Drug Money is a series of very strange stories about the pharmaceutical industry’s ignoble goals. The first in the series, a look at “the most expensive drug in the world,” is here.
In early July, Daniel Kubuya Mastaki, a forty-six-year-old evangelical pastor, traveled straight into what some describe as the epicenter of the latest outbreak of Ebola in central Africa. Mastaki went to Butembo, a Congolese city of one million, where he prayed with at least seven different church congregations, participating in the usual laying of hands on the sick. Butembo is in North Kivu, a province on the eastern border of the Democratic Republic of Congo, about four hours by car west of the Ugandan border, and the location of the second largest outbreak of Ebola in history, which began last August 2018.
Talk Africa’s Nina Mitch reported that Mastaki “preached the word of God with great charisma in different churches,” and “won many souls to Christ.” Mastaki then boarded a minivan and rode more than 180 miles south to Goma to “continue his apostolic assignment.” On the eighteen-hour ride, the bus passed through three medical checkpoints. Mastaki used a different name at each, perhaps to avoid being tracked in the conflict-riddled region; he displayed no symptoms of illness observable by checkpoint authorities.
By the time the nineteen-passenger bus reached Goma, however, he was feverish and ill. Perhaps he thought he had contracted malaria, hepatitis, or another of the diseases that often exhibit symptoms similar to Ebola: fever, severe headache, muscle pain, vomiting, diarrhea. Mastaki went to a nearby hospital. When Ebola was confirmed, he was transported back to Butembo, where special Ebola treatment facilities were available. He was dead on arrival.
Goma is a city of more than two million on the north shore of Lake Kivu and very near the borders of Rwanda and Uganda. When the North Kivu outbreak began, health workers looked warily toward Goma; should Ebola reach Goma, a city with an international airport and a vibrant transportation hub for numerous countries, they decided, the DRC could no longer be trusted to manage the outbreak on its own. After Mastaki’s death, the DRC Ministry of Health stated, “Given that the patient was quickly identified, as well as all the passengers on the bus from Butembo, the risk of the disease spreading in the city of Goma is low.” But last week another two cases were confirmed in Goma, and Rwanda briefly closed its border.
Containing the epidemic is vastly complicated by the region’s history, mistrust of aid workers, and ongoing armed conflict. There have been ten outbreaks of Ebola since its discovery in the DRC in 1976, but they have predominantly been in the west of the country, away from the volatile eastern region and the deadly undulating conflicts there. Shortly after Mastaki’s trip, two health care workers were killed in their homes in Mukulia, a village on the outskirts of Beni, just north of Butembo. The workers had been receiving threats for months, and one had been attacked previously.
Ebola is first transferred to humans through what is called a “spillover event”; when an animal, typically a bat or a primate, scratches or bites a human, the virus spills over from one species to another. The infected person, who does not show symptoms right away, is not infectious until symptoms develop. Transmission of the virus between humans requires contact with bodily fluids. Urine, saliva, sweat, feces, vomit, breast milk, and semen make up the Center for Disease Control’s list. (It can also be contracted by eating “bushmeat,” the raw or unprocessed meat of animals.) But this means of transmission removes those who become infected from the love and care of their family members; no physical contact can be risked after the illness hits—or even after death. As with all of Ebola’s victims, Mastaki was likely buried by strangers wearing yellow and white hazmat suits, goggles, hoods over their faces, and rubber gloves to their elbows. His family never again straightened his collar, never wiped his brow, never held his cooling hand.
“Ebola is a heartless killer,” Jina Moore wrote for BuzzFeed News during the 2014 outbreak in Liberia in which more than eleven thousand died. “It demands what most people consider a ruthless response to suffering: distance. Its secret weapon is not the scientific mystery of its seven proteins. It’s love. It’s the human need to show compassion and care.” Congo is no stranger to heartless killers or bridled compassion. The history of the Democratic Republic of Congo—and the rest of the world’s self-serving involvement there—has prepared the way for Ebola’s heartless devastation.
The Dark Heart
In her 2001 book, In the Footsteps of Mr. Kurtz: Living on the Brink of Disaster in Mobutu’s Congo, Michela Wrong writes, “In newsrooms across the globe, shaking their heads over yet another unfathomable African crisis, producers and sub-editors dusted off memories of school literature courses and reached for the clichés.”
Wrong was writing about conflict that led to the 1997 unseating of “Papa” Mobutu Sese Seko Kuku Ngbendu Wa Za Banga, the ostentatious, leopard print-wearing dictator of Zaire, what is the present-day Democratic Republic of Congo. But Wrong’s words can just as easily be applied to any one of a litany of subsequent events in that dark heart of the African continent, events that have dared to ripple the surface of international attention: the millions of people who were killed or died of disease and starvation during the “Second Congo War” after Mobutu’s overthrow, which was engaged by official and unofficial forces from at least six neighboring countries; the killing of Mobutu’s successor, the rebel leader Laurent Kabila, allegedly by one of his own bodyguards in 2001; the devastation in Goma by the eruption in 2002 of Mount Nyiragongo; the outbreak of Ebola in the DRC in September 2007. More recently, the killing of protesters in 2015 and 2016, and the 1.7 million Congolese displaced by conflict in 2017.
The history of Ebola on the continent upsets the PHEIC designation’s promise of black salvation at the hands of white saviors.
Wrong’s words can also be applied to the World Health Organization’s long-delayed declaration, on July 17, of the latest Ebola outbreak in the DRC as a public health emergency of international concern (PHEIC), an official designation that activates international resources and response coordination. This is only the fifth time such a designation has been made. After one year and 1,650 deaths—making it the second largest Ebola outbreak after the 2014 crisis in Liberia—in will swoop teams of the “Westernized,” a term tainted with biases that convey developed, clean, science-based, professional, caring, orderly, civil, but also civilized. Ebola has become another “unfathomable African crisis,” one in a numbing list of faceless and far-away horrors that has little to do with “us.”
But behind the grade-school clichés, the history of Ebola on the continent—a tale of pharmaceutical profiteering, post-colonial resource grabbing, and ruthless regime meddling—upsets the PHEIC designation’s promise of black salvation at the hands of white saviors. Mr. Kurtz’s dying words, “The horror, the horror,” Wrong reminds us, did not, after all, refer to the Congo, its people, customs, or places, but rather to the “unparalleled cruelty” of white colonialism.
The Congo was “discovered” by Henry Morton Stanley, a British journalist made famous by his 1871 query, near Lake Tanganyika, of another famous explorer: “Dr. Livingston, I presume?” Europe was at the beginning of a colonial binge of plunder and acquisition on the African continent. Stanley found the greed and ruthlessness of Belgium’s King Leopold II up to the task of bringing Congo’s vast wealth in hand. Wrong calls Leopold “the only European monarch to ever personally own an African colony.” He named his possession, sadly, ironically, the Congo Free State. The brutal system he put into place incentivized and systematized abuses that, even on the continent during that era, were extreme, enforced by white Belgian agents and the Force Publique, a mercenary army of West Africans and Congolese. “Soldiers in the Congo were told to account for every cartridge fired, so they hacked off and smoked the hands, feet, and private parts of their victims. Body parts were presented to commanders in baskets as proof the soldiers had done their work well,” Wrong writes.
The worst of these atrocities ended in 1908, when Belgium annexed the Congo from Leopold, but a bitter system of exploitation and forced labor lasted until independence, when Western-backed Mobutu established his own brutal and unique ways to exploit the country’s unparalleled natural resources—diamonds, copper, rubber—for his own personal gain, very much like Leopold before him. The appearance of outsiders has always been the harbinger of death and destruction for the Congolese, since the time of Arab slave traders before Stanley. Suspicion, wariness, avoidance, attack: these are the methods of self-preservation for a population that has long been prey to the rest of the world.
The Gobs of Money
What we call the Merck vaccine for Ebola, rVSV-ZEBOV-GP, was created by the Public Health Agency of Canada in 2003. Several trials on animals were conducted by the United States and Canada before it was licensed to a small pharmaceutical company, NewLink, which continued development. Merck, the New Jersey-based pharmaceutical company with a net worth of $215 billion, licensed the vaccine in 2014, just as the West Africa outbreak was ravaging Guinea, Sierra Leone, and Liberia. Phase II and III trials of the vaccine were conducted on the ground during that outbreak—but not without criticism from outside sources. “Battling a high-profile U.S. science project is only one of several issues that the WHO trial faces,” Miriam Shuchman wrote in The Lancet in May 2015.
Criticisms of the trials included that a primary care facility wasn’t up to the standards required for a clinical trial, that the trials were rushed in order to reach completion before the number of infected—trial subjects—declined, and that the mechanism for reporting adverse effects from the vaccine was flawed. In Guinea particularly, when community members were asked to report to the village chief if they or a family member experienced symptoms or adverse effects, mistrust prevented many from doing so. (Shuchman’s article includes an example of a village chief stealing donated food from the local population and selling it for profit.)
Nonetheless, Merck has received lavish praise for their work on the vaccine. In 2018, Time magazine named it one of their “Genius Companies.” “We do not intend to profit from this vaccine,” executive vice president Roger Perlmutter, who earned about $7 million last year, told the magazine, scoring serious do-gooder marketing capital. A Fortune article by Clifton Leaf from August 2018 titled, “Deploying the Profit Motive to Beat Ebola,” has not aged well—it is a glowing, saccharine piece that reads like Merck marketing copy and credits the corporation with defeating Ebola in the DRC, deaths capped at a mere thirty-three. Nonetheless, the piece ran after Ebola reappeared in more eastern parts of the country, resulting in the current outbreak. The magazine included Merck on its list of corporations that “Change the World,” ranking the global pharmaceutical juggernaut at number two. Writes Leaf, with over-the-top praise:
The drug giant isn’t doing this out of charity. Rather, the company’s vaccine business—which includes inoculations against pneumonia, shingles, and the cancer-causing HPV—had more than $6 billion in sales last year. Even if the Ebola vaccine doesn’t make gobs of money on its own, the knowledge gained from developing it should help inform R&D across the business.
Merck, in short, is doing what so many great companies do: trying to fix something that needs fixing and trying to turn a profit while doing it. Indeed, businesses around the globe manage to accomplish both of these things—they do well by doing good—every day, and often away from the headlines.
To misquote the title of Adam Hochschild’s 1998 book about the utter ravages of the Congo Free State, “King Leopold’s ghost, indeed.” The Merck drug, which has an efficacy rate of more than 97 percent, is not yet licensed, and its administration in the DRC is currently considered “compassionate use.”
“The problem is not because you have an inferior vaccine response,” Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, told STAT’s Helen Branswell in April, “The challenge is getting it into people.” This equation can sound an awful lot like that aged, racist trope: Western competency once again hindered by Africans’ inability to get their shit together.
The Western Plot
In a brief report of the Beni health worker killings, Voice of America felt it appropriate to tag this to the end, without context or explanation: “Some Congolese people have also contributed to the spread of the disease by refusing to take their loved ones to treatment centers and not adhering to burial guidelines designed to reduce Ebola transmission.” But the reasons for the Congolese’s noncompliance with Western dictates, particularly ones that violate their ability to show love and affection to neighbors, family members, loved ones, is not caused by ignorance or simple recalcitrance. The Congolese know that, century after century, Western involvement brings death and destruction for the sake of profit.
A survey of beliefs about Ebola in the DRC, released by The Lancet in March of this year, found that more than one quarter of the respondents do not believe that Ebola exists. About one third of them believe that Ebola was fabricated for financial gain or to destabilize the region. As the Wall Street Journal reported in April, others don’t understand why Ebola is more important than the diseases that appear to be killing larger numbers of people: diarrhea, malaria. Or why Ebola is more important than poor conditions, like a lack of running water. “These guys have a hidden agenda,” Katsongo Bayole, told the Wall Street Journal’s Julia Steers and Gabriele Steinhauser. Bayole is a fory-five-year-old farmer in Butembo. “When you get there [at the clinic], you are dead. This is their game,” she said.
In the past seven months, according to the WHO, fifty-eight health care workers have been injured and seven have been killed in nearly two hundred attacks. “Health-care workers have found themselves deliberately targeted—both by militias that have ravaged the area for nearly twenty-five years and by locals who think they’re part of a Western plot,” Steers and Steinhauser wrote.
On July 20, DRC’s president, Félix Tshisekedi, brought oversight of the epidemic under the purview of himself and a “multisectorial expert committee” of international organizations. The announcement came nearly one year after the outbreak began and only days after the WHO designated the DRC outbreak an international public health emergency. Minister of Health Oly Ilunga Kalenga was in Goma at the time, overseeing operations, and resigned in protest. He had been wary of western pressure for the PHEIC declaration. As Lisa Schnirring wrote at the website of the Center for Infectious Disease and Research Policy, “Kalenga, MD, has been . . . voicing concerns about outside groups pressuring the country and potentially harmful effects of border closures and travel restrictions that could hurt the response.”
The Congolese know that, century after century, Western involvement brings death and destruction for the sake of profit.
Kalenga also resisted suggestions that, in order to make the most of existing vaccine doses, a second drug being developed by Johnson & Johnson be used. Kalenga felt that doing so would be an error: not only had his agency worked to build up public trust in the Merck drug, but the Johnson & Johnson drug required two doses administered fifty-six days apart, a near impossibility given the DRC’s limited resources. “Pressure to view the outbreak as a humanitarian crisis seems to invite the establishment of a parallel management system, which [Kalenga] said never strengthens existing health systems,” wrote Schnirring. Kalenga released his letter of resignation on Twitter on July 22. The banner image on his account shows the Minister sitting on a park bench, his elbows on his knees, overlooking a slow-moving river.
The pressure to accept the PHEIC designation was fierce. Three prior attempts had been made, the last on Friday, June 15. On July 10, an op-ed in the Washington Post by Ronald Klain, a former Ebola “czar” for the Obama administration (and an advisor on the Biden 2020 campaign), and Daniel Lucey, a fellow at the O’Neill Institute for National and Global Health Law and an adjunct professor at Georgetown’s Medical Center, emphatically pleaded for international intervention.
Theirs is a convincing argument that systematically identifies the benefits of the PHEIC, including the increased pressure it would put on the Trump administration to release funds. (Centers for Disease Control and Prevention workers were banned from the outbreak area by the U.S. government last August.) But the PHEIC will do little to improve agencies’ image in the region. It comes with the large-scale enforcement of armed guards who will protect foreign aid workers and their clinics. In the end, the designation may contain Ebola in the DRC, but it’s hard to know at what cost.
Meanwhile, USAID and others are using the hashtag #heroism to highlight health workers’ efforts. Some of the images coming out of the region, however, do little to encourage trust. In one, a man in a tan vest, “Dr @WessamMankoula” we’re told, aims an object at the head of a black woman in a sleeveless pink dress. She looks nervous, scared, embarrassed. The object is a thermometer; an elevated temperature is an early sign of infection. But, from the image, it looks like the health care worker is holding, execution-style, a gun.