The latest Ebola outbreak – which began in August 2018 in the Democratic Republic of Congo (DRC) – is nothing short of a perfect storm of medical and political factors, writes the Brookings Institution. TheWorld Health Organisation has so far resisted classifying the outbreak as an international public health emergency.
It is the tenth such outbreak in the DRC, and the second-worst in history, after the outbreak in West Africa in 2014 where an estimated 28,652 people were infected and 11,320 died. Since last August in the DRC, over 2,000 people have contracted the Ebola virus, resulting in over 1,600 deaths.
Without an appropriate response from government leaders, medical experts, and the international community, the DRC government may not be capable of containment, and can expect continued outbreaks. Under current conditions, the public health status deteriorates further. While this is certainly a public health crisis, the solution isn’t solely a medical one. Rather, it’s essential to recognise that volatile relations between the DRC government and the its citizens – as well as the ongoing effects of conflict play a central role in perpetuating the problem.
This recent Ebola outbreak began in the North KIvu and Ituri provinces, which is about one thousand miles east of the DRC’s capital of Kinshasa. In such widespread locales, the DRC government is steadily working to gain control of the outbreak. Lack of training for medical staff, poor infection-control measures, and a failure to properly educate people all make containment very difficult.
These actions – and in-actions – in turn breed a lack of public trust in the DRC government as well as the UN. Neither the government nor outside agencies succeeded in bringing bring peace or sustainable health care to the DRC for many years. So, after years of neglect, communities are reasonably suspicious of authorities arriving suddenly to deal with Ebola.
The Congolese also blame the DRC government for the way it handled the recent election in December 2018. Leading up to the election, President Joseph Kabila made a decision to bar approximately 1.2m people in the cities of Beni and Butembo (located in the Ebola-affected regions) from voting until March 2019, but did not restrict voting in other communities with Ebola. Many believe this was done deliberately to suppress their vote.
This fuelled protests and violence, which resulted in the destruction of several health care facilities and restricted access to others. Concerns of election fraud raised questions about the election’s legitimacy and diminished efforts toward containing the outbreak.
Aid agencies are increasingly calling for a “reset” in the response, says a Devex report. “I think the reason we’re asking for reset is that … it will soon be one year of this response. So that clearly means that things are not working well. We have had a lot of money, a lot of funding, a lot of people on the ground, and if we are still in a response mode, we’re still seeing transmission at the numbers we’re seeing, then that means that something has to change in the way we’re working,” Tariq Riebl, emergency response director for the International Rescue Committee in theDRC is quoted as saying.
The report says based on conversations with multiple international NGOs involved in the response, two international organisations, and the DRC Ministry of Health, it appears there is some frustration and confusion among different actors in the response. Some NGOs feel they are not being heard, while others aren’t sure where they could be falling short or feel they are being misunderstood.
DRC’s Ministry of Health spokesperson Jessica Ilunga confirmed those sentiments when asked what her country needed from the international community. But she was quick to call the overall response a success, because without it, there would have been thousands more diagnosed with the disease. “I would say what we need is … more cohesion, more harmonization between the different interventions, more alignment with the strategic plan of the ministry of health. Because despite everything … like all the challenges or the violence and all the setbacks we’ve had, the public health response has been quite a success.”
The report says representatives from NGOs were unanimous in their opinion that the goal of putting communities at the heart of the response remains a work in progress. Some of them think this is due to the response’s heavy focus on medical approaches, such as on treatment and case detection. “Medical expertise is not sufficient to end epidemics,” said Tamba Emmanuel Danmbi-saa, humanitarian programme manager at Oxfam in the DRC, noting that previous Ebola outbreaks have demonstrated this. “The logic that has been used was mostly to focus on treatment, instead of equally focusing on patients and their fears and beliefs … We are calling all actors to include community authorities and nonformal leaders as decision-makers of the response.”
The report says calls for stronger community engagement date back to the 2014-2016 Ebola epidemic in West Africa, the largest in history. An important lesson from that outbreak was the need to engage communities, including recognising the significant role community leaders such as local chiefs, traditional healers and local men and women’s groups play in the response.
There is a sense among some NGOs that those important lessons on community engagement are not being applied in the current outbreak, though others argue the complex dynamics on the ground have made community engagement a challenge.
Security is a big impediment in the response, and so are the political and social dynamics in the affected areas of North Kivu. It’s known to be an opposition stronghold, marked by decades of conflict and insecurity, leaving communities more suspicious of outsiders — even of Congolese from other parts of the country. The “level of acceptance is not as easy as one would imagine,” said Oxfam’s Danmbi-saa.
According to the report, the World Health Organisation realises that community engagement is “crucially important,” but it’s one of the hardest things to do in an Ebola outbreak response, especially one with ongoing insecurity as is the case in North Kivu. WHO spokesperson Margaret Harris said: “The context – with insecurity and political tensions – makes all response interventions complicated, including community engagement. This outbreak is unique in comparison to previous ones because of this context: A densely populated area struggling with internal displacement, ongoing conflict, and a weak health system. Much of the population is, understandably, suspicious of outsiders, and it (takes) time to create a relationship of trust.”
“People have asked for responders who are local, familiar and speak local languages. We’ve heard this feedback and have worked very hard to develop the capacity to place local workers on vaccination and disinfection teams, for example, while being aware of the risk and challenges this entails,” Harris said.
Carlos Navarro Colorado, principal health adviser on public health emergencies at UNICEF headquarters, said in the report that community engagement activities have been very “intense” from the beginning of the outbreak, although there were times, especially around the presidential elections late in 2018, when they had to play a “low profile” so as not to be accused of playing politics. “The community, whether it is community leaders and traditional leaders, religious leaders, or the leader of a football club or a chess association or the students’ association, all of those have political views. We are working in an opposition area … and so it is not possible to speak to the community without engaging with people who are perceived to be either opposition or supporting the government,” he said.
But activities have been going well since, and successfully, in his view. “I can tell when 92% of people who are eligible for vaccination do get vaccinated, where more than 90% of the burials are actually done as planned, that doesn’t tell me that there’s poor community engagement,” he said. “In any other kind of response that will be considered a success (although) of course in Ebola anything below 100% is not successful.”
A common understanding of what community engagement looks like could help the response, said Whitney Elmer, Mercy Corps country director in DRC in the report. Some actors, she said, approach community engagement by focusing on prevention messages. But community engagement needs to be seen as a cross-cutting issue. Every element of the response – from safe burials to treatment, security or infection prevention and control – needs to have a targeted community engagement approach. She said it was important to get more feedback from communities and use that to adapt the response
“The focus up until now, it’s really been heavily on the medical side. So the treatments and the detection, that type of thing, and less on actually … engaging communities to understand what are their concerns to understand what are their fears, what are the things that are blocking them from going to health centres when someone is showing symptoms, or all of the gamut,” Elmer said.
Harris said WHO is “deeply aware” that the key to ending the outbreak was effective community engagement. “For example, we and our partners are providing cutting-edge treatments and optimized care at Ebola Treatment Centres – but if people who become sick with Ebola are afraid to go to them, the response can’t succeed,” she wrote.
She added that WHO knows that “cutting and pasting (community engagement approaches) from locality to locality isn’t an option” in the current outbreak. This view was echoed by Emanuele Capobianco, director of health and care at the International Federation of Red Cross and Red Crescent Societies, who spoke of the need to “hyper contextualise” the response, understanding there is great diversity from one community to another.
The report says others would like to see a stronger community engagement voice at the coordination table. While UNICEF has been leading the risk communication and community engagement pillar of the response, as they did in Equatoria during the brief Ebola outbreak there in 2018, IRC’s Riebl said some UNICEF staff at the coordination table are “maybe not experts in community engagement.”
UNICEF has senior experts in the role to support the ministry of health-led Communication Commission, and has also “regularly brought up issues of community engagement” at the strategic level coordination group, according to Colorado. He said the UN agency “has focused as much in technical expertise as in coordination capacity and experience” when recruiting staff to help coordinate the response.
IFRC has been involving communities, particularly Ebola-affected families, in the funeral rites in an effort to respect local customs and traditions while mitigating the risk of the disease spreading, Capobianco said in the report. They allow a family member of the deceased wear a personal protective equipment so he or she can watch over the preparation of the body for burial. The family can also decide which items to include in the casket to accompany their deceased loved ones, and the route to the funeral site. Families are also allowed to touch the coffin where the body of their deceased loved ones has been placed. “These are examples of the negotiations that ensure that burial is safe from our perspective and dignified from the perspective of the family,” said Capobianco.
The report says the DRC’s Ministry of Health, which has been leading the Ebola response, is aware of the calls for more community engagement by the different humanitarian agencies. But the situation is “tricky,” ministry spokesperson Ilunga said.
One issue is that humanitarian organisations – NGOs and UN agencies alike – employ different types of approaches but don’t coordinate in their community engagement efforts, creating confusion in the communities, she said.
“One feedback that came back quite often from the community is they said that the messages were too, how can I say? They said it was too confusing because different people will come around … talking about Ebola but not the same way, not the same messages. And that comes actually from … the way humanitarian actors work in the field in general because in general they don’t necessarily collaborate much,” Ilunga explained.
“That’s one of the reasons David Gressly was also appointed. It was to bring more cohesion and more coherence to the way humanitarian actors interact with each other, but also with the government and the community,” she said, referring to the newly appointed UN emergency Ebola response co-ordinator.
The report says one difficulty relates to the weak traditional community structures within the communities. Normally, responders would be talking with the village chief who can advise them who to talk to and what they need to do. But in North Kivu, Ilunga said the community dynamics are completely different. A street chief or street leader they may be working with may not command as much respect or influence in a community.
They’ve also had issues with hiring because of this weakened community structures. There are about 3,000 people working on the response under the ministry’s direction, the majority of whom are hired locally, with only an estimated 100 to 150 coming from the capital Kinshasa, Ilunga said. Because traditional social structures are not in place, she said the ministry devised an incentive to get more local people to be part of the response by paying them on a daily basis, with some paid a minimum of $5 to $10 a day.
But that has created social tensions. The report says in a region with high unemployment, the response has been seen as a huge employment opportunity, which means sometimes people will pretend to be from one area when in reality they come from a different neighbourhood, Ilunga said. “But we don’t know that. We work with the fact that, OK, they were recommended by local authorities,” she said, noting that without a national ID system it is hard to verify where people are from.
According to the report, some NGOs said the coordination in the response has not been very inclusive, with some of them raising issues of their involvement in coordination meetings. For example, IRC, which has been working on infection prevention and control, said they were not included in coordination forums for the first seven to eight months of the response. That changed six to seven weeks ago, when they were invited to participate in a coordination meeting in Goma. NGOs have also been invited to some coordination meetings in Butembo.
But now the meetings take place so frequently and in different locations, it strains responders’ capacity, Riebl said. For most NGOs, he said, it’s difficult for senior staff to meet in multiple locations without disrupting their operations.
The report says in previous outbreaks, the Health Ministry has only worked with specialised medical NGOs including Médecins Sans Frontières, the Alliance for International Medical Action, and International Medical Corps, given the specific expertise they bring to the table. But in the current outbreak, Ilunga said the ministry was faced with collaborating with several other NGOs, some “with no specific expertise, to be truly honest, wanting to be involved. And it’s not a bad thing. It’s a good thing to see that people want to engage and want to help out,” she said.
“What has been tricky I think even for them, was to find a place in the response, because the way the response is organised is it’s organised in different pillars with a specific expertise and they didn’t actually all have this expertise. So that’s how most of NGOs end up being involved in community engagement, because that’s the easiest thing they can do,” she said.
She said that doesn’t mean they are not valuable to the response, and that the ministry has tried to be as “inclusive as we can.” “We say every partner that has an expertise in one or several of (the response) pillars can be part of the working group. And so, coordination meetings are open to any organisation that is involved,” she said. “But like we said, the Health Ministry has always been very clear about … that Ebola was first and foremost a health issue. But then of course, considering the context, we need to take into consideration the other aspects.”
The report says UNICEF’s Colorado understands some of the frustration to date on the effectiveness of the coordination of the response, and that some NGOs wanted a separate coordination system similar to during a humanitarian response, but he said since the outbreak is a public health emergency, coordination is led by the government.
“At the end of the day, the outbreak is coordinated by ministry colleagues. So, I understand that that may create a frustration, but (we don’t want to) supplant the government on those key positions. We are there supporting the government,” he said.
WHO director-general Tedros Adhanom Ghebreyesus meets regularly with NGOs in DRC, said Harris. A number of them have his phone number or chat with him on WhatsApp. But she said WHO and other response partners are aware that some NGOs wanted to be further involved in coordination. “We welcome this and continue to strive to ensure that all who wish to contribute practically to ending this outbreak can do so,” she said.
The activation of the system-wide scale-up of the protocol of the control of infectious diseases at the end of May helped improve coordination, appearing to clarify the roles and responsibilities of the different actors responding on the ground, NGO representatives said.
Mercy Corps’ Elmer is quoted in the report as saying in mid-June that “there has been a lot of confusion and a lot of inefficiencies around how things have been coordinated,” but more recently said they are seeing “positive steps on changes to the overall coordination of the response.”
Much of the improvements have been attributed to Gressly’s appointment in May as the UN Ebola response coordinator. He has created two new forums that are welcomed by humanitarian organisations. One is an Ebola emergency response team, which met for the first time 28 June and is open for all humanitarian groups involved in the response. The second is the partners coordination forum, which is also open for NGOs to participate in, even via conference call, Riebl said. “It’s something that we think is healthy because it’s once a week. So, we can actually plan our calendar,” he said.
Tim Ziemer, senior deputy assistant administrator at the US Agency for International Development said that “there has been a less than optimum engagement of the NGOs” in the response. He also said there is a need to “reset leadership and coordination” in the Ebola response and “take it out of the hands of the WHO,” which some believe to have been stretched thin in the response, having taken various roles in the response besides providing technical expertise.
Asked whether there will be changes in WHO’s role with Gressly on board, Harris said “WHO will continue to play a strong technical and operational role,” and will continue to be the lead agency for the public health response.
“We welcome the UN coordinated strengthening of the response – indeed, it is something we asked for. This will allow WHO to focus on the health response while others focus on their areas of expertise, and allow the response to go to the scale required whilst playing to the strengths of partners,” she wrote.
The DRC recorded at least 51 new cases of the Ebola virus since the beginning of last week, while two screening tents in Kasese, a Ugandan village that shares a border with the DRC, were burned after Ugandan workers detected a high fever in a Congolese boy trying to gain entry into Uganda.
Since the outbreak started nearly a year ago in North Kivu and Ituri provinces, DRC, neighbouring countries have screened travellers through hundreds of points-of-entry (POE) screening sites.
On 3 July, officials said the fires started after a teenage boy entering Uganda from the DRC tested positive for a high fever and was taken to a hospital in DRC.
In June, Uganda confirmed two cases of Ebola in a Congolese family that had travelled back and forth between the two countries to attend an Ebola victim’s funeral. Since then, Uganda has increased border surveillance.
In a new update on the outbreak, the WHO said no new cases of Ebola had been detected in Uganda among case contacts. “As of 26 June, 108 exposed contacts were identified, and they are in the process of completing the 21-day follow-up period. Contacts are visited daily for 21 days until the last contact completes follow-up on 3 July. All contacts remain asymptomatic to date,” the WHO said.
According to the WHO’s online Ebola dashboard, the DRC will likely confirm 7 new cases, raising the total to 2,389. Officials said earlier there were 1,606 deaths and 420 suspected cases were still under investigation.
Mabalako, Mandima, and Beni remain the most active virus hotspots, with Mabalako recording 30% of new cases in the last 3 weeks, and Beni recording 27%, according to the WHO.
The DRC also said that a vaccinated health worker in Beni was diagnosed as having the virus, raising the total number of health workers infected in this outbreak to 128, including 40 deaths.
Vaccination with Merck’s rVSV-ZEBOV continues throughout the outbreak regions, and 150,566 people had been vaccinated.