One year after an Ebola outbreak in the Democratic Republic of the Congo (DRC), the crisis is far from over. Sarah-Leah Pimentel and Shrikant Peters examine the complex challenges that have prevented the effective containment of the epidemic. There is a real risk of Ebola spreading to neighbouring countries unless the DRC government, regional and international bodies, and local communities work together to eliminate it.
The 1 August marked the one-year anniversary of the latest outbreak of the deadly Ebola virus in the DRC. It is the second-worst recorded outbreak in history.
A joint statement by the humanitarian agencies working on the ground to contain the epidemic — including the United Nations International Children’s Emergency Fund (UNICEF), the World Health Organization (WHO) — declared that in the last year, they had registered 2 600 cases, resulting in 1 800 deaths, of which one third were children.
Let that sink in for a minute. Nearly 70 percent of all diagnosed patients die.
These are just the reported cases. These are the patients who are able to get to a facility in time to be treated or die an excruciating death.
These statistics don’t include Ebola victims who are misdiagnosed with other illnesses presenting similar symptoms at local health centres that don’t have the technology and facilities to test for Ebola. These figures don’t include isolated communities who never make it to a health facility. These figures don’t include the spread of the disease in impenetrable areas, mostly in the North Kivu and Ituri provinces. The reality is, we don’t really know how many people have contracted Ebola or have died from it.
The disease is spreading
Doctors Without Borders (MSF) reported that two cases of Ebola have been confirmed in Goma, a city of one million people, on 3 August.
A city that is less than 100km from the Ugandan border and 15km from the Rwandan border. A city on the banks of Lake Kivu that feeds other parts of the DRC and Rwanda. A city that sees fluid and often uncontrolled movement of the citizens from these three countries.
Over the course of a year, this epidemic seems to have spread unabated over a 400km belt in the Eastern DRC, in a volatile region of intense conflict and bordering several East African states.
The WHO in its July Emergency Declaration warned that an international outbreak is possible, and that its prevention requires a co-ordinated, well-resourced response, but that this can only occur in a stabilised context.
What is Ebola?
Ebolavirus is a type of Viral Haemorrhagic Fever. Large outbreaks of Ebola occur due to its high proclivity for person-to-person transmission, and a high case fatality rate of up to 90% of all infected individuals.
The disease was first reported in two almost-simultaneous outbreaks in 1976, across the Sudanese-Zaire (now DRC) border, in the vicinity of the Ebola River, from which the disease came to take its name. Most cases have since been reported within Sub-Saharan Africa, except for outbreaks in Europe and the United States of America, associated with either transport of infected primates or international human tourism.
The virus circulates naturally in animals. Transmission to human hosts occurs when encountering the blood, secretions, organs or bodily fluids of infected animals. Once it has crossed the species barrier, Ebola can spread within human communities from direct contact with the saliva, blood, semen, stool or urine of infected people. There is thus a high risk of transmission during close familial or sexual contact, funeral embalming and interring rituals and healthcare provision.
After an incubation period of approximately one week, infected individuals will experience body pains, fever, vomiting, diarrhoea and a rash, and bleeding from the mucous membranes, shock and loss of consciousness, before death. Due to the inability to treat or cure patients with Ebola, medical interventions rely on breaking the cycle of transmission, both from animals to humans to prevent outbreaks, and between humans during outbreaks.
To prevent crossing from animals to humans, medical authorities need to study mortalities, allowing for the early detection the disease and prepare rapid responses to anticipated human outbreaks.
This requires an organized and well-resourced health system. During epidemics, human, financial and medical resources must be co-ordinated to conduct prevention, control and awareness. Affected areas need to isolated and rapid response teams are directed to provide and support barrier medical care. This includes the performance of safe burials, preventative support, and the provision of personal protective equipment to patient’s families and their communities.
A key element in the arsenal to prevent further spread of disease is vaccination. During the 2014-2016 Ebola outbreak in West Africa, trials demonstrated a safe and efficacious vaccine of close contacts of Ebola cases, to prevent further spread. The (necessary) stringent regulatory process to ensure the safety of vaccines has delayed roll-out, and production of each vaccine requires a year-long laboratory process.
Currently, Merck, who manufactures the vaccine, has a stockpile of 1.5 million vials which is sufficient to ‘ring-vaccinate’ communities of infected cases. This does however rely on accurate modelling, and the amount of vaccine antigen required to induce immunity, which is currently being studied.
The high-risk, high-benefit stakes of an Ebola vaccine makes this particularly difficult for the clinical research community, who must balance the need for immediate response to prevent loss of life with the charge that Sub-Saharan Africans are exposed to clinical trial standards of a lesser quality than the rest of the world.
Similarly, the provision of healthcare services needs to balance the need for safe working conditions (both in terms of safety from violence and access to pre-vaccination) for any healthcare workers seconded to work in Ebola areas.
Distrust and conflict prevent effective containment
The critical shortage of medical personnel working in the epidemic-ravaged areas and vaccination supply problems alone cannot be blamed for the seeming inability of aid organisations to make significant gains in containing the spread of Ebola.
The DRC’s politico-economic situation has contributed to an already complex medical challenge in stemming the spread of Ebolavirus.
Most of the eastern DRC has been ravaged by conflict for more than two decades. Since 1994, five million people have died in a spill over of the Rwandan genocide. Many of the Hutu militia who were largely responsible for the mass killings in Rwanda fled to the DRC.
Without opposition from Mobutu Sese Seko’s government, these militia began to attack the Congolese ethnic Tsutsi population. Rwanda’s Tsutsi government backed the groups fighting both the Hutus and the Congolese government troops, in a conflict that resulted in the overthrow of Sese Seko’s government in 1997.
Since then, the eastern region of the DRC has remained restive and volatile. The militias splinter and create new groups. Two Kabila regimes were unable to put an end to the violence and the armed groups.
READ — The world’s second-biggest Ebola outbreak is still raging. Here’s why // Nadia Drake, National Geographic
Elections were finally held in December 2018 following multiple postponements as the government sought ways to contain political infighting and the continued violence in the eastern DRC. It remains to be seen whether Felix Tshisekedi’s controversial ascent to power will improve things.
In the meantime, the eastern DRC has essentially been without any form of governance for more than 25 years. The authorities are distrusted. Outsiders are viewed with suspicion. At best, tribal chiefs hold together these dispersed communities that are regularly forced to flee their homes.
The continued internal displacement of peoples may have contributed to the spread of the Ebola virus. In such a terrain, it is hard to carry out containment and awareness campaigns. The communities also don’t know who to believe.
Health workers become the targets of the people’s fear. Some even believe that the medical units are not trying to eliminate Ebola, but to spread it. In February, two Ebola treatment centres were attacked. In July, two aid workers were killed by unidentified attackers in Beni, North Kivu.
A better solution needs to be found
The DRC’s former minister of health, Oly ILunga Kalenga, called for an “integrated approach” in containing the epidemic.
In particular, he called on aid workers to engage the community, especially the traditional leaders who are the only form of authority in many of these areas. Kalenga spoke of the need “to respect communities and to listen to them, not to approach them with an expert approach.”
Disappointingly, Kalenga resigned his position on 22 July, citing government “interference in the management of [his] ministry’s response to the epidemic.” It is unclear whether a new minister has been appointed.
The African Union (AU), as the only continent-wide decision making body, should have taken a lead role in coordinating medical efforts and awareness campaigns. However, compared to some of the international efforts, the AU’s interventions appear reactive rather than proactive.
Since the outbreak in 2018, the AU has trained 1 600 local health workers and community leaders on Ebola prevention and infection control, set up treatment centres and implemented cross-border screening. In July, following the confirmation of the two Goma cases, the AU announced that it would increase the number of experts deployed to the affected regions.
The role of the churches
The presence of medical personnel are vital to containing the epidemic. But Kalenga quite rightly pointed out that without the support of the community, the fear and suspicion of the local populations and the militias will render any outside help ineffective.
The Catholic International Development Charity (CAFOD) recognises that “the Church networks are closer to the people, and their messages are listened to and accepted. They can reach every corner of this city [Goma] and are ready to go where others might fear to go.”
The local Catholic churches are educating people as they come to Mass and have changed some of the local Mass traditions to keep people safe. Similarly, The DRC Anglican church reported that it is working to raise awareness and combat misinformation.
In fact, the churches were instrumental in helping to bring the West African Ebola outbreak to an end.
In the DRC they stand as a sturdy bridge between the central government authorities, medical teams, regional and international initiatives to contain an epidemic that has already destroyed far too many lives.
The WHO warning of a possible international outbreak is real. We can stop it, but only if the armed groups put down their weapons, and the DRC and neighbouring governments work together with regional bodies, medical teams, international aid organizations, religious institutions and donors.
The Ebola epidemic really is everybody’s problem. The solution also requires everyone.