Last week, the Ebola outbreak in the Democratic Republic of Congo (DRC) reached a sobering milestone by becoming the second largest Ebola outbreak in history, second only to the 2014–16 epidemic in West Africa. There were 453 total cases and 268 deaths in the affected provinces of North Kivu and Ituri, according to the latest World Health Organization (WHO) situation report issued December 5.
The situation prompted the UN Security Council to pass Resolution 2439 on October 30 calling for an immediate end to hostilities by armed groups. The resolution also urged all parties to ensure unhindered access for humanitarian and medical personnel. On November 7, the director-general of the WHO, Tedros Adhanom Ghebreyesus, joined UN Under-Secretary-General for Peacekeeping Operations Jean-Pierre Lacroix in visiting the affected city of Beni to explore options for enhancing security in the country’s east.
According to the director of the WHO Health Emergencies Programme Peter Salama, the situation represents a “perfect storm” characterized by weak health systems in one of Africa’s poorest countries; proximity to borders with Uganda and Rwanda; a dense and mobile population of 6 million people living in North Kivu—including over 1 million internally displaced people; and violence and insecurity, heightened by national elections scheduled to be held on December 23.
Security and “Contact Tracing”
The security situation remains a key obstacle to containing the deadly virus. Health workers face the possibility of attack or kidnapping by the Uganda Allied Democratic Forces (ADF) or one of a hundred other armed groups estimated to be active in the region. According to the DRC Ministry of Health, response teams face an average of three or four attacks per week.
Besides direct threats to health workers, the civil conflict is impeding access to affected populations. Security concerns are contributing to gaps in identifying and following up with contacts of known cases, or contact tracing. Security incidents have been associated with a noticeable drop in the percentage of contacts followed. The fact that new Ebola patients are being identified without epidemiological links to current cases suggests there may be “considerable transmission” that is going undetected, according to Outbreak Observatory.
To ensure a safe environment in which health workers can operate, some experts have stated that the UN “should not delay” sending in additional peacekeepers. DRC is home to the UN’s largest peacekeeping force, the UN Stabilization Mission in the DRC (MONUSCO), which is comprised of roughly 17,000 uniformed personnel. However, the mission is stretched thin. According to a recent analysis, MONUSCO is “squeezed by political and budgetary pressures,” including an ongoing troop drawdown, budget cuts, and Security Council expectations since 2014 to draw up an exit strategy.
MONUSCO reports it is supporting the Ebola response in a variety of ways, including providing airlift and transportation, information and communications technology, and logistics and operations support, including constructing an emergency operations center and an Ebola treatment unit. Upon request, it provides armed security escorts to health teams along the roads entering and exiting Beni.
The mission has recently taken “an active approach to armed groups operating in North Kivu,” according to an official statement. Days after the visit by Tedros and Lacroix, seven peacekeepers and several Congolese soldiers were killed while conducting joint operations with the DRC army, or FARDC, against an ADF stronghold. In a possible revenge attack on November 16, the ADF attacked a peacekeeping base in Beni. An unexploded ordinance landed on a residence where several WHO staff were staying.
There are “limits to the security protection MONUSCO can offer,” according to a Center for Strategic and International Studies (CSIS) brief. The local population views peacekeepers with suspicion due to their association with the FARDC, which has been accused of human rights violations. Due to its politically compromised position and force protection concerns, MONUSCO’s logistics and operations expertise may ultimately prove more valuable to the Ebola response than its ability to tame local militia or rebuild community trust.
With national elections expected this month, however, it could present an opportunity for the Security Council to consider reconfiguring MONUSCO and its mandate once it is up for renewal in March. While troop increases are unlikely, one proposal by CSIS calls on MONUSCO’s Force Intervention Brigade (FIB) to concentrate around the outbreak zone and improve access for public health and humanitarian workers.
The robust FIB, comprised of southern African troops with special forces and intelligence capabilities, has shown greater willingness to engage the Uganda ADF than some Rwanda-linked militia, according to a recent analysis. The operation on the ADF compound last month involved FIB participation, and it appears its headquarters has recently moved to Beni. The risk is that fierce militia resistance and additional casualties will degrade the FIB’s will to confront these accidental spoilers to the Ebola response.
Signs of Progress
Despite these challenges, the WHO-led international response has shown signs of progress by incorporating lessons learned from the 2014–16 Ebola outbreak. Following critical reforms to its emergency operations, and coming on the heels of its successful containment of the Ebola outbreak in DRC’s Equateur province in July, the WHO is displaying a stronger leadership and operational role than it did in West Africa. The WHO has deployed 285 experts to support the government response, according to the WHO situation report.
The response has also benefited from several new initiatives created in the aftermath of the West Africa crisis to shore up the global outbreak response system. Launched in 2017, the Africa Centers for Disease Control (CDC) has deployed health professionals to support surveillance, trained health workers, and provided laboratory services. African countries, which fund the Africa CDC, have a strong interest in ensuring the virus does not extend beyond DRC’s borders. The likelihood of national and regional spread is “very high,” according to a WHO Ebola risk assessment issued in September.
Established in 2016, the WHO Contingency Fund for Emergencies allocated roughly $11 million to the DRC in 2018, representing about 40 percent of total funding. The fund has been “well supported,” according to Salama and, unlike during the epidemic in West Africa, financing is not a significant barrier to the response.
Finally, a variety of experimental countermeasures are being leveraged. Health workers vaccinated 42,000 vulnerable individuals against Ebola with a vaccine licensed by Merck. Four other experimental therapies are being made available to patients under compassionate use agreements.
The outbreak in North Kivu poses the most difficult test of the global outbreak response system since the 2014–16 Ebola epidemic in West Africa. Despite the availability of new initiatives that have been put in place since the West Africa crisis—including the Africa CDC and the WHO Contingency Fund for Emergencies—the security situation has impeded contact tracing and other vital activities. UN peacekeepers, while playing an important operational role in the response, are unlikely to provide an easy solution to the security challenges facing public health personnel.
With the US government reportedly taking a backseat in the response—a stance criticized last week in dual statements issued by independent global health experts and published in American medical journals—the pressure is mounting on the multilateral system to contain the outbreak. Ironically, at a time when some powerful governments remain skeptical of multilateral institutions such as the UN and WHO, they are putting their faith in these very arrangements to prevent a catastrophic pandemic from threatening millions of lives in the affected region and beyond.
The views expressed are the opinion of the author.