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The Centers for Disease Control and Prevention has defined a list of human pathogens that are of highest concern for possible use as bioweapons. These agents, most of which had been developed as agents for biological warfare, are described in this chapter. The diseases caused by these agents are now quite rare, and the experience of medical and public health personnel in dealing with them is limited. The course of diseases resulting from various means of exposure are described, along with what is known of the ability of humans to respond to and recover from them. In most cases, adeqaute vaccines do not exist, and only a few effective drugs are available.

This chapter presents an introduction to viruses. Viruses have played a major role not only in evolutionary history but also in recent history. They have shaped human genomes and physiological features, they can be deadly or good, and they can change so fast and affect so many cellular pathways that mounting evidence supports a picture of evolution largely dependent on the driving force provided by these entities. Some viruses' names have become popular in the media because of their terrifying impact through deadly pandemic events. Among them are the human immunodeficiency virus type 1 (HIV-1) and the Ebola virus (EBOV). The remainder of the chapter discusses the expanding viral universe, structural and genetic diversity of viruses, and growth in the importance and understanding of ecological and evolutionary impact of viruses over the last century.

This chapter examines the Ebola virus in detail. Since 1976, with the exception of the 2013–2016 epidemic in West Africa, all outbreaks of Ebola virus infection have occurred in central Africa. The initial 1976 eruption of Ebola in Zaire in central Africa provided lessons for how to control future outbreaks of this disease. Unfortunately, those lessons were not well learned or sufficiently applied to the massive Ebola outbreak that followed in 2013–2016 in western Africa. Ebola virus can spread either through the air or by exposure to contaminated blood of infected humans. The clinical course of Ebola virus infection is that of a severe hemorrhagic fever. An Ebola vaccine was developed and administered to over 40,000 individuals for the 2018–2019 outbreak. However, the vaccine’s effectiveness in the outbreak has not been formally assessed, and critical scientific assessment will be difficult to achieve. Ultimately, Ebola virus remains endemic in Africa. Whether the fruit bat is the only natural reservoir for such viruses, how Ebola is transmitted, and where it lurks are still unresolved.

This chapter considers the ways in which the lines between authoritarianism and democracy and between the past and the present remain blurred in Guinea today. It considers the new role of the private sector in neoliberal cultural initiatives, as illustrated by two concerts held to celebrate the end of the Ebola epidemic in Guinea in 2015. It also notes the continuing endurance of praise singing and musical practices rooted in tradition, collective pride, and cultural memory. It concludes the book with a call to understand authoritarianism from the bottom-up, as a system of power that ordinary people at times invest with meaning and feeling, while also asking how pleasure and aesthetics might create and sustain a different kind of politics in Guinea and a new sense of self-recognition for Guineans in the future.

There are dangers of over-simplification when discussing the development challenges and opportunities facing a continent as vast as Africa at a given point in time! Africa is made up of 54 disparate countries in five regions, and is not a single monolithic whole. The 2014 Ebola crisis in three countries in West Africa once again revealed the tendency of those outside the continent to classify it as a distinct entity. Despite the frequent allusion to a new “Scramble for Africa”, the continent is planning, managing and starting to finance its own destiny, as it attempts to reclaim the twenty-first century. After 2015 Africa anticipates a future that is not just fraught with challenges but also with opportunities. Africa’s vision for the future as it looks beyond the MDGs has been endorsed by Heads of States in the name of Agenda 2063, forming the core element for shaping development conversations for the next 50 years or so.

This chapter highlights three of the recently identified viruses: Lassa fever virus, Ebola virus, and hantavirus. All three are equally lethal infectious agents, but they are members of different viral families. They share the ability to cause hemorrhagic fever. Once infected with any of these viruses, the victim soon suffers profuse breaks in small blood vessels, causing blood to ooze from the skin, mouth, gastrointestinal tract, and rectum. Internally, blood flows into the pleural cavity where the lungs are located, into the pericardial cavity surrounding the heart, into the abdomen, and into organs like the liver, kidney, heart, spleen, and lungs. Eventually, this uncontrolled bleeding causes unconsciousness and death. There is currently no established vaccine to prevent these potential plagues, although several are in various stages of development, and an Ebola vaccine is currently undergoing trial in Africa. The chapter also considers a newly emerging and undefined but serious disease of children, which arose primarily in 2014. Based on clinical observations, the disease is identified by the signs and symptoms of acute flaccid myelitis.

This story of an encounter with a remarkable young man, Prince, during a small incident in an Ebola treatment center provides a window to the lived experience of Ebola caregivers, patients, and survivors. In the Ebola ward, as anywhere else, the living, both the patients and the caregivers, had to go about the business of normal daily life with all its boring routine while they dealt with the fear of crisis and the unexpected. With the high rate of healthcare worker infection, some healthcare workers were not just caregivers but also patients and, for the fortunate, survivors. As Prince’s story reveals, many survivors still grapple with the discomforts of post-Ebola syndrome, social stigma, and the struggle for survival that is life for so many in a resource-poor nation. Prince and others like him continue to conduct themselves with professional integrity and commitment, dignity, and determination.

The study of metapopulation dynamics has had a profound impact on our understanding of how species relate to their habitats. A natural, if naïve, set of assumptions would be that species are to be found wherever there is suitable habitat that they can get to; that species will rarely, if ever, be found in unsuitable habitat; that they will be most abundant in their preferred habitat; that species can be preserved as long as a good-size chunk of suitable habitat is conserved for them; and that destruction of a species’ habitat is always detrimental for its abundance. We will see that none of these reasonable-sounding assumptions is necessarily true. Metapopulation biology is a vast field, so to focus this chapter I will be guided partly by questions relevant to conservation biology. There are two important kinds of metapopulation. The so-called Levins metapopulation idea (Levins, 1970) is illustrated in Figure 4.1. It is imagined that patches of habitat suitable for a species are distributed across a landscape. Over time, there is a dynamical process of colonization and extinction: the colonization of empty patches by occupied patches sending out colonizing propagules and the extinction of local populations on occupied patches. This extinction can occur for a number of reasons. Small populations are prone to extinction just by the chance vagaries of the environment, reproduction, and death—environmental and demographic stochasticity (May, 1974b; Lande et al., 2003). An example of a species for which this is important is the Glanville fritillary butterfly (Melitaea cinxia), which has been extensively studied by Hanski and colleagues (Hanski, 1999). This Scandinavian butterfly lives in dry meadows which are small and patchily distributed. Another reason for local population extinction is that the habitat patch itself may be ephemeral. For example, wood-rotting fungi will find that their patch ultimately rots completely away (Siitonen et al., 2005) and epiphytic mosses will ultimately find that their tree falls over (Snall et al., 2005). The second type of metapopulation consists of local populations connected by dispersal, but without the extinction of the local populations.

Respiratory illness, fever, diarrhoea, and dermatitis are the four most frequent medical problems in the returned traveller. Unexplained fever is the most urgent of these because febrile conditions such as malaria, meningitis, and typhoid can all deteriorate rapidly and become life-threatening. Respiratory infections are also very common and are often viral in origin. A persistent cough or a doubtful CXR warrants further investigation. Diarrhoea that persists may well be helminthic in origin with giardiasis high on the list. In cases already treated with antibiotics one must consider C. difficile infection while the unmasking of inflammatory bowel disease or irritable bowel syndrome is probably more common than supposed. Dermatitis is often due to exacerbation of an existing condition, e.g. psoriasis or eczema. Tropical-related dermatitis is most frequently due to infected arthropod bites. CLM is the main parasitic cause. Exanthems and enanthems occur in a variety of systemic conditions ranging from acute HIV to dengue fever to coxsackie infection. Rashes are seldom diagnostic unless the cause is obvious, e.g. scabies or typhoid (rose spots). In all cases the practitioner should adhere to a strict protocol that involves a good history, careful physical examination, and routine screening and microscopy of blood, urine, and stool. Simple X-rays and ultrasound examination may also be considered. In no case should the practitioner hesitate to refer the patient to a specialist physician. Nowadays computer-assisted diagnosis is becoming more popular and more reliable. The Kabisa Travel System, developed in Antwerp, has been shown to perform equally well with travel physicians in diagnosing the cause of fever in those returned from a tropical environment. Kabisa is the Swaili word for ‘hand in the fire, I am absolutely certain’!

This chapter considers viral hemorrhagic fever outbreaks in Africa. The best known African viral hemorrhagic fevers are yellow fever, Marburg, and Ebola. Viral hemorrhagic fever outbreaks are promoted by the prevalent mode of medical practice in which etiology is only of interest when a cure fails, and not always even then. Because of the challenges associated with infection control and patient diagnosis, in typical African hemorrhagic fever epidemics the death toll is high and the spread throughout the hospital has already begun before the cause of the outbreak is known or even suspected. As Africans move deeper into forests, and improved travel networks allow individuals to move from the heart of the forest to a city with international connections in just a few hours, contact with wildlife and the risk of contracting and spreading Lassa, Ebola, Marburg, and as yet unknown zoonotic infections will continue to rise. It is essential to focus diagnostic support and research in countries where the diseases occur in nature.

I have said that the dangers of catastrophe are growing. One reason is the rise of apocalyptic terrorism. Another, however—because many of the catastrophic risks are either created or amplified by science and technology—is the breakneck pace of scientific and technological advance. A clue to that pace is that between 1980 and 2000 the average annual growth rate of scientific and engineering employment in the United States was 4.9 percent, more than four times the overall employment growth rate. Growth in the number of scientific personnel of the other countries appears to have been slower, but still significant, though statistics are incomplete. Of particular significance is the fact that the cost of dangerous technologies, such as those of nuclear and biological warfare, and the level of skill required to employ them are falling, which is placing more of the technologies within reach of small nations, terrorist gangs, and even individual psychopaths. Yet, great as it is, the challenge of managing the catastrophic risks is receiving less attention than is lavished on social issues of far less intrinsic significance, such as race relations, whether homosexual marriage should be permitted, the size of the federal deficit, drug addiction, and child pornography. Not that these are trivial issues. But they do not involve potential extinction events or the modestly less cataclysmic variants of those events. So limited is systematic analysis of the catastrophic risks that there are no estimates of what percentage either of the federal government’s total annual research and development (R & D) expenditures (currently running at about $120 billion), or of its science and technology expenditures (that is, R & D minus the D), which are about half the total R & D budget, are devoted to protection against them. Not that R & D is the only expenditure category relevant to the catastrophic risks. But it is a very important one. We do know that federal spending on defense against the danger of terrorism involving chemical, biological, radiological, or nuclear weapons rose from $368 million in 2002 (plus $203 million in a supplemental appropriation) to more than $2 billion in 2003.

This introductory chapter provides an overview of how viruses have caused geographic, economic, and religious changes. Smallpox alone, in the twentieth century, killed an estimated 300 million individuals, about threefold as many persons as all the wars of that century. In the sixteenth and seventeenth centuries, smallpox killed emperors of Japan and Burma as well as kings and queens of Europe, thereby unseating dynasties, altering control of countries, and disrupting alliances. In addition to propelling the establishment of Christianity in Mexico and Latin America, viruses played a role in enlarging the African slave trade throughout the Americas. In contrast to viruses such as smallpox and measles which are now harnessed by the innovations of healthcare, new viral plagues of fearful proportions have appeared. These include HIV/AIDS, sudden acute respiratory syndrome, Ebola, Zika, and bird flu. This book looks at the history of viruses and virology, which is also the history of the men and women who have worked to combat these diseases.

On May 26, 2014, it was acknowledged that the Ebola virus disease (EVD) epidemic had swept over to Sierra Leone, although several indices imply that EVD infections were more likely to be present much earlier. This chapter was written by one of the first international doctors to answer this first call for aid in May. He describes the situation on the ground, including the challenges of providing medical care for patients suffering from EVD in Sierra Leone’s Kailahun district. He also discusses difficulties in epidemiological surveillance and laboratory diagnostics. He compares this early period of the epidemic to his experience nine months later in Guinea, when a multitude of governmental and nongovernmental actors were present, facilitating and complicating things at the same time.

In early February 2015, the author prepared to leave for her second Ebola mission, this time at an Ebola treatment center in Conakry, the capital of Guinea. During the two-month mission she discovered that the Ebola epidemic created havoc not only by leaving sickness and death in its wake, but also by its perversity. When it seemed to be in decline, new flare-ups would spring up to extend its life. The author recalls a storm of anger and sadness from one bereaved family in a particular violent episode. This made the absurd cruelty of Ebola even more apparent for her.

In chapter 3, John D. Kraemer and J. Mark Siedner map the effect of the Ebola epidemic on health outcomes and systems in Guinea, Liberia, and Sierra Leone. The chapter provides a comprehensive review of existing literature to assess how Ebola caused short- and long-term harm to health that exceeded the direct consequences for those infected. The authors assess the capacity of the already weak healthcare sectors in the three most afflicted countries prior to the outbreak, how redirection of resources to the outbreak compromised critical gains in individual and population health, and what may be expected in the near to long-term as those healthcare systems recover. The chapter identifies opportunities for building stronger, more resilient health systems, focusing on measures that would improve outcomes during both routine and emergency situations.