The geography of waiting: surveillance latency as the hidden driver of Ebola risk in East Africa.

Ebola virus disease remains a persistent public health threat in East Africa, yet preparedness strategies continue to emphasise response after outbreaks are recognised rather than the period preceding detection. This Perspective argues that surveillance latency the cumulative delay between the earliest clinically meaningful signal and organised public health action is a critical but insufficiently measured determinant of Ebola risk. Although diagnostic and reporting delays have been widely documented, they are often treated as isolated operational challenges. We introduce the concept of the geography of waiting, an integrative framework that links biological, clinical, diagnostic, administrative and community delays to spatial inequalities in physical, technical and relational infrastructure. Unequal access to diagnostics, transportation, laboratory networks, trusted communication channels and community reporting systems creates substantial variation in detection timelines across settings. Where surveillance latency is prolonged, transmission may continue undetected, increasing the likelihood of larger and more complex outbreaks. Drawing on evidence from outbreaks in Uganda, the Democratic Republic of the Congo, Guinea and Rwanda, we examine the mechanisms underlying delayed detection and consider them alongside performance frameworks such as Uganda's 7-1-7 strategy. We propose a practical approach that integrates syndromic and event-based surveillance, decentralised molecular testing, community early-warning systems and regional data sharing. Because shorter detection intervals are associated with smaller eventual outbreaks in the cases reviewed here, reducing surveillance latency is a plausible high-value investment for Ebola preparedness, although this remains a hypothesis pending formal economic evaluation rather than an established finding.