If the Democratic Republic of the Congo truly wants to break free of Ebola, it should focus on the people who survived its 10th and most recent Ebola outbreak — the second largest the world has ever seen.
And it must act quickly: Although the World Health Organization declared on June 25 that the DRC’s latest Ebola outbreak had ended, the 11th has begun. More than 60 cases have been confirmed in western DRC in recent weeks, which means the disease is not under control.
The 10th outbreak, which began in North Kivu, was officially declared on Aug. 1, 2018. According to the WHO, it killed 2,287 people. The 1,171 survivors could hold the key to preventing another outbreak, but the DRC needs to develop a program for systematically screening, testing, and supporting them. A survivor program established in Liberia following the end of its devastating Ebola outbreak in 2016 shows the importance of focusing on this group.
During the Ebola outbreak in West Africa between 2014 and 2016, 28,600 people were infected with the Ebola virus and 11,325 died. I was Liberia’s assistant minister of health when the epidemic broke out and led the country’s Ebola response, including establishing its Ebola survivor program. (Later, as deputy health minister, I expanded the program.) The program had two overarching two goals: stopping human transmission to prevent the next outbreak and providing survivors with desperately needed support.
Although sexual transmission of the Ebola virus is uncommon, it can be transmitted through semen up to 199 days post-recovery. That meant several thousand men could have been spreading the disease for months after recovery. At the time, Liberia had no way of testing semen.
In 2016, we launched a comprehensive program that provided health services for Ebola survivors and a screening program for men that included semen testing, counseling about reducing sexual risk, and the provision of free condoms. We also set up routine Ebola screening in hundreds of health care facilities within Liberia’s borders, as well as in neighboring Guinea and Sierra Leone, which had also been hard hit by the outbreak. Routine screening continues.
Shortly after Liberia was declared Ebola free, five flare-ups in West Africa’s three most affected countries — Guinea, Liberia, and Sierra Leone — were directly or indirectly linked to sexual transmission. These cases were quickly detected by Liberia’s disease surveillance program and semen screening, preventing the flare-ups from turning into widespread outbreaks. Liberia remains Ebola free, due in large part to its comprehensive survivor program and active surveillance.
Survivors pose no threats to their communities once they test negative, but they need support. As we are beginning to see with Covid-19, survivors often face chronic health issues. Many Ebola survivors experience fatigue, headaches, muscle and joint pain, eye and vision problems, and loss of appetite. Less commonly reported problems include memory loss, swollen neck, hearing loss, inflamed heart tissue, depression, anxiety, and post-traumatic stress disorder.
People who survive Ebola also face other types of challenges: stigma, discrimination, grief if family members have died, survivors’ guilt that they didn’t die, unemployment, and the loss of personal possessions that were taken away or burned. Survivors often find it difficult to reintegrate fully into their communities, where they may be treated as if they still carry the virus in their blood.
Liberia’s survivor program supported recovery and reintegration into the community, built community trust, and provided care for those affected beyond the emergency period. What Ebola survivors most needed was the commitment to uphold their human rights and guarantee them access to essential medical and social services. The program provided job opportunities in Ebola research activities and as Ebola case finders. It also provided mental health counseling, routine health care, and specialized eye care that were integrated into the country’s hospitals.
The DRC faces many challenges to implementing a similar program, including political disarray, continued violence, and lack of funding. And it may have to do this on its own, since international partners often pack up and leave after an outbreak is declared over.
Fortunately, that didn’t happen in Liberia. After the outbreak ended in 2016, the country received critical international support. The U.S. National Institutes of Health sent ophthalmologists to treat uveitis and other eye issues that Ebola survivors commonly experience. Those NIH ophthalmologists also trained a cohort of local physicians to treat eye diseases, which they continue to do. The WHO, the United States Agency for International Development, and the U.S. Centers for Disease Control and Prevention all provided financial or technical support, while the National Public Health Institute of Liberia and the Ministry of Health jointly implemented the programs.
It is vital for these international partners to do the same for the DRC: investing in a survivor program will cost everyone less than responding to the next full-scale outbreak.
With more than one thousand survivors of its most recent Ebola outbreak, the DRC needs a robust, effective, and integrated disease surveillance system, including survivor semen testing. It also needs a survivor care and support system to help survivors deal with chronic health issues caused by Ebola and to reintegrate into their communities.
Without such a system, Ebola will be back in the DRC. It is just a matter of time.
Tolbert Nyenswah is a senior research associate at the Johns Hopkins Bloomberg School of Public Health and was Liberia’s deputy minister of health for disease surveillance and epidemic control from 2015 to 2017.