J. Stephen Morrison. "The Ebola Virus Is Winning in Eastern Democratic Republic of the Congo." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, September 12, 2019. Accessed January 24, 2020. https://healthsecurity.csis.org/articles/the-ebola-virus-is-winning-in-eastern-democratic-republic-of-the-congo/
Hard barriers to access lie at the very heart of the agonizing struggle by international and Congolese responders to contain and ultimately arrest the Ebola outbreak in eastern Democratic Republic of the Congo (DRC). As of early September 2019, there have been over 3,000 cases and 2,000 deaths. Foremost among the barriers to access are insecurity and chaos, which gravely and consistently thwart access to the hot zone, in effect providing shelter for the virus. Four other forces contribute profoundly to creating an environment in which it has not been possible to confront and circumnavigate DRC’s insecurity and chaos in order to carry out the public health actions essential to end the Ebola outbreak. These compounding factors include DRC’s dysfunctional governance, the absence of high-level major power engagement, the overload created by DRC’s high number of infectious disease outbreaks amid a roiling humanitarian crisis, and the flawed implementation and management of an underfinanced international response.
The current Ebola outbreak—the tenth and most dangerous of the disease in the country since it was first discovered there in 1976—was first declared on August 1, 2018 though it is believed to have ignited months earlier in April 2018. As of late May 2019, UN Secretary-General António Guterres appointed David Gressly, a highly-respected, senior U.S. United Nations official, to oversee an integrated approach with greater accountability and greater focus on security and community trust. On July 17, 2019, the World Health Organization (WHO) declared the outbreak a global emergency. It remains uncontrolled, a steady “slow burn” that continues to expand its geographic footprint while hotspots flare and skip across a dangerous, complex terrain populated by over 8.5 million people, including a million displaced.
More than one year has now passed, and though the virus fortunately is not a runaway contagion, it is winning. The opportunity for early, swift, concerted action has come and gone. In the meantime, conditions on the battlefield have deteriorated. The international and Congolese response has evolved into a reactive, anxious effort to “reset” itself in hopes of regaining the initiative. While the game is far from over and hope has not been jettisoned, the outbreak is now recognized to pose an open-ended, long-term threat.
As the enterprise enlarges, it is becoming much pricier. The issuance of a new six-month strategic response plan from the DRC Ministry of Public Health, in partnership with the WHO and other UN partners, has been seriously delayed and is expected to call for $600 million, more than double the cost of the previous six-month plan. Finding those resources will not be easy. For the first time since the discovery of the virus, there is the real possibility that Ebola in eastern DRC may become endemic, circulating indefinitely within the population. That raises the specter of multiple, concurrent Ebola outbreaks in the future.
How to Explain This Ominous, Unprecedented Outcome?
Failure up to now, paradoxically, comes against a backdrop of courage and achievements. More than 1,400 health and humanitarian workers have been mobilized, along with thousands of others who enlisted to provide support in various ways. The WHO for its part has brought to the fight much improved capacities and strong leadership under Director-General Dr. Tedros Adhanom Ghebreyesus joined by DRC experts with the longest history and experience of any government in battling Ebola. The World Bank stepped forward to finance 60 percent of the first year’s costs and has pledged $300 million towards the new strategic response plan, 50 percent of the estimated costs of the total plan—a fortuitous boost given the otherwise wan commitments of most major donors. Over 215,000 persons have been vaccinated, a major technological advance borne of the 2014-2016 West Africa Ebola crisis, which has helped keep a “slow burn” from becoming a full-blown, runaway catastrophe. Clinical field trials of four experimental therapies moved forward, remarkable considering the turbulent environment, leading to the announcement in August that preliminary data showed that participants receiving two of the therapeutics early after infection had a significant chance of survival (approximately 90 percent). Those two therapeutics will continue to be offered under a compassionate use basis.
Yet these valiant, promising efforts have simply not been enough. They have not yet cleared a path to reach the virus effectively in the fluid hot zones. The principal reason: eastern DRC’s wall of exceptionally dense and formidable insecurity and chaos.
This is a zone of active armed conflict that features enduring armed movements such as the Allied Democratic Forces (ADF), rooted in North Kivu province since 1996, where the group has honed its signature reputation for massacres of civilians along with proving its ability on several occasions to kill significant numbers of UN peacekeepers when confronted. At local levels across eastern DRC are diverse Mai Mai militias, a collection of protection rackets; defenders against outside marauders (a legacy of the post-genocide Rwandan invasion); and guardians of illicit trafficking of arms, humans, high-value minerals, drugs, and other commodities. In the daytime, the official Congolese police and military are the ADF’s and Mai Mai’s ostensible adversaries. As night falls, it becomes far less certain who is on whose side.
Eastern DRC’s fractured, confounding environment invites violence by opaque networks that this year have deliberately targeted health providers and facilities on more than 50 occasions. Seven health providers have been murdered and scores injured. Reliable, timely, quality intelligence on these networks, essential if they are ever to be cracked, has been wanting.
Recurrent attacks stop the international response in its tracks and trigger spikes in new infections after each episode. A nasty cycle ensues. Attacks perpetuate the outbreak, which in turn perpetuates the need for a continuous flow into the hot zone of ever higher resources that, in turn, invite unwanted attention from those controlling the illicit underground economy who insist upon their cut. Trapped in this swirl, denied access, and its integrity compromised, health delivery inexorably degenerates.
This systemic chaos has evolved hand-in-hand with deep-seated community resistance, built on a long history of violent abuse and marginality. These communities reside in an environment rife with paranoia, conspiracy theories, and disinformation, aided and abetted by social media and local political opportunists.
The Price of Insecurity and Chaos
Eastern DRC’s insecurity barriers—attacks on health workers, armed group violence, and ongoing community resistance—thwart those essential public health functions that need to happen early and quickly if there is to be any chance of containing and arresting an outbreak. They stand in the way of the quick identification of Ebola cases and subsequent, swift isolation and entry into treatment; rigorous contact tracing; the establishment of a unified data system that integrates response activities, including vaccination and laboratory results; the strengthening of basic infection control inside health facilities; and safe and dignified burials.
In the absence of full and effective implementation of these essential measures, control has been lost, the virus has spiraled, and visibility into the epidemiological twists and turns of Ebola transmission has dimmed. Roughly half of deaths are occurring outside of health facilities. For half or more of those newly diagnosed with Ebola, there is no known origin of the infection. Long delays of six to seven days persist between the diagnosis and isolation and treatment of patients.
Yet insecurity and chaos in eastern DRC are not the sole explanation of what has transpired. These barriers do not operate in a vacuum and are not immutable. Four forces in particular—DRC’s maladministration, the void in major power engagement, DRC’s saturated infectious disease environment and ongoing humanitarian crisis, and weak management of the response—impose barriers in their own rights that compound the impacts imposed by insecurity and chaos. Their deep impact has often not been anticipated or well understood. Each in its own way has fed delays and diverted attention from the central job at hand: how to confront head-on—and circumnavigate—the chaos and disorder in eastern DRC.
DRC’s Long Broken Governance
The DRC’s perverse governance stands conspicuously apart. Under the DRC’s crisis-prone, fractured, repressive form of governance, what happens in the distant, remote east has been and remains a residual concern. Where and when Kinshasa has become engaged, it has made things worse, not better.
Paradoxically, when a flawed democratic renewal of sorts accelerated in the DRC in 2018 after several years of protracted negotiations, it only worsened conditions for those public health officials clamoring for attention to the Ebola emergency unfolding in the east. Over the course of its first year, the Ebola outbreak took a back seat to the DRC’s bumpy and ultimately fraudulent electoral transition to a post-Joseph Kabila order. In this critical period, high-level Congolese leadership on Ebola was conspicuously absent, otherwise preoccupied with who was going to be next in power. (That uncertainty and danger reached far and wide. U.S. embassy personnel were under forced departure orders from December 17, 2018 to late January 2019.) In retrospect, the DRC government’s fateful decision to suspend elections in the Ebola hot zones—opposition strongholds—in early 2019 lit up community resistance, fueling preexisting suspicion that Ebola was nothing more than a new moment of external exploitation and abuse. It was only in July 2019, six months after being installed as the head of state and long after the ignition of the Ebola outbreak, that newly installed President Felix Tshisekedi confronted the deep divisions within his own government over control of the Ebola response and placed his own team at the helm.
A Vacuum in Major Power Interest
The absence of high-level international leadership also stands out starkly. For the leaders in Washington and London presiding over their own turbulent tenures, Ebola in the DRC has been a distant, low-priority threat to be managed largely by others at the public health and humanitarian levels.
Even getting the United States’ best and brightest from Centers for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID) into the center of the action has proved to be highly problematic. Washington very early in the crisis withdrew its CDC and USAID personnel from the hot zone following a security incident in August 2018. In the year since, as insecurity has persisted and memories of the Benghazi tragedy of 2012 have hung over White House decisionmakers, the reentry of key U.S. experts has been denied. This is in spite of repeated vocal entreaties from CDC Director Robert Redfield, who has made the convincing case that small teams of highly experienced U.S. Ebola experts, deployed early and protected effectively, are essential to managing the crisis from the inside. In their absence, the overall international response suffers considerably, lacking strategic direction and oversight. The administration has also been significantly constrained in its funding capacity by U.S. sanctions imposed on DRC under the Trafficking Victims Protection Act. Congress has repeatedly called for use of waiver authority to increase ease and volume of funding.
To date, there has been no credible call to action by the world’s powers to tackle the disorder and chaos in eastern DRC. No group of ambassadors from the UN Security Council’s permanent members has ventured to Beni or Butembo. No world leader has taken on the cause, in the op-ed pages and the cable news circuit, to sound the alarm and insist higher action be taken to penetrate, demobilize, or otherwise neutralize the ADF and Mai Mai militias.
The UN Security Council did pass a resolution in October 2018 following repeated ADF attacks on providers. An eloquent plea for action, it was nonetheless toothless, laid out no concrete path for action, and stirred little follow-up. Important behind-the-scenes steps to better deploy UN peacekeepers against the ADF and to secure health facilities achieved some modest but largely temporary gains. The first week of September 2019, UN Secretary-General Guterres travelled to eastern DRC with WHO Director-General Dr. Tedros and head of UN peacekeeping Jean-Pierre Lacroix. U.S. Secretary of Health and Human Services Alex Azar and other high-level U.S. government officials are set to visit the DRC in mid-September. It remains to be seen whether these long overdue visits will change the thinking of the major powers about what is truly needed to tackle the security barriers and chaos of eastern DRC.
DRC’s Curious, Saturated “Microbial Sky”
The outbreak is occurring in an area where the risk of cross-border and international spread is extremely high. Eastern DRC borders Rwanda, the most densely populated country in Africa; Uganda, which has already experienced a handful of cross-border cases successfully contained; and South Sudan, another active warzone lacking a functioning health system.
Yet the steadily expanding Ebola outbreak has not been exported cross-border in any significant numbers, a curious phenomenon for which there is no clear explanation. Nor has there been significant spread inside the DRC into Goma, a populous transport and trade hub on the Rwandan border. If there had been significant spread to Kinshasa; Goma; or neighboring urban centers in Uganda, Rwanda, South Sudan, or Burundi, far greater world attention would have been paid to what was happening in eastern DRC, including presumably how also to fix the insecurity and chaos.
Ebola also competes with other pressing health security demands. Ebola arrived in 2018 as other outbreaks unfolded in the east and across the vast reach of the DRC—malaria, diphtheria, cholera, and diarrhea. At the same time, the DRC’s longstanding, chronic humanitarian emergency has left over 12 million in need of humanitarian assistance.
A final critical barrier to success is weak management, implementation, and supervision of the response effort. There are poor lines of communication among the many players involved in the response. Public health data is housed in distinct databases, not shared with those who need it and not integrated to provide an overall picture. Standardization of and visibility into the response structure, protocols, and training are sorely lacking. International donors are increasingly frustrated with the lack of transparency. The coordination and communication fundamental to a unified and effective public health response are not yet in place.
Where Does This Leave Things?
The answer: far behind and in danger of further regression. The virus is winning and may continue to win. In the judgment of CDC experts, eastern DRC remains a long distance from the critical milestones that would signal transmission is being stopped and the outbreak ended. That sobering sentiment hung over the WHO declaration of a global health emergency on July 17, 2019, which reversed three previous emergency committee determinations that there was no emergency. Previous hesitation reflected pressure from Kinshasa and neighboring capitals in Rwanda and Uganda, fearing disruptions of trade, transport, investment, and sovereign control. Awareness of mounting risks clearly informed the visits by several senior U.S. officials to the outbreak hot spots in the spring, their purpose to think through a “reset” in both U.S. approaches and broader multilateral strategies.
Ebola in eastern DRC is not going away anytime soon. Nor are the hard barriers to access rooted in insecurity and chaos and the companion barriers linked to DRC’s governance, major power indifference, an excess burden of health security challenges, and weak management.
The last year has delivered cutting, loud lessons. There are no ready-made solutions to fixing insecurity in eastern DRC or building lasting trust within communities. There does not appear to be any long-term strategy, articulated or advanced, that brings to the table much greater expertise outside public health: diplomacy, policing and mediation, intelligence, communications, and community trust and development. A narrow, overwhelmingly public health approach, even if it were implemented effectively, would still fall far short of what is required. Building the engagement of alienated communities and securing the ground require enhanced local knowledge and far more systematic outreach than has existed up to now. If the seasoned teams of renowned U.S. Ebola experts cannot be deployed safely into the center of the fray at the earliest moment, the initiative is lost, critical public health interventions founder, and an enormous hidden price is paid. If management is not tightly coordinated and held accountable, there is waste, and that quickly becomes an excuse for donor inaction and excess caution, particularly given the DRC’s notorious brand of corruption.
We should press for immediate action in three areas.
The first is to provide answers to the basic question of what it is truly going to take to overcome the threats posed by the Mai Mai and the ADF, who is charged with fixing these threats, and how. Up to now, there have been no answers to these questions.
Second, a glaring high-level political vacuum remains to be filled. Guterres would benefit enormously from the active partnership of a small number of global opinion leaders committed to working with him to eliminate the security barriers and advance an adequately funded, integrated strategy.
Finally, the U.S. government should move ahead to reinstate its seasoned civilian Ebola experts to operate effectively and safely in the hot zone one year after withdrawing them. The benefits of having such a high-impact capability warrant assuming a higher risk tolerance and taking special measures. Beyond DRC, the frustrations and costly delays experienced in DRC are likely to be repeated elsewhere in the future in other austere, disordered settings. In recognition of this problem, the CSIS Commission on Strengthening America’s Health Security is calling for the establishment of a U.S. global health crises response corps, which would receive special training and support to operate safely and effectively in diverse insecure settings. With this enhanced capability, the U.S. government would be equipped to intervene early, in collaboration with international partners, to stop outbreaks at their source and to save lives.
This commentary was made possible by the generous support of the U.S. Agency for International Development (USAID).