On May 8, the Democratic Republic of Congo made an announcement, one they had made six times prior since 1976. Ebola, the rare but deadly hemorrhagic fever virus, had returned. Alarm bells rang and local practitioners quickly rallied together to alert international health organizations. Just two years earlier Congo was at the center of the world’s deadliest Ebola epidemic on record, one responsible for the death of over 11,000 people worldwide, a fact almost certainly on their minds. Fearing for the worst, aid workers poured in from around the world and offered support. Miraculously, just 42 days later, the last case of Ebola was eliminated from the country. In total, four people died. To many, the exceptional containment strategy appeared a momentous turning point in the fight against infectious disease in developing countries.
That reprieve was short lived.
Seven days after the last Ebola case received treatment, a new outbreak appeared across the country. That outbreak, now 77 days since first reported contact, still plagues the Congo and all signs point to it getting worse. The World Health Organization classified the outbreak as “high risk,” leading many to fear the virus may soon jump borders into neighboring Uganda or South Sudan. Late last week, with death tolls surging past 200, the country’s Minister of Public Health, visibly fatigued, released a statement: Congo, which had just fought off the virus, now faces the worst outbreak in it’s recorded history.
So what happened? How did a story of medical and community triumph yield to yet another outbreak in such a short period of time?
Tech and Communication Can Beat Ebola
The summer success story owes itself to three main factors: scientific development, improved detection, and intervention readiness.
Scott Dowel, who serves as the Deputy Director for Surveillance and Epidemiology at the Bill and Melinda Gates Foundation, said the successful containment began with effective surveillance and disease detection methods. Dowel assisted aid workers on the ground during the outbreak this summer and told me over the phone that discovering the disease early made a dramatic difference. By isolating infected people — who aid workers refer to as “contacts” — before the virus matures, workers can limit the possibility of the virus spreading throughout the community. New testing technologies have fundamentally reduced these detection times. One of these testing devices, called GeneXpert, has shortened the time it takes to diagnose Ebola from days or weeks to hours.
Rapid containment of the virus this summer proved how relatively low-tech solutions, when coordinated properly, can produce momentous results. Dr. Ray Arthur, who leads the Center for Disease Control’s Global Disease Detections Operations explained to me that finding and containing Ebola relies on a process called, “contact tracing.” This involves aid workers individually interviewing every person with a confirmed Ebola case as well as everyone living near the patient. Each one of those contacts is then visited daily for Ebola’s twenty-one-day incubation period before they are cleared. Isolating those stricken with Ebola early on is imperative, Arthur said, because the virus grows more contagious the longer someone has it. By the time a victim dies from Ebola, Arthur said, the corpse “is literally teeming with the virus.”
The containment plan spearheaded by the CDC relied heavily on the vast dissemination of accurate, targeted information and an understanding of local cultural norms. Arthur, who has assisted in containment efforts on the ground, explained the importance of involving local communities in this process.
Part of the CDC’s community outreach involves what Arthur called, “knowledge attitudes and practices surveys.” These questionnaires ask community members specific questions on where one goes to receive health care and which members of the community they most trust. Once they collect a sufficient data set, the CDC uses those responses to create outreach programs with language and topics geared specifically towards individual communities. Somewhat similar to a targeted advertisement online, these messages are more easily acceptable and play a part in building trust between local communities and foreign aid workers. Those targeted questions are spread in person, (through government leaders, religious leaders and tribal leaders) and massively through DRC’s most used communication vehicle: radio.
Healthcare practitioners also encourage people to come forward through monetary incentives. During the summer outbreak, Arthur said clinics would offer small monetary awards for people offering information on a potential victim. While this led to many false positives, Arthur sees that as a better alternative than less people coming forward.
Possibly the most important advancement in the fight against Ebola came from the development and deployment of viable vaccines. One of the vaccines, researched and tested by the National Institute of Health and distributed by the World Health Organization, has been in development since 2014. Over a phone call, Director Anthony Fauci acknowledged that while it’s difficult to definitively determine the vaccine’s exact effectiveness, they believe it has had a significant effect. Many experts believe the wide distribution of these vaccines played a significant role in protecting people in close proximity to those with Ebola, as well as aid workers, who are often the most likely to contract Ebola when treating patients.
Dowel was on the ground assisting vaccine distribution in Mbanka for the Gates Foundation and said he remembers lines of people, men and women of all ages, snaking around homes of initial contacts, eager to receive vaccines. Dowel said the vaccine helped not just through its effectiveness but because it also allowed aid workers to enter an area offering a physical, tangible solution.
Thanks to the vaccine and rapid effective detection technologies, Congo managed to limit the outbreak to 54 cases. In Mbandaka, a dense urban city housing over 1.2 million Congolese, that number could have been devastatingly high.
That optimism soon changed.
A Bug in the War
The DRC was Ebola free for only one week. On August 1, DRC’s health minister confirmed a new outbreak of Ebola 780 miles away — this time, in the North Kivu province. While the virus is genetically identical, the Centers for Disease Control believes the two outbreaks matured independently of one another. Unlike the previous outbreak, the new case of Ebola spread quickly, with 319 cases reported and over 200 deaths. Also unlike before, this outbreak takes place in the middle of a densely populated urban area, rife with warring militias.
Over 70 militias have been engaged in constant armed skirmishes with the Congolese military, generally referred to as the Kivu conflict, dating back to 2004. At least 250 civilians have been killed by armed forces, since the outbreak began, making safe and dignified burials (crucial for containing the virus) even more difficult. Technology and communication defeated Ebola, but war has brought it back. It’s because of these reasons that DRC Health Minister Oly Ilunga Kalenga calls the outbreak “the world’s most complex epidemic.”
While Arthur and Dowel emphasized the strategy for Ebola containment is relatively straightforward, armed conflict besieging the current outbreak area has completely thrown a wrench in the process. The constant threat of gunfire from warring militia groups prevents some health care workers from interviewing contacts and similarly dissuades nervous civilians from coming forward to identify themselves. The contract tracing method used is like the foundation of a house. Once it fails, other intervention attempts are mere patchwork preparing for an inevitable collapse.
The outbreak’s positioning in the middle of a conflict zone represents the greatest challenge for healthcare workers attempting to treat the virus, according to Arthur.
“It’s a risk to staff in the field working,” he said. “There have been situations where everything stops and then you lose the ability to get out and see the contacts.”
To operate effectively, aid workers operate on trust — a rare commodity in the midst of a warzone. Despite numerous CDC led initiatives to improve communication, Arthur said the climate remains tense. Rumors, both intentionally crafted by militia members to sway public opinion, and unintentionally spread as misinformation, make matters worse. Some of the worst of these false rumors accuses western aid workers of purposely spreading the virus themselves, and most egregiously, of harvesting organs.
Distrust of western intervention manifests itself through degrees of violence. Aid workers have had vehicles attacked, and windows broken. Some, Arthur said, have had their bodies pelted with rocks. In cases where armed militias intervene, the resistance turns deadly.
Last month, a group of unarmed aid workers traveling with the Congolese army’s rapid intervention team were ambushed. Members of the Mai Mai militia — one of several factions contesting Congo’s northeast regions — emerged from the dense forest. Two aid workers were killed. The attack highlights the constant threat of danger with which healthcare workers operate.
“If the current trajectory doesn’t change, I don’t see an end to this outbreak.”
The conflict also mutes some of the gains the vaccine procured. Arthur estimates that over 21,000 Congolese have received the vaccine, but many who need it most are displaced by fighters or feel unsafe traveling to clinics to receive treatment.
Fuci of the NIH added similar sentiments. “Given the security problem, we are not able to vaccinate all the people that should be vaccinated,” he said.
All these harsh realities, when combined, point to a situation made ever more tragic due to its preventability. The disease killing hundreds and infecting hundreds more, does not have the ability to do so because of some unforeseen, unsolvable medical mystery. The technological tools and human willpower to fight back exits, yet they are stymied by the human propensity for war. While many of the militia's contributing to the conflict surely do so with legitimate and significant grievances levied towards the DRC government, Ebola cares little for these particularities. Under the surface the virus persists, and continues to kill indiscriminately, infecting all regardless of one’s faction or innocence.
Worse still, without a major shift, experts predict the outbreak will worsen. The DRC is nestled geographically next to South Sudan, Rwanda, and Tanzania. If the disease were to jump borders, experts told me these countries would be even less prepared to deal with the disease than the DRC, regardless of military conflict. From there, the the threat for a global event mirroring that of 2016 starts to seem much more plausible.
“If the current trajectory doesn’t change, I don’t see an end to this outbreak,” Arthur said. “One of the major concerns is if it gets into Butembo, there is going to be a much bigger problem.” Dowell shared similar concerns. “I think things could easily get worse before they get better.”