HUMANITARIAN CHALLENGES IN THE CONGO’S EBOLA EPIDEMIC

Humanitarian Challenges in the Congo’s Ebola Epidemic By Ben Grobman

In December 2013, an unidentified disease began to spread in the small Guinean village of Meliandou. On March 22nd, more than 3 months after the initial transmission of the disease, the World Health Organization, confirmed the identity of the disease as Ebola virus disease. 1 By the time Guinea was declared Ebola-free in June 2016, 28,600 people had been infected and 11,325 had died, more than all other Ebola outbreaks in history combined. 2, 3 The severity of the 2014-2016 outbreak put the global health community on high alert, leading to a far better understanding of how to prevent such devastation in the future. 4 And yet, less than 3 years after the end of the last epidemic, the Democratic Republic of the Congo is quietly experiencing the second worst outbreak of Ebola in history—in the middle of a war-zone.⁵

On August 1, 2018, the Congolese Ministry of Health declared an official outbreak of Ebola virus disease in North Kivu, a province in the Northeastern Democratic Republic of the Congo. 6, 7 The outbreak has been propelled, and thus made particularly difficult to contain, as a result of ongoing armed conflict in the Northeast Congo that has displaced over a million people. 7 The North Kivu region, which borders Uganda, has long been a site of conflict between DRC government forces and militant rebel groups, most notably the Allied Democratic Forces, a group from Uganda. 8 According to an August 2018 estimate, over 100 armed groups are currently active in North Kivu, leaving the population “virtually in a stage of siege since October 2017.” 7 During this conflict, observers have reported numerous vicious human rights violations, including machete attacks, recruitment of childsoldiers, rampant sexual violence, razed villages, and frequent stories of “massacres, extortion, forced displacement, and other humans rights violations.” 7 And yet, less than 3 years after the end of “

To further exacerbate an already dire situation, the Congolese government routinely commits human rights violations. For one, the last epidemic, the Democratic Republic of the Congo is quietly experiencing the second worst outbreak of Ebola in history.

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Dr. Tedros Adhanom Ghebreyesus in Beni evaluating the Ebola response.

they have condoned and even supported the rape and murder of civilians. 9 Additionally, the government has been accused of using the Ebola outbreak as a way to further an already flawed democratic process. They also banned people in affected areas from voting in already delayed national elections, citing supposed fear of worsening the epidemic as a justification for the ban.⁵ Some local politicians from opposition parties have tried to leverage the epidemic to support their political agendas, “spreading rumors that Ebola was concocted by the government to exterminate them.”⁹ The overall effect of this conflict has been to produce an atmosphere of chaos, violence, and distrust, which has only compounded the severity of the Ebola outbreak and created new difficulties in containing the outbreak. Health officials are forced to contend with not only a catastrophic disease, but also a terrorized and traumatized population that now has a deep fear of both authority and outsider intervention. 9 This has created a particularly difficult situation for health workers, as they are forced to deal with a dangerous political system in conjunction with one of the world’s most devastating infectious diseases.

Ebola virus disease, previously known as Ebola hemorrhagic fever, is a lethal viral disease characterized by initial symptoms of headache, fever, and muscle pains, followed by vomiting, diarrhea, and sometimes severe bleeding. 3 During Ebola outbreaks, the disease is initially transmitted to humans from wild animals through the bodily fluids of infected animals, including apes, fruit bats, and monkeys. It is suspected that fruit bats are Ebola’s natural host, but this has not been confirmed. 3 The majority of human transmission occurs due to contact with the bodily fluids of infected people. 3

Ebola is a particularly devastating disease for a number of reasons, many of which contributed to the catastrophe of the 2014-2016 epidemic. First, Ebola has an extremely high mortality, averaging 50%. During some outbreaks, however, mortality rates have reached up to 90%. Second, as shown during the 2014 outbreak in Guinea, many of the symptoms of Ebola are similar to those of other much more common diseases such as malaria and typhoid fever, reliance on which could easily lead to misdiagnosis. As a result, Ebola requires laboratory diagnostic tests for identification, a process that saps valuable time from appropriate disease control response. 3 When people are infected with Ebola, they often take over a week to begin presenting symptoms. While they are not infectious during this span of time, they can travel long distances

before the infectious symptomatic stage begins, a factor which increases the risk of spreading the disease over a wide area. 10 Third, due to Ebola’s transmission through interpersonal contact, health workers are placed at particular risk of contracting (and dying from) the virus, weakening already fragile health systems. 10

Director of Programs for UNICEF, “the burial rituals and the socioeconomic taboo processes in the local communities [require] heavy presence in terms of social mobilization communicant strategies/being able to reach out to women’s groups, local leaders, [and] religious leaders. That was critical in the case of the West African outbreak. I see a

...an aggressive approach to treatment both denies people their humanity and creates a situation in which people lose faith

Ebola was first documented in human populations in 1976, when two separate outbreaks of hemorrhagic fever struck the Democratic Republic of the Congo (then called Zaire) and South Sudan Sudan (formerly Sudan), leading to 431 deaths. 2 In subsequent years, there were multiple smaller outbreaks of Ebola, largely concentrated in Central Africa. 2 The 2014-2016 outbreak, on the other hand, infected people in West Africa, where there was little prior knowledge of the disease in addition to insufficient public health infrastructure that might have otherwise mitigated further disease transmission. 1 Additionally, previous outbreaks had been largely concentrated in rural areas, while the 2014-2016 outbreak primarily impacted people in large urban centers, where high population density helped it to spread like wildfire. 1 The world learned numerous lessons from the 2014-2016 Ebola outbreak, lessons which were meant to ensure that no such large outbreak could happen again. Aside from the devastating death toll in Africa, the infection also spread to wealthy countries, including the United States, Italy, and the United Kingdom, prompting fears of a global pandemic. 2, 4 As panic spread through the populations of wealthier countries, the global health community took serious steps to prevent another catastrophe from happening. 4 Since 2014, global health officials have been on much higher alert for Ebola outbreaks. Researchers quickly went to work on developing experimental Ebola vaccines, one of which has even been shown to reach up to 100% efficacy. 4 In particular, health authorities working on the West African outbreak learned the importance of human connection in working with populations affected by Ebola. 11 Due to political instability in the Congo, however, many of these lessons have not been properly applied. According to Dr. Nicholas Alipui, former lack of that level of engagement and mobilization happening in the Congo.” 11 Due to the severity of the situation in the Congo, global health officials have taken an aggressive approach to treating and quarantining infected people. While this seems necessary on the surface in order to contain a deadly disease in a dangerous region, an aggressive approach to treatment both denies people their humanity and creates a situation in which people lose faith in health workers. As stated by Dr. Joanne Liu, International President of Doctors Without Borders, “Using police to force people into complying with health measures is not only unethical, it’s totally counterproductive. The communities are not the enemy. Ebola is the common enemy.” 12 As a result of these tactics, attempts at treatment have often backfired. Many people who lack a clear understanding of Ebola are already terrified by the presence of health workers in full protective gear, sometimes accompanied by armed forces, a form of response which is particularly counterproductive in already wartorn areas. 5 Additionally, police officers in the region have used force in order to make people comply with treatment, a strategy which has further alienated the afflicted populations. 13 In order to stop the spread of Ebola, health workers must take extreme precautions with infected people, placing the living into isolation units and putting the still-contagious dead into plastic body bags, a process which interferes with traditional burial rituals. 5, 14 Many locals question why health workers have only now arrived to treat Ebola, when the area has long been plagued by far more common but equally deadly diseases such as cholera and malaria. Given that they are constantly surrounded by disease, locals feel that health workers only care about preventing the spread of Ebola as opposed in health workers.

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to improving people’s overall health. 5, 15 As stated by Dr. Alipui, “In situations where government services have always been lacking and the basic primary health care systems don’t deliver health to the local population, people don’t suddenly have a great deal of trust in the government health worker and government system.” 11 This lack of trust in authority has caused people to ignore official health information. For example, in a survey published in The Lancet, over a quarter of people in affected areas did not believe that there was an Ebola outbreak, and less than two-thirds were willing to accept the new Ebola vaccine. 16

The pervasive atmosphere of mistrust has led to multiple attacks on treatment facilities, severely impeding the efforts of health workers even to this day. In the February 2019 alone, there were over 30 separate attacks on relief efforts. 5 On March 9, just hours before Dr. Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization, was supposed to visit an Ebola treatment center in the most severely hit area, the center was attacked by heavily armed assailants, leaving one police officer dead, many health workers injured, and numerous frightened patients trapped in isolation units. 14, 17, 18 The attack came less than a week after the center reopened after having previously closed in response to an arson attack. 14 In addition to these organized attacks, of which the source is unclear, individuals have staged their own resistance to what they see as an invasive presence. In a particular striking story, police officers trying to remove an infected infant from his home were threatened by the boy’s grandmother, who wielded a machete and threatened to kill them. 9 Many locals question why health workers have only now arrived “

The combination of aggressive treatment methods, isolated people, and social instability has created an epidemic with a devastating impact. As of October 20, 2019, there to treat Ebola, when the area has long been plagued by far more common but equally deadly diseases such as cholera and malaria. ”

UN peacekeepers hand supplies to Congolese police maintaining security in sites occupied by health workers.

have been 3,243 reported cases and 2,171 total deaths. 19 Of particular consternation for health officials is that 40% of the deaths are occurring in communities as opposed to health centers, indicating that sick people are not using health centers. This lack of healthcare utilization makes it much more difficult to track the spread of the disease, as many more people could be exposed without the knowledge of health service providers. 5 Many of those who do seek out treatment decide to go to traditional healers, who do not keep a record of their patients, adding further difficulty to tracking efforts. 9

Ironically, it is this type of medical and political situation, under the most inhumane and austere circumstances, that requires the most humanistic, rightsbased approach to care. As stated by Dr. Liu, “Ebola is a brutal disease, bringing fear, and isolation to patients, families and health care providers. The Ebola response needs to become patient and community centred. Patients must be treated as patients, and not as some kind of biothreat.” 20 These effects are only exacerbated by the political and social situation of the Congo, where a preexisting atmosphere of fear and paranoia only compounds the psychological havoc wreaked by Ebola. According to Dr. Alipui, one of the most important things he learned from the West African outbreak was that “this is not a medical emergency. This is a socioeconomic and communication challenge. It’s beyond the vaccine and beyond the emergency services, it’s what the dynamics [are] in people’s homes, people’s lives, people’s relationships.” 11 A similar sentiment was reflected by Doctors Without Borders physician Dr. Vinh-Kim Nguyen in an opinion piece for the New England Journal of Medicine. He stated that “the most important part of my job is building trust with the communities we serve. Greater trust means more patients presenting early, and early presentation strongly affects the prognosis for many conditions. Building trust starts with relationships with patients and families, which can be nurtured even if patients are in isolation.” 15

The failure of aggressive approaches in quelling the Ebola epidemic has led health officials in the Congo to begin implementing a rights-based approach to care. Some health officials have already taken steps to humanize the Ebola response. One striking example is placing body bags inside of coffins before burying people in order to maintain the deceased’s dignity while also preventing further spread of the virus. 9 After increasing community dialogue, a previously closed treatment center in the province of Katwa was reopened. Community-based response measures have caused communities previously unreceptive to outsider help to admit health workers. And, although new cases continue to appear, as of October 2019, the incidence rate is down to fifteen new cases a week. 21 In order to stop the second-worst outbreak of one of the most devastating infectious diseases in the world, it is thus essential that health officials take a humane response despite the pervasive violence and danger, a response which focuses on treating people instead of the single disease.

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Ben Grobman ‘21 is a History major from Chicago, Illinois. When he’s not writing for the Global Health Review, he plays piano in the Yale Jazz Ensemble and works on blood drives with the American Red Cross at Yale.