The Ebola outbreak raging in the Democratic Republic of the Congo, where health workers are under attack, is challenging the globe’s capacity to respond. It is also calling into question whether the use of a major weapon intended to address such health crises might be futile in this case.
Despite the gravity of the situation, the North Kivu outbreak hasn’t been declared a public health emergency of international concern — a PHEIC in global health parlance. That fact has frustrated some health security experts, who insist it’s long past time to proclaim an international emergency.
Other experts argue, however, that labeling this outbreak a global health crisis would not help to halt spread of Ebola in the region. They worry that it could even make an already perilous situation worse.
“I do not see what a PHEIC is going to add,” said Ilona Kickbusch, director of the global health center at the Graduate Institute of International Development Studies in Geneva.
“If you say it’s supposed to trigger a call to action and international attention, that’s already happening. If it’s supposed to trigger coordination, that’s already happening. If it’s supposed to trigger international response and monies, that’s already happening,” Kickbusch said. “There’s not enough money … but that, per se, is not going to resolve the problem. You don’t stop a war with money.”
The outbreak, which likely began in late April of 2018, was recognized as Ebola in late July. On Aug. 1 the World Health Organization declared that an outbreak in North Kivu was underway.
In the intervening months, the Congolese health ministry, the WHO, and a range of NGO partners have struggled to stop the spread of the virus. Their efforts have been hamstrung by the fact that this outbreak is occurring in a highly populous part of the country that has been a conflict zone for decades.
As of Sunday, there had been 1,705 cases and more than 1,124 deaths, making this the second-largest Ebola outbreak on record.
In the autumn, response teams found themselves caught in the crossfire when insurgents attacked government forces or United Nations peacekeepers in the region. But in recent months, the Ebola response workers have been the target of repeated violent aggression; at least three health workers have been killed.
The response is the subject of dangerous rumors spread on social media — that Ebola doesn’t exist, or that the response workers brought it to the region. In recent days pamphlets have been disseminated giving the response workers an ultimatum: Stop the epidemic and leave the region within days, or else.
Twice Tedros Adhanom Ghebreyesus, director-general of the WHO, has convened a meeting of outside experts to advise him on whether the outbreak should be declared a PHEIC. Both times, in October and again in April, the so-called emergency committee has concluded that the epidemic, while highly concerning, is not a global health emergency. That decision was based on the fact that, so far, the disease has not spread across Congo’s borders to start transmission in neighboring countries.
Tedros, as the WHO director general is called, has heeded the advice against the declaration of an emergency.
The chairman of the emergency committee convened in April, Dr. Robert Steffen, acknowledged at a press conference at the time that the WHO is having trouble raising money to finance the outbreak response, and declaring a PHEIC might open additional pockets.
But Steffen said that’s not a good enough reason to declare an emergency. “It would be not appropriate to declare a PHEIC just to generate funds,” he said.
More funds and more responders might actually increase the danger, said Dr. Jeremy Farrar, director of the Wellcome Trust. Already some of the violence has been motivated by money, with some people complaining that the WHO is actually profiting from the outbreak.
“Having a lot of non-North Kivu, non-DRC other nationalities — at the moment I think that could easily inflame the situation and it could get completely out of control from a violence perspective,” Farrar said.
The region is rife with armed militia groups, some of which finance their operations by kidnapping aid workers for ransom. “The more money, the more kidnapping possibilities,” he said. “You could make the situation significantly worse.”
Farrar acknowledged that if the choice had been his, he probably would have declared this outbreak a public health emergency, but he doesn’t think it would make a material difference on the ground.
“I think it’s a bit of a red herring in a way,” he said.
Another problem with declaring a PHEIC has been seen in other instances where the tool was used. The International Health Regulations — a treaty designed to combat health threats — stipulate that countries should not penalize nations that disclose they have a dangerous disease outbreak by imposing travel or trade restrictions on the affected country. In reality, many have used the declaration of a PHEIC to do just that.
Many countries cut off visas for people from Liberia, Guinea, and Sierra Leone during the 2014-2016 West African Ebola crisis. A number of international airlines stopped flights to those countries, making it much more difficult for response workers and crucial supplies to get into the region. That could happen again.
“The main challenges on the ground are the insecurity and the community reluctance, fueled by conspiracy theories. A PHEIC declaration will not change that; it’s not a magic wand,” said Dr. Preben Aavitsland, Norway’s former state epidemiologist, who was among the experts who drafted a revision of the International Health Regulations in 2005 that created the PHEIC instrument.
“We know all too well the probable side effects of a PHEIC declaration: unfounded travel and trade restrictions. This may both hamper the response work and severely affect the local economy, thus increasing the community resistance,” said Aavitsland. He was a member of the WHO’s Ebola emergency committee that met in April, but said the views he shared with STAT were his own.
David Fidler, director of the Center on American and Global Security at Indiana University, said he believes it is inappropriate to hold off declaring a PHEIC because of fears of it might turn out to be unhelpful or counterproductive.
“Those concepts are highly subjective and not clearly anchored in public health principles and scientific data — the things at the heart of what a PHEIC analysis under the [International Health Regulations] is to be,” Fidler said.
He, too, suspects declaring this outbreak a global health crisis would not solve the problem. But he is concerned the debate over whether to declare a PHEIC in this case is undercutting the credibility of the tool.
“In this outbreak, we have seen this massive gap between experts dismissing its relevance and other experts insisting that calling a PHEIC is critical to managing this outbreak,” Fidler said. “This controversy has the potential to bring the PHEIC power, and the IHR more generally, into disrepute.”
Kickbusch agreed some clarification or shoring up of the International Health Regulations and the PHEIC tool is needed, but now is not the time to undertake that work.
“In the present political situation, I don’t think anyone should reopen any international document at all,” she said. “It’s much, much too risky.”