Inside Congo’s Ebola emergency

‘The world has never seen anything like this.’

Photo of protective gear and health workers for Ebola in Democratic Republic of Congo.
Photo of protective gear and health workers for Ebola in Democratic Republic of Congo. (Vincent Tremeau/World Bank)

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It was first detected last July in a small Congolese town called Mangina, where a 65-year-old woman died after exhibiting Ebola’s tell-tale symptoms – high fever, vomiting, diarrhoea, bleeding from inside and out.

Now, 11 months on, the Democratic Republic of Congo’s tenth Ebola outbreak since 1976 has turned into the world’s second deadliest on record – claiming more than 1,500 lives, infecting 2,244 people, and spreading across the border into neighbouring Uganda.

Many had hoped that medical advances, including a new experimental vaccine, would help avoid a major Ebola epidemic of the kind that ripped through West Africa between 2014 and 2016, costing 11,300 lives, mainly in Guinea, Liberia, and Sierra Leone.

Health workers in Congo were initially optimistic after an Ebola flare-up in the country’s northwestern Equateur province was successfully contained last July in under three months, following 54 cases and 33 fatalities.

But this outbreak – in Congo’s eastern provinces of North Kivu and Ituri – proved unlike anything that had come before: it is the first to occur in an active conflict zone where dozens of armed groups have wreaked havoc for decades.

Here, the basic work of stopping an outbreak – treating patients, tracing and vaccinating their contacts, and safely burying the dead – has been undermined by violent clashes, attacks on Ebola responders and treatment centres, and mistrust of health workers.

Now, as cases rise and the risk of regional spread grows, aid groups are calling for a “reset” that puts local communities at the heart of the response. The UN has meanwhile triggered a system-wide scale-up designed to attract more funding and resources, and experts from the World Health Organisation have recommended a complete overhaul of the agency’s vaccination strategy.

Four takeaways

  • Responders must involve local communities. Aid groups and researchers are calling for greater involvement of local communities in the response to help build trust and prevent further attacks.
  • Dealing with attacks requires understanding the local context. Decades of conflict and neglect have fostered a climate of distrust between local communities, national authorities and international interveners. This is affecting the Ebola response.
  • Militarisation makes things worse. Treating patients as bio-threats and forcing them to comply with Ebola care can alienate communities and heighten distrust with responders.
  • A vaccine is only as good as the ability to vaccinate. Despite the success of an experimental vaccine, insecurity has affected the ability of response teams to reach and vaccinate contacts effectively.

An epidemic of violence

Decades of conflict and neglect have left communities in eastern Congo with little trust in the national authorities – or in the aid groups and UN peacekeepers supposed to help them. The government’s decision to suspend voting in last year’s presidential elections in the Ebola-affected areas of Beni and Butembo – ostensibly to prevent the virus from spreading – fuelled suspicion that the disease was a pretext to disenfranchise the largely opposition-supporting population. The scale of the relief effort, after so many years of neglect, left many feeling the virus was also a money-making scheme. Social media helped spread further disinformation and a “militarised” response that saw patients treated as bio-threats rather than human beings did little to help. Between January and May, a total of 174 attacks against Ebola workers and operations were recorded, causing 51 injuries and five deaths including a Cameroonian WHO doctor. The attacks have forced health workers to suspend their work, giving the virus time to spread. “The world has never seen anything like this,” said WHO’s director general Tedros Ghebreyesus in May.

A spreading crisis

Authorities in Rwanda, Uganda, and South Sudan – three countries that border North Kivu and Ituri – have worked hard to keep Ebola from spreading beyond Congo: vaccinating health workers in high-risk areas; setting up treatment centres; screening for Ebola at border posts; and increasing awareness among local communities. But the countries face an uphill struggle. Populations in border areas are highly mobile, with residents of both sides frequently crossing to see their relatives or conduct business. Border checkpoints are often informal and hard to secure – a problem highlighted by the recent spread of Ebola to western Uganda. After years of conflict, South Sudan poses a particular risk due its lack of health infrastructure, while Rwanda has one of the highest population densities of any African country. Inside Congo there is a risk of further spread as insecurity rises. Ethnic clashes in Ituri displaced 300,000 people in June alone and may hamper the Ebola response in the months to come.

A life-saving vaccine

An experimental vaccine produced by the American pharmaceutical company, Merck, is being used and has proved highly successful, delivering 97.5 percent protection for more than 147,000 people inoculated. The vaccine – not yet approved for commercial use – has been administered using the so-called “ring vaccination” method, which involves tracing and vaccinating the contacts of confirmed cases, followed by contacts of contacts. But insecurity and distrust of responders has hampered the ability of health workers to reach and vaccinate contacts effectively, according to the WHO. For that reason, experts from the agency are now recommending expanding the population eligible for the vaccination and switching to smaller doses to prevent a shortage.

A local response

Aid groups and researchers are calling for greater involvement of local communities to help build trust with responders and prevent further attacks. This includes doubling down on communication and outreach, and providing locals with a better understanding of the virus and how it is treated. According to Joanne Liu, the international president of Médecins Sans Frontières, it is affected communities who “have answers, not the foreigner who comes and gives them lessons and preaches to them about what they should do”. The medical charity has criticised a heavy-handed, “militarised” response for alienating the public, with the Congolese police and military often forcing local communities to accept Ebola treatment. This has caused some locals to stay away from Ebola clinics.

(TOP PHOTO: Health workers put on protective gear in Beni.)

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