The Ebola outbreak in the Democratic Republic of the Congo still does not warrant the declaration of a global health emergency, the World Health Organization said Friday — a decision that is sure to trigger substantial debate as the virus continues to spread unabated.
The case count in the 8-month-old Ebola outbreak, already the second largest on record, topped 1,200 on Thursday and has surged by double digits most days over the past two weeks — a far faster rate than earlier in the epidemic.
The decision was made by WHO Director-General Tedros Adhanom Ghebreyesus on the basis of a recommendation by a committee of outside experts that has now concluded twice that the outbreak does not warrant an emergency declaration.
“I have accepted their advice,” Tedros, as he is known, said during a news conference in Geneva.
The panel’s chairman, Robert Steffen, said declaring an emergency would provide no added benefit given that the WHO was already receiving significant support for the effort to control the outbreak.
He acknowledged, though, that the committee was concerned by the recent spike in cases.
“But … there is an explanation for these rising numbers,” Steffen said, noting that the new cases are concentrated in or originating from Katwa and Butembo, where the outbreak response teams have had difficulty gaining the cooperation of the communities. “There was turmoil in these areas, which were just not accessible for a certain period of time.”
Given the success the response has achieved stopping transmission chains elsewhere, “we are moderately optimistic that this outbreak can be brought into control. Not immediately, but still within a foreseeable time,” Steffen said.
Declaring a public health emergency of international concern — called a PHEIC for short — would raise the level attention it receives from the WHO’s member countries. It would also likely increase the amount of human and financial resources that countries are willing to contribute to the effort to stop the outbreak.
Tom Inglesby, director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, disagreed with the call.
“I do think it’s a mistake. I do think conditions have been met for declaring it. It’s at least as serious as public health emergencies of international concern that have been declared so in the past,” Inglesby told STAT. “And I think it’s a mistake because I think it could have drawn in more international attention, political will and support.”
More must be done to contain this outbreak, he insisted.
“It needs to be made clear to all those who are involved that the current course that we’re on, despite the resources being brought to bear, despite WHO being completely in and flat out, it’s not enough,” Inglesby said.
The WHO, which along with DRC’s ministry of health is leading the outbreak response, has been under pressure for some time to declare a PHEIC, which is a tool of the International Health Regulations, a treaty to which WHO’s member states are party. Its first decision not to do so came in October.
David Fidler, a professor of global health law at Indiana University’s Maurer School of Law, warned that such a declaration would not on its own change the trajectory of this outbreak.
“It’s not a Harry Potter wand,” Fidler said. “We need to be honest here. The IHR were not designed to deal with this. WHO is not equipped to deal with this.”
Fidler was referring to the fact that the outbreak is occurring in what is effectively a war zone. Multiple armed factions have been fighting the Congolese army for years. A United Nations peacekeeping operation has been in the region for the past two decades.
The danger in the affected region has meant some countries — including the United States — have declined to send personnel to the outbreak zone to help. Highly experienced experts from the Centers for Disease Control and Prevention, for instance, have been barred from working at the epicenter of the outbreak.
Attacks against government and UN forces hindered the containment effort throughout the fall. Every time there was a major violent event, a spike in Ebola cases would follow. But in late February, the violence took a frightening turn, with armed attackers firebombing Ebola treatment centers in areas where transmission of the virus is most intense.
Suddenly a containment effort that had been making real progress saw gains evaporate. Doctors Without Borders, which had been operating the two treatment centers, withdrew its staff, saying it could not ensure their safety. Both centers have been rebuilt and are being operated by the ministry of health and the WHO.
Dr. Tom Frieden, who was CDC director during the gargantuan West African Ebola outbreak of 2014-2016, said he recently met with someone who has worked on the current response; the person told him of being shot at while in the field.
“It’s very hard to control disease when you’re shot at,” said Frieden, who is now president and CEO of Resolve to Save Lives, an initiative of nongovernmental organization Vital Strategies.
Frieden said controlling this outbreak will be very difficult. And he acknowledged there is real concern it could spread further, for instance into Goma, a city of 1 million people. Goma is a regional transportation hub that sits on Congo’s border with Rwanda. The concern has long been that if the virus starts to spread in Goma the risk that cases will be exported to other countries will rise significantly.
“Urban Ebola is a very different animal. Urban Ebola is very, very difficult to control,” Frieden warned.