In the week since the Democratic Republic of the Congo declared a new Ebola outbreak, health officials have set in motion a plan to distribute an experimental vaccine, logistics experts have established an airbridge to ferry responders and equipment into the epicenter, and the director-general of the World Health Organization has flown in from Geneva to take stock.
It has been an extraordinarily rapid response — and a far cry from the tragically slow reaction by the global community following the West African Ebola outbreak that began in 2014.
“I think the response so far has been impressive,” said Tom Inglesby, director of the Center for Health Security at Johns Hopkins Bloomberg School of Health.
Inglesby said the early engagement of many partners — the Wellcome Trust has already committed funds; Doctors Without Borders is setting up treatment facilities; Gavi, the Vaccine Alliance has agreed to finance the vaccination efforts — suggests health experts across different organization are coordinating well.
“The speed with which they’re doing it and the apparent coordination on a rapid pace seems to be different than in the past,” he said.
At the center of the response is the WHO. Many longtime observers say it is too soon to conclude that the beleaguered agency has ironed out all its emergency response problems — even if the initial steps it has taken are encouraging.
Ron Klain, who served as President Obama’s Ebola czar during the West African outbreak and who has been critical of the WHO, is among those urging a wait-and-see approach. He cautioned that the early days after an Ebola outbreak is declared are plagued by misinformation and too little information. Figuring out what is happening takes some time.
“In every kind of incident like this, there’s just a lot of confusion at first. What the facts really are. Where is this disease? How long has it been there?” Klain warned. “Until that sorts out a bit, it’s also premature to make conclusions about how well we’re doing.”
In the meantime, Klain suggested there’s no room for complacency. “I just think vigilance is the most important thing — and a little humility,” he told STAT. “And not too much ‘Hey, it’s all great!’ Because we don’t know if it’s all great or not.”
The outbreak is in the western part of DRC, in Equateur province. As of Tuesday the WHO estimated there have been 41 cases, three of them health care workers. Of the confirmed, probable, and suspected cases, at least 19 have died, including one of the health workers.
Cases have been identified in three locations that are miles apart — in a region of the world where roads are poor and traveling 100 miles can take half a day or longer.
On Monday the WHO reported there are two probable cases in a village called Wangata. It borders on the Equateur capital, Mbandaka, which is home to 1.2 million people. Both are situated on the Congo River.
The epicenter of the outbreak is Bikoro, a town about 175 miles south of Mbandaka. Bikoro, too, is a port, on a lake that feeds into the Congo and Ubangi rivers. Those two major water highways link the outbreak zone to the capitals of DRC and the Republic of the Congo to the south and the capital of the Central African Republic to the north.
The combined population of those capitals — Kinshasa, Brazzaville, and Bangui respectively — exceeds 14 million people.
That sobering geography has ignited fears that this outbreak could again see Ebola racing through crowded African cities, as it did during the West African outbreak. The WHO warned of the potential for urban spread almost immediately after DRC sounded its alarm, and that concern is clearly fueling the urgency behind this response.
That is headway, Klain conceded. “No one’s being complacent, no one’s just assuming that it will go away on its own, no one’s assuming it’s going to be small. That by itself is progress. No question about that,” he said.
Ashish Jha, a global health expert who served as co-chair of an independent panel that analyzed the WHO’s response to the West African Ebola crisis, shares Klain’s view that it is too soon to know if the early and positive optics are indications that the WHO has fundamentally changed its approach to disease events like this.
His question: Is this a one-time fix or evidence of systematic change at the WHO?
So far, he sees developments like the weekend visit to Bikoro by WHO Director-General Tedros Adhanom Ghebreyesus and Peter Salama, who runs the WHO’s emergency response operations, as symbolic rather than substantive.
“I believe in symbolism, so I think the symbolism was good. But I’m not sure it tells me a lot about how much better prepared we are, and how much more effective WHO’s response is going to be,” said Jha, the director of the Harvard Global Health Institute.
“As long as we’re doing the work of actually building up an effective response system, then I think this is fine, this is good. I just want to make sure that we don’t confuse this for that,” he said.
David Fidler, an adjunct senior fellow on cybersecurity and global health at the Council on Foreign Relations, said he, too, is holding off on drawing too many conclusions.
“We have seen in the past accolades for WHO appearing to learn the lessons from past outbreaks and mistakes. And then things fall apart again,” said Fidler, who is also a professor of global health law at Indiana University.
“That’s the story of the 2014 Ebola disaster — all the lessons WHO and countries supposedly learned were not in fact learned. This one in the DRC just doesn’t feel enough to pat the WHO on the back yet,” he said.
Klain worries about what he calls “the execution gap.”
“I do think there is always, always a gap between public statements and declarations that things are going to be done and then actually those things happening,” he said.
How big that gap will be in this outbreak remains to be seen.
But for now, there are at least some reasons to take heart, said Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University.
“Tedros seems to be right on top of it. He’s been responding publicly almost daily on his Twitter feed and elsewhere,” Gostin said. “The tone is right. He’s partnered right away with the ministry of health and with other international organizations and has been responsive.”
The timing of the outbreak may be added motivation for the WHO to move quickly. Next Monday is the start of the World Health Assembly, the WHO’s annual general meeting. It will be Tedros’ first as director-general, and he and the agency are being closely watched.
In an interview from Kinshasa on Sunday, the director-general noted he and his team had planned to use the past weekend to prepare for the World Health Assembly. Instead, he flew to DRC on Friday night, flying back to Geneva on Sunday night.
Inglesby said delegations to the assembly will be looking for assurances that the WHO is on top of this outbreak.
“I think everyone will be watching. I’m sure it will be very important for WHO to report on exactly what their risk assessment is, what they’ve been able to do in the last 10 days since this all was uncovered, and to report to WHA,” he said.