7 December, 2018
Jonny Elswood – Junior Fellow
Forty-two years after its discovery among fruit bats on the Ebola River in 1976, one of policymakers’ most feared viruses has sprung up again in the Democratic Republic of Congo (DRC). On the 1st of August, in the north-eastern provinces of the country nearest South Sudan, Uganda and Rwanda, the ninth known Ebola epidemic was declared. This time, it has flared up alongside a parallel epidemic of cholera, and, in a world first, it has actually penetrated an area of significant violent conflict. Patients seeking care and carers seeking patients will, for the first time, be confronted with an environment of dozens of armed militias and a swell of more than a million internally displaced persons.
As students, analysts, policymakers and responders, we might think we know what we’re dealing with after the 2014 outbreak in West Africa, when 11,300 people died of Ebola. However, while it is currently uncertain whether this fresh epidemic will reach the same proportions – so far fewer than 150 people are confirmed to have died – it is already qualitatively different.
Ebola is a viral disease; a haemorrhagic fever that passes from human to human not through the air, but through fluid and bodily contact. Usually, a person incubates Ebola for a week or two before symptoms even manifest themselves – this is one of the reasons it’s so challenging to tackle. However, in extreme cases, it can take less than a day to die. After contracting an infectious agent, extreme exhaustion and aching can overwhelm the body within hours, before the patient is plunged into the potentially terminal phase of intensive bleeding, diarrhoea, vomiting and rapid dehydration.
Over six million people have been screened going in and out of the DRC since the outbreak, and within days of the epidemic’s declaration, the World Health Organisation (WHO) had deployed technicians, epidemiologists, vaccinators and cultural specialists to the Congo. This demonstrated an impressive adaptation to the last epidemic, which drew major criticism for the lethargy of the international response. However, new kinds of obstacles faced the international teams who arrived in Kinshasa and headed to the epidemic zone.
There is currently no cure for Ebola, but there are several effective vaccines. This means that when it comes to an epidemic that has already started spreading at a significant rate, responders can only approach it with comprehensive tracking and logistics. Such is the exhausting process of so-called ‘ring-vaccination’: a known carrier of Ebola is isolated and cared for, while every individual they have physically contacted is also identified and isolated. The concentric circles multiply, and infection rates are closely monitored. The procedure is onerous for the obvious reason of scale: if 150 patients are ‘ring-vaccinated’, for example, that requires the monitoring of 8-10,000 others. In turn, therefore, if 200 patients contract Ebola but hide from the authorities, then up to 12,000 unknown individuals are potentially at risk of contagion.
Geographically, too, this can be a staggering exercise: so far, Ebola has spread hundreds of kilometres and may already have spilled into Uganda. (Porous borders were a key feature of the 2014 epidemic). Indeed, while Ebola can spread quickly in urban environments, the closer proximity to sophisticated healthcare is a mitigating factor and it is actually a greater challenge to effectively protect rural communities in areas with little or no roads or clinics.
The humanitarian strategy of ring-vaccination is also challenging for two cultural reasons in Central Africa. For one, hand-washing a loved one’s body after death is an important and widely-practised tradition in the Congo. With funerals being sacrosanct and widely attended affairs, this direct contact with the recently deceased can be the foremost force multipliers of a viral epidemic. This aspect of the crisis response overlaps with another: the communal distrust of foreign medics. While it is reported that most Central Africans, particularly in the cities, tolerate or embrace aid workers, some have fallen victim to mob violence. They are seen by some as unwelcome representatives of a failed international safety net, or even the bringers of the disease itself: the appearance of large tents and yellow haz-mat suits is never a good sign. Nurses and vaccinators have been attacked with rocks or intimidated by large groups, often when wearing their contaminated protective gear.
Incidents of communal distrust stem in large part from the insecurity situation and can result in a faster spread of Ebola. The DRC is currently a warzone, in which a precarious government has been fighting dozens of armed militias – such as the Allied Democratic Forces, which have in the last month engaged in child kidnapping – for control of towns and resources. The decades-long conflict insecurity has regularly seeped across national boundaries and eliminates the interoperability of the Central African bloc’s health systems. Moreover, the daily fears of violence, abduction, rape and displacement are a constant reminder of the global community’s failure in the DRC. Medical staff from around the world need military protection to treat the infected, which compounds the frustration local people feel about Western ‘fixers’. As a result, in a field survey conducted by the medical journal The Lancet, nearly one in five people stated that they would not report a loved one to the authorities in the event of suspected infection. A further one in five would actively hide the ill family member, an action which now carries a jail sentence in the DRC.
As ever with Sub-Saharan Africa’s relationship with the West, there is the overarching threat of crisis fatigue. In other words, epidemics such as Ebola can rise and fall, but the fundamental factors of their regularity are often forgotten in between emergencies. Millions of Congolese residents – not to mention the internally displaced – feel disenfranchised with national government too. Elections are scheduled for December, but even if the seventeen-year President Joseph Kabila exits office, his successors will be unlikely to revolutionise the country’s cohesion or capabilities. Positively, however, this summer’s outbreak was the first instance of an Ebola vaccine roll-out and the use of the ring strategy that helped eradicate smallpox in 1980; the vaccines are the reason why this ninth epidemic hasn’t spiralled out of control yet.