Conflict in DRC compromises battle against Ebola
US's Center for Disease Control has pulled its staff out of the country over safety concerns
World Health Organisation (WHO) director-general Tedros Adhanom Ghebreyesus responded to recent editorials calling for the return of US Center for Disease Control (CDC) personnel to the frontline of the most recent Ebola outbreak in the Democratic Republic of the Congo (DRC) by saying: “[We] can mobilise from other parts, from those institutions who don’t have very strict security provisions. We can cover it.”
Well, can they cover it? The CDC, twice as large as the WHO, has pulled its staff out of the DRC due to concerns over their safety. The WHO has great enabling authority to legitimise and oversee response efforts, but they rely on external support from countries and organisations with epidemic response expertise and human and financial resources.
The CDC continues to provide support in the areas of data and analysis, but Ebola response director for the International Rescue Committee Stacey Mearns told Associated Press that the absence of CDC experts can be felt acutely, citing their rich experience in tracking cases, testing and treatment. The battle against this particular Ebola outbreak will be a struggle unless the CDC returns to the field.
But to do so requires the stabilisation of the political situation in the DRC and a dramatically scaled up role for a stronger African Union (AU) and the UN in settling the conflict. It is difficult enough to bring such vicious hemorrhagic fever outbreaks caused by a hyperpathogenic virus such as Ebola under control in times of peace; it is quite another matter in circumstances of war. War and civic strife are critical risk factors that cannot be left unaddressed.
The world has learnt and achieved much since the devastating West African Ebola outbreak of 2014-2015, when 11,312 people died. Then the virus spread rapidly in densely populated slums and urban settings, including the capital cities of Guinea, Liberia and Sierra Leone. By the end of the outbreak, the number of cases surpassed that of any preceding outbreak by two orders of magnitude. The severity of the outbreak can be attributed to a variety of factors.
Unlike many countries in equatorial Africa that have experienced outbreaks for the past four decades, Guinea, Liberia and Sierra Leone had minimal experience with Ebola. Clinicians, laboratory technicians, politicians and communities were unprepared to identify the disease and mount a response. Most outbreaks can be brought under control in three weeks to three months, but the outbreak in Guinea smouldered for months before a response could be mounted.
In addition to a lack of specific experience with containing Ebola outbreaks, basic health infrastructures had been left severely damaged by years of civil war and unrest. West Africa had a high degree of population movement and porous borders. No vaccine was available to prevent infections from taking hold. These factors helped make the 2014 outbreak the largest and deadliest in history, with 28,616 cases resulting in 11,312 deaths.
The Global Health Security Agenda, a multination effort to upscale prevention, detection and response to epidemics by accelerating compliance with the WHO’s 2005 International Health Regulations, was launched in 2014 and introduced a standardised system of metrics to assess the preparedness of nations. By 2018, 38 African countries had been assessed, 22 had begun developing national action plans and 19 concluded simulation exercises including in countries that had Ebola outbreaks.
When the May 8 outbreak in the Équateur province occurred, accumulated knowledge and experience resulted in more efficient handling: provincial health authorities reported 21 cases of hemorrhagic fever, experts were sent to investigate, and within five days, on May 13, the WHO declared an Ebola outbreak. And this time there was a vaccine. This declaration was followed up with shipments of emergency response supplies, the assembly of a team of contact tracers and the arrival of experienced vaccinators from Guinea.
They began a campaign of ring vaccination — a technique whereby individuals who have had contact with a person with a confirmed case of Ebola are traced, and invited to be vaccinated with members of their household. A “ring” may comprise about 150 people on average. On July 24, less than three months after the first cases were reported, the WHO declared the end of the outbreak, which had resulted in a total of 54 cases of Ebola and 33 deaths.
What sets the current outbreak — declared on August 1 — in the DRC apart from all the others is the social disruption caused by war and internal civil strife in the highly unstable northeastern North Kivu province, home to more than 1-million internally displaced persons. Because of the circumstances, the outbreak fast became the second-largest in history with a total of 422 confirmed cases as of November 27. The risk is that it would spiral out of control into a pandemic.
War and internal strife affected the public health basics. Reporting was delayed due to a breakdown of the surveillance system. Access and movement were impeded by the security context. There was a strike by the health workers of the area in May due to non-payment of salaries. The conflict reached a climax on November 16 when an armed group attacked the UN Organisation Stabilisation Mission base in the city of Beni, the epicentre of the outbreak in North Kivu province.
Important strides have been made in controlling the current outbreak such as the use of vaccines and treatments in clinical trials and case investigation, but it is worrying that two-thirds of Ebola cases have been discovered among people not on existing contact lists. People are often unwilling to name those who have been infected due to mistrust of the system. There are also instances of “community deaths”, such as the recent cases in Komanda, where the individuals die without seeking help from an Ebola treatment centre or hospital. This raises the chances of transmission because people in the community lack the personal protective equipment necessary to look after themselves when caring for loved ones.
Conflict continues to pose a major challenge. Two violent attacks resulting in civilian deaths were reported near Beni on December 5. As the centre of the outbreak moves from Beni to Butembo, an even more dangerous part of North Kivu, addressing security concerns must be a priority.
Peace must return to this troubled part of the world, brought about by a much more vigorous UN and AU, the latter in a very weak state. US CDC personnel should be allowed to return to the field.
The WHO is a public health agency, not a political institution or global government. It is hard to see how the WHO would cover the absence of the CDC, especially under circumstances of war, which is why the CDC withdrew in the first place.
- Dr James is a Columbia University visiting professor, and Bender research assistant to the Children’s Hospital in Africa Mapping Project.