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As the Ebola epidemic in West Africa staggers onward, attention to the acute crisis is beginning to die down. But an outbreak of this magnitude will have longer-range and complex effects. Can an infectious disease specialist shed light on this epidemic and how its impact relates to violence?
Gary Slutkin can. He heads Cure Violence, an organization that has dramatically decreased homicides in cities worldwide. Their method relies on the insight that violence is an infectious disease and that the transmission of violence occurs when one person victimizes another. Slutkin, a doctor trained at the University of Chicago and San Francisco General Hospital, borrowed the idea from his work fighting cholera and AIDS in Africa in the 1980s and 1990s.
"Cure Violence takes an infectious disease control approach to reducing violence," he explains. "It’s the idea that these people have a contagious disease that they, in a way, infect each other with,” by victimizing each other. Instead of assuming that people who commit violence are inherently bad and must be punished, Cure Violence attempts to “interrupt” people before they commit violence and to prevent the negative behavior from spreading further. “We reach out to people who are doing the violence, through people who they trust and respect, and who are highly, highly trained to do that amount of persuasion, behavior change, and so on,” Slutkin says.
The key to slowing and stopping its spread has been the same in every epidemic he’s seen: hiring community health workers to explain prevention and care to the most affected and at-risk groups.
The current Ebola epidemic mirrors what Slutkin has seen with other infectious diseases as well as gun violence. The key to slowing and stopping its spread, he says, has been the same in every epidemic he’s seen: hiring community health workers to explain prevention and care to the most affected and at-risk groups.
“When I was doing tuberculosis control in San Francisco, our tuberculosis [patients were] refugees from Vietnam, Cambodia, Laos, and also Central America. So we hired outreach workers from those same countries to reach them because they were believable to them,” Slutkin says. “And then when I was in Somalia, again doing work this time in refugee camps themselves, we had refugees reaching refugees, we had moms reaching moms.” The same is true for the Ebola crisis: “That’s one of the most important things going on with Ebola right now, is community health workers reaching out to the families,” to explain prevention and care for the very ill, he says. “You’re going to listen to people you trust.”
Infectious disease and violence often share more than an analogy about transmission: “These epidemics kind to lead into each other, one after another, and they sequentially and synergistically keep adding to the destruction of social fiber,” Slutkin says.
Disease outbreaks have been exacerbated by violence before. HIV was spread farther in sub-Saharan Africa in the 1990s by sexual violence against women, author Helen Epstein explains in her 2007 book The Invisible Cure. In other cases, violent conflicts have worsened disease, as in 2008, when displaced Zimbabweans suffered a cholera outbreak as they fled a collapsing dictatorship.
Violence is already pandemic in the three nations suffering large Ebola outbreaks. Sierra Leone and Liberia have faced decades-long armed conflicts. Relatively peaceful Guinea has recently endured violent protests and an attempted coup. Violence is a longer-lasting infection that can erupt after remaining quiescent within a social group for years; the trauma of Ebola may provoke an upsurge in violence that lasts long after the disease has been stamped out.
In fact, reports of violence from the Ebola zone are already popping up. After a trip to Liberia this October, global health expert Paul Farmer wrote that the same problems that prevent people from seeking care are also prompting outright assaults: “There have been incidents of violence linked to fear and stigma.” This includes the murders of a team of eight community health workers in Ebola-afflicted Guinea this September.
Slutkin explains that the problem is panic: “Epidemic fear is not ordinary fear. It’s panic when there are fast epidemics,” like Ebola, which can kill an otherwise healthy person in just days. Guinea Prime Minister Mohamed Said Fofana agrees. When riots in late August shut down health outreach activities in the southeast of the country, he said crowds were “intoxicated by information making them believe this sickness does not exist or was created to eliminate them.”
Another common denominator to Ebola and violence is the grief that follows. “Post-Ebola, should we be lucky enough to get to the other side of this, you just have chaos,” Slutkin predicts. “You have seriously traumatized people.” Health organizations like AmeriCares are already sending mental health workers abroad to treat grief-stricken individuals and panicked communities. But how long the psychological suffering takes to resolve is unclear. Some 20 years after his work in Africa, a shadow still crosses Slutkin’s face when he describes epidemics he's witnessed. “Cholera was awful in the refugee camp. There were too many people dying too fast, every day. It was frightening.” In Uganda in the 1990s, “so many people lost so many friends and so many relatives [to AIDS].... Running out of nails for coffins, running out of wood. It was a horror.”
Is any of this—the raging epidemic, the violent aftermath—plausible here in America? Slutkin says no: “It’s, to me, inconceivable that America would have a real out-of-control epidemic.” All the attention paid to preventing spread will likely pay off. But the country's gun violence problem—which has taken exponentially more lives and led to far more trauma—remains America’s worst infectious epidemic.