The decision to declare the yearlong Ebola outbreak in the Democratic Republic of the Congo as a public health emergency of international concern (PHEIC) will almost certainly help focus the world’s attention on this deepening crisis. But while it is already bringing much-needed donor funds and international assistance, the danger is that this decision could have unintended repercussions that further hinder the emergency response on the ground.
If this gamble is to be successful, then the response will need to go beyond the immediate Ebola crisis and address much deeper long-term issues that have plagued the region — issues that ultimately created this situation in the first place. Because in truth it is not just Ebola, but more broadly the situation in the DRC itself, that represents a public health emergency, and one that really should be of international concern.
On the need to end this outbreak, there is no question: It has already infected 2,600 people, killing 1,700 of them. In terms of severity and size, this outbreak is second only to the West African epidemic of 2014. And if you take into account the challenges in trying to contain it, and the fact that it would be unimaginably worse if we didn’t now have an effective vaccine against the Ebola virus, then this is arguably the worst and certainly the toughest outbreak ever, with no clear end in sight.
But Ebola is not the only epidemic the country is experiencing, nor is it the most deadly. Some of the same challenges — poor infrastructure and weak health systems — have led to a measles outbreak that is currently sweeping across most of the country. Since January, there have been more than 100,000 measles cases in 23 of the country’s 26 provinces, resulting in more than 2,000 deaths. This constitutes a 700% increase compared to the previous year.
Over the same period there have been more than 13,400 suspected cases of cholera, and 266 deaths, leading to emergency vaccination of more than 1.2 million people. There have also been five separate outbreaks of vaccine-derived poliovirus ongoing across seven provinces, a signal of low polio vaccination rates.
All of this represents the clearest indication that public health in the DRC is in a state of emergency.
While poor infrastructure and weak health systems present challenges with Ebola, the lack of security is often cited as the main reason why the number of cases continues to rise. With regular attacks on health care workers and treatment centers by armed individuals, it’s easy to see why. Since January there have been around 200 of these attacks, with five deaths and 58 injuries, as well as facilities burned to the ground. This is particularly tragic because frontline health workers have historically been at high risk of becoming infected with Ebola. Now, even though we have a means to protect them — more than 34,000 health workers, volunteers, and contact tracers have been given a vaccine that is 97% effective — they are still having to risk their lives.
It’s easy to put these attacks down as a consequence of the enduring conflicts in the affected areas. But this is not normal. For the last century, even in the most bitter conflicts, such as Sri Lanka’s brutal civil war, there has been a tradition of opposing military forces allowing essential medical supplies and support to reach people on both sides.
In the DRC, this is not about conflict, it is about an inherent mistrust and suspicion of the government and any outside influence. If an Ebola emergency response plan is to be effective, it will need to take this into account.
This is one reason why calling a PHEIC declaration in the DRC is so tricky. By definition, it is supposed to signal an international threat. And given the geography of this outbreak, with nearby porous trading borders with Uganda, South Sudan, and Rwanda, there is a genuine risk of the virus spreading to these countries. There have already been three Ebola cases in Uganda and an infected man recently reached the heavily populated Congolese city of Goma, just one kilometer from Rwanda.
As important as it is to stop the outbreak from spreading to other countries, it is equally important that part of the response involves building trust within the affected communities, to ensure that efforts are not perceived by locals as being undertaken merely to protect others, and then leaving once the job is done. This can be achieved by ensuring there is local engagement and leadership in the response, and by making sure that in addition to tackling the virus there is as much focus on strengthening health systems in affected areas and building strong and sustainable primary health care to address the broader health issues these communities face.
This week I have traveled to Goma to discuss with the DRC government and other partners how Gavi, the organization I lead, can help them do this better.
One way would be to ensure that the Ebola response is aligned with other initiatives aimed at addressing broader health issues, such as the Mashako Plan. Created last year, it will enable 220,000 more children in the DRC to be protected against preventable infectious disease through increased access to vaccines, improved monitoring and inspection of health zones, and more coordinated health financing.
By working through this sort of government-led initiative and with the support of President Tshisekedi, it may possible to begin to rebuild trust and halt the epidemic, while reducing outbreaks of other infectious disease and improving disease surveillance at the same time.
If we are to stop this epidemic and prevent future ones from spiraling out of control, then we need to recognize that this Ebola outbreak should not be viewed in isolation, but must be seen as a symptom of a deeper public health crisis.
Seth Berkley, M.D., is the CEO of Gavi, the Vaccine Alliance.