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Ebola in the DRC one year later – Boiling the frog?

Open AccessPublished:July 19, 2019DOI:https://doi.org/10.1016/j.ijid.2019.07.014
      The outbreak of Ebola virus disease in the Democratic Republic of the Congo (DRC), of which the World Health Organization (WHO) was first notified on August 1, 2018, is now approaching the first anniversary of its initial detection. At the fourth meeting of the Emergency Committee of the WHO regarding this epidemic on July 17, the Director General of the WHO, at the recommendation of the Committee, declared a Public Health Emergency of International Concern (PHEIC). What were the conditions that led the Committee to recommend the declaration at this point, after 3 prior meetings failed to reach the same result despite multiple calls for such an announcement? (Nuzzo and Inglesby, 2018;
      • Klain R.
      • Lucey D.
      Time to declare a public health emergency on Ebola.
      ) And now that it has been declared, what are the best approaches to respond?
      Very little has changed in the last several months in terms of disease incidence. As total cases have topped 2,500, we have seen a steady, weekly toll of approximately 60–100 new cases since mid-February 2019 (
      • World Health Organization
      50: Situation report on the Ebola outbreak in North Kivu 16 July.
      ). The specific episodes that the Director General of the WHO, Dr. Tedros Adhanom Ghebreyesus, indicated as provoking the convening of the Committee were the detection of a case in Goma, a city of 2 million people on the border with Rwanda, and the identification of an individual who had traveled while symptomatic from DRC to Uganda and back again before being identified (
      • IHR
      Emergency Committee on EVD DRC North Kivu; Speech by Dr Tedros Adhanom Ghebreyesus.
      ). In addition, the recent murder of 2 Congolese citizens, reportedly specifically targeted because of their involvement in the response (
      • RDC
      Deux agents de la lutte contre Ebola tués dans la région de Beni.
      ), has highlighted the complex social and security challenges that hamper response activities.
      What was different about these episodes, which were not unexpected? Preparations have been ongoing to respond to a case in Goma, and a functional Ebola Treatment Unit (ETU) has been in place since February. In Uganda, establishment of treatment units and vaccination of health care workers has also occurred, and the identification of 3 patients in that country earlier this year did not lead to a PHEIC. Community distrust and the machinations of multiple armed groups have already resulted in direct attacks on outreach teams and treatment centers with numerous previous casualties (
      • UN News
      DR Congo: Strengthened effort against Ebola is paying off, but insecurity still major constraint – UN health agency.
      ).
      Resurrecting an analogy used in the 2013–16 outbreak, we liken this new situation to the proverbial frog, which will leap immediately when placed in a pot of hot water, but if placed in a pot of cool water then put on a flame, will allow itself to be boiled (

      Hussein M. Ebola response of MSF and ‘boiling frog’ WHO under scrutiny. Reuters, 2014 21 Aug https://www.reuters.com/article/us-foundation-health-ebola-response/ebola-response-of-msf-and-boiling-frog-who-under-scrutiny-idUSKBN0GL1TT20140821 (Accessed 23 July 2019).

      ). After the 2013–2016 West Africa outbreak, with images of bodies left in the streets of capital cities, the slow simmer in the DRC seems manageable, and perhaps easier to ignore, from afar. Despite the security issues, vaccination uptake has been relatively high, and ring vaccination strategies have no doubt had some effect in preventing the explosive intensification of spread that occurred in West Africa, even in the urban areas of Beni and Butembo. So far, the gloomy predictions of significant international spread have failed to materialize. The latest incidents were recognized and responded to quickly before any secondary cases have occurred, and strategies of contact tracing and ring vaccination are in place. However, the Committee recognized that the water is getting hot. The borders remain porous, outbreak epicenters continue to shift, and vaccine is in short supply. Resources from the global community to support the response, although generous, have been inadequate. It is therefore hoped that the announcement of the PHEIC will lead to increased coordination and galvanize additional support from the international community to control the epidemic (
      • Statement on the meeting of the International Health Regulations
      Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on, 2019 virus disease in the Democratic Republic of the Congo on 17 July 2019.
      ).
      It is often said that the military seems to habitually prepare for the previous war. The same would appear true of the global community in its response to Ebola (and to other disease outbreaks). It is time to stop viewing Ebola in the DRC through the lens of the West Africa outbreak. This is a different outbreak. We need to recognize it for what it is — a complex humanitarian emergency inside the DRC, a country with a complicated and ongoing history of civil and international conflict with roots in the colonial era. Standard outbreak responses, although necessary, are inadequate.
      The announcement of the PHEIC will provide the chance to reassess strategy, focus global attention on the outbreak, and spur a more dedicated involvement from the global community, which until now has played the role of the slowly warming frog as Ebola heats up. When that frog leaps, what is the best direction to get out of the pot?
      We recommend the following approaches for global partners:
      • 1
        With new international assistance, add resources to support of the overall medical and public health systems to address the many other diseases recognized by the community as causing more morbidity and mortality than Ebola. In addition, linking Ebola response activities with contributions to community infrastructure, agricultural technologies, and economic opportunities may yield a more receptive posture in resistant communities by demonstrating that the goal of intervention is to improve the health of the community, not simply to prevent spread of the disease to western countries. This strategy has proven successful for polio eradication in active conflict areas (
        • Garon J.R.
        • Orenstein W.A.
        Overcoming barriers to polio eradication in conflict areas.
        ).
      • 2
        Assemble a multi-agency working group with expertise in anthropology, sociology, and communications to reinforce ongoing activities of messaging and community engagement, and to improve the effectiveness of conflict prevention and resolution interventions with armed rebel groups. We need to gain a better understanding of the motivations of these groups in their opposition to Ebola response efforts. This working group could be a sustainable resource, not only for this outbreak, but for other global health-related emergencies.
      • 3
        Support the Congolese personnel involved in the outbreak, both professionals who have been involved since the onset and surge personnel hired locally. Many of the former group have put their usual lives on hold and are living far from homes not near the epicenter. Local personnel have suffered death threats and attacks for participating. Increasing the Congolese “ownership” of the outbreak by utilizing Congolese nationals is vitally important for reasons of national autonomy, investment, accountability, and local acceptability among others, but the magnitude of the contributions being made by these individuals cannot be overemphasized.
      • 4
        Develop new strategies for security. Regular attacks on Ebola Treatment Units (ETUs) demonstrate that existing security arrangements are either insufficient for this type of complex humanitarian emergency or are too limited by current mission constraints to protect ETU workers and patients effectively. Sending armed forces into communities alongside response teams is not a preferred approach and may increase community resistance; however, this consideration does not obviate the need to ensure a robust, measured defense of ETUs (
        • Nguyen V.K.
        An Epidemic of Suspicion - Ebola and Violence in the DRC.
        ) Consultation with security experts from a variety of industries may lead to strategies which are less confrontational but nonetheless enhance safety for response personnel.
      In summary, security concerns in DRC provide a significant barrier to outbreak assistance; however, maintaining the current level of international engagement is likely to allow the outbreak to continue to spread within DRC, and eventually to neighboring and in turn distant countries. This will not be the last outbreak of Ebola in the DRC or elsewhere. It is to our benefit to seek ways to demonstrate this is not another case of “helicopter” intervention, but a long-term commitment for humanitarian aid and to bolster the health care system overall in DRC and develop sustainable response strategies that can be deployed to other communicable disease outbreaks in the future.
      A deliberate, thoughtful scale-up of involvement in support of and in collaboration with partners on the ground, including the WHO and DRC government would ensure a seamless effort that is responsive to the communities’ and partners’ needs and help tip the scales. Such a demonstration would go a long way in winning the hearts and minds and cooperation of the local population who are there for the long term.

      Disclaimer

      The opinions in the manuscript are those of the individual authors and are not intended to reflect the opinions of their respective institutions.

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