Health workers carry a coffin containing a victim of Ebola virus in Butembo. Picture: JOHN WESSELS/AFP
Health workers carry a coffin containing a victim of Ebola virus in Butembo. Picture: JOHN WESSELS/AFP

Rising insecurity and attacks on health-care workers in the eastern Democratic Republic of Congo (DRC) could undermine efforts to bring the second-worst Ebola outbreak in history under control.

The outbreak started in the conflict-affected region in August last year. By July it had reached the bustling city of Goma, on the border with Rwanda, prompting the World Health Organisation (WHO) to declare it a public health emergency of international concern.

In little more than a year, more than 2,200 people have died, out of a total of 3,220 confirmed cases and 118 probable ones. (The 2014-2016 epidemic in West Africa killed more than 11,000 people.)

At the height of the eastern DRC outbreak, in April, authorities recorded 120 new cases a week — a figure that had dropped to 15 a week by mid-October, and 12 by early November. Just six new cases were confirmed between November 20 and 26.

The decrease encouraged a cautious optimism in the Ebola emergency committee, which said: "We have contained Ebola in former hotspots such as Beni [in the northeast], and successfully prevented onward transmission in Goma and Uganda."

Dr Mory Keita, field co-ordinator and deputy incident manager of the WHO’s Ebola response team, tells the FM the situation was calm, apart from three hotspots: Mandima, Mabalako and Mambassa. "The goal is to get to zero case[s] in the next [few] weeks," he says. But two weeks ago health authorities started evacuating workers amid rising insecurity in the restive Beni area. The WHO flew 49 nonessential staff to Goma, while Unicef temporarily relocated 27.

Then, on November 27, armed assailants killed four Ebola response workers and injured five in two separate attacks in Biakato and Mangina, in the east of the country. This is on top of the more than 300 attacks on health-care facilities in the DRC this year, which have resulted in the deaths of at least six health-care workers and patients, and injuries to more than 70.

The new attacks threaten the gains made in recent weeks. "Ebola was retreating," WHO director-general Dr Tedros Adhanom Ghebreyesus tweeted last Thursday. "These attacks will give it force again, and more people will die as a consequence."

Picture: 123RF/lightwise
Picture: 123RF/lightwise

The Ebola-affected zones in the DRC are among the country’s most volatile. In Beni, for example, Ugandan rebel group ADF-Nalu — just one of a multitude of armed groups in the region — has been terrorising civilians. Early last month, government forces started operations against rebels in the east.

But while Keita noted at the time that the move may alleviate the insecurity hampering the Ebola response, he was quick to caution that "we don’t know what will be the consequence".

What is clearer is the effect instability has had on efforts to control the spread of the virus. An important part of managing Ebola is surveillance and control: finding cases, tracing contacts and administering vaccinations.

According to a WHO Ebola update, the number of daily alerts it received from health-care facilities and community workers dropped from 400 to 120-150 a day amid escalating violence in Beni last week.

A similar pattern was observed after two days of protests disrupted the Ebola response in Butembo.

Likewise, the tracing, registering and monitoring of contacts of Ebola cases dropped from an overall seven-day average of 86% to 59% on November 25.

But disruptions to the Ebola response have also come from affected communities themselves.

In early November, armed assailants killed radio presenter Papy Mumbere Mahamba and set his home on fire shortly after he hosted a show to raise awareness about Ebola.

"The killing of a community radio journalist because of his commitment to providing public service information on a deadly disease is a tragic illustration of the cost to society that violence against the media represents," Unesco director-general Audrey Azoulay said at the time.

And while the authorities said they could not be certain of the motive for Mahamba’s killing, the health ministry, together with the WHO and other partners, released a statement at the time calling "any act of violence against individuals involved with the [Ebola] response unacceptable".

It speaks to one of the challenges health workers face in containing the outbreak: community resistance. Myths and misinformation spread fast. When 1-million citizens in the east of the country were barred from voting in the 2018 election in an attempt to prevent the spread of the disease, some citizens and politicians claimed it was a political ploy on the part of the authorities.

And some believe Ebola response workers have entered their communities simply to make money.

DRC President Félix Tshisekedi acknowledged the issue recently. "We did not take seriously the negative attitude of the population at the beginning," he said in an interview broadcast on Russian television. "[The communities] did not understand the humanitarian workers’ intention, as they were driving big, luxurious cars without explaining to the community what they came to do."

To allay fears, the response teams have been working towards a more inclusive approach. "We are trying to build the confidence between local communities and response team[s]," Keita tells the FM.

By bringing on board locals who know the affected areas and speak the local languages, his team hopes to boost community participation in preparedness, prevention and other control efforts.

Health authorities and local leaders have also intensified their campaigns to educate communities about Ebola. At bus terminals, for example, radio messages and songs about the virus play on loudspeakers, and billboards contain informational messages.

A call centre has also been set up to provide affected communities with related information.

"Goma has been in response mode since the first confirmed case was [reported] on July 14," says Keita. "There are also preparation and readiness activities ongoing in all the health zones around Goma."

It’s resulted in changing cultural practices in some parts of the country.

For example, people have started raising elbows to greet each other instead of shaking hands.

Francine Kaboya, a resident of Goma, tells the FM that the community there has taken preventative measures following various awareness campaigns. "The situation is calm now," she says. "It’s been more than four months without hearing [of] any Ebola case [in Goma]."

The case she refers to is that of a pastor who transmitted Ebola to his wife after travelling to an affected zone. Though he died, his wife was treated and cured — but then subject to the problematic public perceptions about the disease. In an attempt to prevent her isolation by the community, North Kivu governor Carly Nzanzu Kasivita accompanied her to her home to demonstrate his support.

Meanwhile, a new vaccine in Goma is drawing opposition.

Last year, international multinational Merck introduced a vaccine in the DRC that the BBC reports is 99% effective. A second, experimental, vaccine, introduced into Goma by Johnson & Johnson last month, will contribute to the authorities’ objective of protecting residents from the virus, says Keita.

The evaluation of a second vaccine is among the recommendations of the WHO’s strategic advisory group of experts on immunisation. Others include new strategies to mitigate the fallout from insecurity, such as pop-up vaccination stations, and increasing levels of vaccination within communities.

But the Johnson & Johnson vaccine has met opposition from a pro-democracy civil society group called La Lucha, which questions its efficacy. The country’s former health minister, Dr Oly Ilunga Kalenga, has also reportedly questioned experimentation with the vaccine.

On December 4 Doctors Without Borders withdrew staff from Biakato as the security situation deteriorated.

A regional response

Neighbouring countries are on high alert for the spread of Ebola beyond the Democratic Republic of Congo (DRC).

In Rwanda, for example, World Health Organisation (WHO) partner Unicef has identified 15 high-risk districts that "either geographically touch on borders or have air links with neighbouring countries either affected or at risk of Ebola", says communications chief Rajat Madhok.

On August 1, the authorities closed the border at Rubavu, one of the country’s busiest borders with the DRC. Though it was reopened the same day, authorities have now started screening the temperatures of people crossing into Rwanda, and ensuring they wash their hands before being allowed entry.

The country has also conducted Ebola simulation exercises, and on December 8 it began a vaccination programme.

Rwanda’s ministry of health says the country targets 200,000 people.

According to the WHO, Uganda is looking to vaccinate health-care workers and strengthen community health-care teams in at-risk districts to enhance community surveillance.

Despite gains in the Ebola response in the DRC, the country’s emergency committee in early November warned that the outbreak has become concentrated in a smaller geographic area that is more rural and difficult to reach, and that "the risk of spread within the DRC and to neighbouring countries remains very high".