It is almost a year since an Ebola outbreak was formally declared in the Democratic Republic of the Congo’s northeastern provinces of Ituri and North Kivu. The current outbreak is DRC’s 10th since 1976 and is now the second largest in recorded history, with more than 2,300 confirmed cases and 1,500 dead.
But the DRC outbreak isn’t just notable because of its length and death toll. This is the first Ebola crisis in an active conflict zone – with dire consequences for the effort to eradicate the disease. The eastern DRC has been caught in a series of successive conflicts since 1994 that have killed more than 5 million people, driven more than 4 million people from their homes, and left 13 million people struggling to feed themselves. That means this Ebola crisis is a humanitarian emergency, not just a public health emergency, and needs to be treated as such. Failure to recognise this will inevitably lead to the failure to control the disease.
Containing Ebola in a conflict zone is more complex, more dangerous, and more challenging than anything the health community faced in the 2014 west Africa outbreak. Operating in a conflict zone brings new dangers, like the burning down of health centres – and the 174 attacks this year on Ebola workers by local actors suspicious of anyone with ties to the central government. It brings delicate negotiations with local politicians, community leaders and more than 50 armed groups operating in the area. It brings new imperatives, including operating in a neutral and impartial way to ensure that saving human lives remains paramount. And it brings new concerns about the spread of the disease, as continued violence and forced displacement close to the Ugandan and South Sudanese borders increase the risk of cross-border transmission.
Ebola virus disease (EVD) first appeared in 1976 in two outbreaks, located in what is now known as South Sudan and the Democratic Republic of Congo. The latter outbreak was in a village near the Ebola River, giving the disease takes its name.
Ebola causes fever, aches and diarrhoea and attacks the immune system, causing blood clotting cells to malfunction so that victims bleed extensively and die if their immune system cannot fight off the viral infection. It is spread from person to person through body fluids.
Infected patients are isolated and treated by medical teams wearing full protective body suits who try to boost their immune response. The average case fatality rate is around 50% – and health-care workers have frequently been infected. Burial ceremonies involving direct contact with the body of the deceased can also contribute to transmission.
A vaccine, still experimental, has proven to be highly effective in preventing the disease, according to the World Health Organization. They estimate that since 1976 Ebola has killed around 13,000 people, most notably in outbreaks in Sierra Leone, Liberia and Guinea between 2014 and 2016.
This failure to recognise the unique demands of a conflict zone response explains why the international community has been unable to eradicate the outbreak one year after the first confirmed cases. Despite successfully vaccinating nearly 150,000 people, screening 70 million people, and throwing $50m at the problem between February and April alone, the Ebola crisis has deteriorated significantly since March. My International Rescue Committee colleagues running disease control operations at 50 health centres in the region say there is good reason to fear the problem will continue to get worse, not better, without a strategic reset of the response.
Today in Geneva there is a vital opportunity for such a reset as the UN’s leadership meets to evaluate the response strategy. Turning the tide on the outbreak and preventing it from spreading to other conflict zones such as South Sudan requires five steps.
First, we need to place community trust at the heart of the response. Of the 1,500 Ebola-related deaths in this crisis, 68% have occurred in the community as opposed to in health centres – a sign that people infected with the virus do not yet trust medical professionals to treat them. Building trust requires a proper dialogue, not just international staff telling local community members what to do. For instance, in 2014 burial services for Ebola victims became a point of contention, but dialogue with community members allowed for compromises that simultaneously reduced the likelihood of infection while allowing families to give their loved ones a proper burial.
Second, there needs to be a different approach to security. The use of armed police and military escorts raises understandable suspicion in a region devastated by 25 years of violence, and makes health workers and facilities targets for attack by local armed groups.
Third, clear and empowered leadership is critical. The UN secretary general’s appointment of David Gressly as UN Ebola emergency response coordinator has been a welcome improvement, but he needs to be the single point of command for all agencies involved in the response.
Fourth, every actor in the response needs to focus on their area of expertise. With multiple UN agencies, the Red Cross, and a number of international and local NGOs – including ours – operating in the region, we need clear roles and responsibilities that reflect our different skills. The World Health Organization has the expertise to provide technical oversight for the response and should be directed to focus on that role, while NGOs and the Red Cross should use their experience in programme delivery to lead the implementation of health services in a cost-efficient and rapid manner.
Fifth, the response should spend well, not just spend more. By using capable local staff, minimising expensive security arrangements, and prioritising services over international salaries, the NGOs participating in the response can deliver better services to more people for less money. The new strategy response plan should direct more funding to implementing partners in order to improve the quality and the cost-effectiveness of the response.
Containing the ongoing DRC Ebola outbreak won’t be straightforward – operating in humanitarian emergencies rarely is. But these five steps, which we have learned the hard way from working in conflict environments, give us a chance to stop the spread of this disease before it goes too much further.
• David Miliband is president and CEO of International Rescue Committee and a former foreign secretary
