not come by this house anymore asking for money!”
– “OK. I’m sorry. I’m sorry.”
As I stood there confused with a look on my face to match, my father realized he had to tell me the truth about what was going on with the “illness” that had befallen some of our neighbors.
That illness was crack addiction.
I had heard about crack through rumblings at school or the occasional blurb on TV, but I didn’t think it was something that would ever affect me. That experience and my dad’s subsequent lecture on the emerging epidemic marked the chillingly harsh and permanent removal of the rose-colored glasses of my childhood. All at once my friends and I were aware of the empty plastic vials in the cracks of the sidewalks that we previously dismissed as innocuous litter. I watched those formerly chatty neighbors from my bedroom window as they stumbled out of our building late at night, looking more frail and twitchy each time, until I stopped seeing some of them altogether.
The National Response to the Crack Epidemic of the 1980s
“Crack” is a form of cocaine that is processed with baking soda to form small crystalline clumps (‘crack rocks’) that users smoke in glass pipes and ‘crackles’ as it burns, hence its name. Crack produces an instantaneous, brief euphoric high for its users, followed by depression, anxiety, exhaustion and ultimately brain damage. Traditional powder cocaine was expensive and was a drug of choice for wealthier people, but this process of cutting cocaine brought down the price to about $5-$20 per dose, making the drug accessible to low-income people.
The allure of crack spread swiftly through low-income, inner-city, mostly black and hispanic communities throughout the U.S. in the 1980s. As someone who is hispanic and was living in a mostly black and hispanic inner-city community in the 1980s and 1990s, I was quite aware of the impact of crack on my community. The terms “junkie”, “crackhead”, and “addict” became prevalent in the common lexicon and on the news. We school children were subjected to regular D.A.R.E. workshops where cops attempted to inure us with enough fear that we’d steer clear of drugs.
The most prominent reaction to this burgeoning catastrophe was the rise of the “War on Drugs” laws and policies enacted by federal and state governments. While First Lady Nancy Reagan was going around the nation telling children to “Just Say No!” to drugs, President Reagan was resurrecting the Nixon-era “War on Drugs” initiative by allocating $1.7 billion towards anti-drug law enforcement programs, which included changing laws to enable more charges and harsher penalties for drug-related crimes, and imposing mandatory-minimum prison sentences for drug offenses. The focus of the “War on Drugs” was, to paraphrase President Nixon, to treat drug abuse as “Public Enemy Number One” in the U.S. This policy emphasized criminalizing the manufacture and trafficking as well as the use of illegal drugs. Addicted persons were seen as criminals with anti-social behaviors rather than people with physical, mental or behavior health issues.
Throughout this peak in the epidemic, families were being devastated by heads of households becoming “crackheads”. Babies were born with debilitating drug addictions. The nation’s prison population exploded, with the number of people incarcerated for nonviolent drug offenses jumping from 50,000 in 1980 to 400,000 by 1997. Federal laws were passed that imposed a 100 to 1 ratio on cocaine versus crack offenses, in an effort to deter growing crack usage. This meant that if a person in possession of 500 grams of cocaine got 5 years in prison, a person in possession of just 5 grams of crack cocaine would incur the same sentence. Since approximately 80% of crack users were African American, poor black communities bore the brunt of the criminal and societal consequences of the epidemic.
Using the “Disease Model” to address the Nation’s current opioid epidemic
Fast forward to current times when the nation is faced with another devastating drug abuse crisis. As it was to the crack epidemic, the government’s reaction to the opioid epidemic has been swift and aggressive, but it has had a noticeably less accusatory and punitive tone. There have been careful actions taken to minimize the use of stigmatizing words like “addicts” and “drug abusers”, instead referring to people as “persons who inject drugs” or “opioid misusers.” Instead of a crime and punishment “Public Enemy Number One” crisis, the opioid epidemic is being treated as a public health emergency, and those affected by it are seen as needing treatment and psycho-social interventions to remediate their problem. News stories that cover the epidemic foster sympathy for the people, families, and communities affected by this crisis, which are predominantly white, rural or suburban areas.
Rather than imposing mandatory harsh jail sentences for opioid offenses, courts are “sentencing” users to mandatory rehab. Fifty-nine million dollars in grants being issued by the Justice Department are not focusing on convicting and jailing opioid misusers, but rather providing resources to communities to improve their capacity to provide medical and behavioral health support to users.
What has spurred this shift in approaches? “Lessons learned” or demographic differences?
I cannot help but to look at the differences in approaches to these 2 drug crises with a cynical eye. There have been acknowledgements from government officials that the current holistic approach to the opioid epidemic was developed from the lessons learned from the harsh response to crack in the 1980s, but I would be remiss if I did not use my mantle as a public health and legal professional to not bring attention to the demographic differences of these 2 epidemics and how that may have influenced the government’s tactical approaches. The fact is that minority groups in the US are woefully accustomed to seeing this type of dichotomy when it comes to issues that affect brown Americans versus white Americans. Like it or not, that is still the reality of this country, even in 2017. Look at the relief response to Puerto Rico and the U.S. Virgin Islands. While there are always those who will scoff at the use of race to criticize governmental actions, those of us who have had to live and breathe racial and ethnic disparity our entire lives have become adept to reading between the lines and interpreting the subtleties of implicit bias in ways that those not from a historically discriminated-against racial group could never understand and quite frankly should not interject an opinion.
Overall, I am glad that the US is using a more holistic, treatment-based approach to the opioid epidemic, because it is proving to be catastrophic. However, I am saddened that millions of others were not given the same benefit to be saved from the grips of crack cocaine, and for their families to garner the same sympathy and compassion from the general public. Our jails are still filled with people serving obscenely long federal prison sentences for non-violent drug crimes. I also see little in the current opioid policies that benefit those affected by other drug epidemics like crack as part of an effort to make these holistic interventions available to them as well, to right the wrongs of the 1980s “War on Drugs” approach.
The nation’s response to the opioid epidemic should serve to reform its policies on drug abuse as a whole, not just drug abuse issues that affect certain populations.
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.