WASHINGTON ― Global public health experts are growing increasingly alarmed about the Ebola outbreak in the northeast region of the Democratic Republic of Congo, which has killed 215 people so far. It is now the largest outbreak that the DRC has ever seen ― with 341 probable and confirmed cases ― and the third largest Ebola outbreak in history. And it’s continuing to expand.
While the risk of it spreading globally remains low, the threat for the country and its neighbors is very high. Constant incidents of rebel violence in the war-torn region, the resulting community protests and community resistance to medical intervention have hampered the ability of the World Health Organization, the DRC’s Ministry of Health and various non-governmental organizations to respond.
In response to an Aug. 24 incident, the U.S. pulled response team members back from the epicenter in North Kivu to the DRC capital of Kinshasa hundreds of miles away. The American response effort is now concentrated in Kinshasa and neighboring countries, and U.S. officials said in a briefing Wednesday that the situation is currently too dangerous for them to go back to North Kivu.
Containment efforts in this outbreak have also been made more difficult because a majority of the newest cases are not appearing among known contacts of other Ebola patients, said Dr. Peter Salama, the WHO’s head of emergency response.
In fact, over the last 30 days, two-thirds of the reported cases of the infectious disease have come from unknown contacts, according to Pierre Rollin, a top Ebola expert at the U.S. Centers for Disease Control and Prevention. That’s 85 cases out of 129.
Last week, Dr. Robert Redfield, director of the CDC, warned of the possibility of an “endemic” version of Ebola ― where the virus is not extinguished but continues to spread over an indefinite period of time among the population of North Kivu. Public health officials have argued that everything must be done to prevent the horror of continuous transmission of Ebola ― a situation that has never previously been seen.
“This [Ebola outbreak] is going to get out of control fast. ... We are on the edge of crisis.”
Yet under a best-case scenario, Salama said the outbreak could be stopped within six months at the earliest. That’s a significantly different assessment from that being made by the CDC.
“Where we absolutely agree, this is arguably the absolutely most difficult context that we’ve ever faced for stopping an Ebola outbreak,” Salama told HuffPost. Global health leaders have had to re-evaluate many of the usual control tactics for battling the hemorrhagic fever, he said, because they’re now dealing with a massive displaced population in a war zone ― a situation that Salama has repeatedly described as a “perfect storm.”
Ron Klain, the Ebola czar under then-President Barack Obama, disagrees with that last characterization of a “perfect storm.” While Ebola has never been fought in a war zone before, he argues that this is the “new normal,” not a one-off situation, in an era of increasing outbreaks of the highest risk.
“We are going to increasingly see these disease outbreaks in troubled areas with histories of conflict, with refugees nearby, with difficult political situations because that’s what more and more of the world itself looks like,” Klain said.
“We can’t just treat this as some sort of flukish perfect storm of horrible facts that we’ll just have to deal with this one time and not ever again,” he said.
Salama acknowledges that 80 percent of serious disease outbreaks are occurring in fragile state settings. And his more optimistic take on controlling the Ebola outbreak comes with this caveat: “as long as the security holds.”
War Zone Nightmare
Since the outbreak began in North Kivu at the end of July, attacks by rebel groups and community demonstrations have hampered the public health response, repeatedly driving response workers into lockdown and stopping vaccination efforts and contact tracing.
There have been at least 20 major security incidents of various kinds since the start of the outbreak, including one this past weekend, Salama said at a briefing Wednesday morning at the Washington-based Center for Strategic and International Studies (CSIS). All of these incidents have “set us back,” he said.
Jeremy Konyndyk, a senior policy fellow for the Washington-based Center for Global Development who previously led parts of the 2014 Ebola response for the Obama administration, stressed that no matter how effective the current response is, each rebel attack derails containment efforts.
“Every time we’re seeing one of these attacks, case monitoring is badly disrupted and drops off, people flee, and you see a corresponding increase in cases the following week,” Konyndyk said. “That means no matter how much progress we think is being made, it’s only as durable as the security situation allows it to be.”
Read more about the security situation in North Kivu here: “Experts Said A War Zone Ebola Outbreak Would Be A Nightmare. It’s Been Even Worse.”
The violence has led to a wave of new cases that began at the end of September. U.S. government and WHO officials say there has been increased coordination with the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo, a peacekeeping force has been deployed in the area for years. MONUSCO (an acronym based on its name in French) is the U.N.’s largest peacekeeping mission, yet many are still concerned that the region’s violence will continue.
The threat of further attacks and protests in the lead-up to what were already expected to be contentious presidential, regional and legislative elections in the DRC on Dec. 23 is worrying global health leaders.
J. Stephen Morrison, the director of CSIS’s Global Health Policy Center who led a panel discussion at the think tank’s event, told HuffPost that “we are kidding ourselves” if people think the situation is going to improve soon.
“This [Ebola outbreak] is going to get out of control fast. Just look at the pattern of ADF hits and our inability to stop it,” he argued, referring to one of the two rebel groups responsible for the vast majority of the violence. “We are on the edge of crisis.”
The ultimate fear ― what Salama called a “game-changer” ― would be a directed attack against outside workers with the WHO or the NGOs who came to help. There have already been multiple attacks on local responders, including volunteers with the Red Cross, and two unarmed members of the DRC’s Medical Immediate Response Unit were killed.
Since the North Kivu region is currently labeled a Level 4 U.N. security threat, some sort of direct attack on outside medical responders would trigger a Level 5 label and result in evacuation of those forces ― which would be catastrophic for efforts to contain the outbreak.
That’s a frightening scenario, said Rear Adm. Tim Ziemer, who is currently serving as the U.S. Agency for International Development’s acting assistant administrator in the Bureau for Democracy, Conflict, and Humanitarian Assistance.
“We probably ought to be having a side meeting at a very high level to address what are the implications of that and what does that require all of us to do,” he said. “We can’t be blind and turn our back on this current challenge, as turning our back on it doesn’t mean it’s going to go away,” he added.
Ziemer previously served as the head of global health security at the National Security Council, which is coordinating the U.S. response to the DRC outbreak. Observers have argued that national security adviser John Bolton’s decision to reshuffle that agency earlier this year diminished the power of global health security experts in the Trump White House.
The State Of U.S. Leadership
While global health experts still commend the U.S. for its financial and logistical response to the outbreak ― and credit it with the experimental but already invaluable Merck vaccine against Ebola, which more than 30,000 people have received in this outbreak alone ― some wonder whether there is a new status quo in global health leadership.
“They are leading from behind,” said Klain, noting the U.S. deference to other stakeholders on issues of security and the on-the-ground situation in North Kivu.
“It’s not the same kind of leadership from the U.S. in a global health crisis that we have seen previously in Democratic and Republican administrations,” Klain added, citing Obama’s Ebola response and George W. Bush’s efforts to fight HIV/AIDS in Africa. “For an administration that likes to talk about ‘America first,’ their approach to Ebola has been ‘America is one of many.’”
“We can’t be blind and turn our back on this current challenge, as turning our back on it doesn’t mean it’s going to go away.”
The fact that U.S. response teams aren’t at the epicenter of the outbreak now is reflective of a “Benghazi hangover,” Konyndyk argued, suggesting that no one in the current administration who is focused on the outbreak has enough influence to lobby Bolton, much less President Donald Trump, on this critical issue.
“There is no substitute for being there,” Konyndyk said.
The lack of an overarching global leadership beside the WHO is also concerning to him. “At a certain point, a response becomes more complex than what WHO can manage on its own,” Konyndyk said.
Indeed, during the 2014 West Africa outbreak, the WHO was excoriated for its foot-dragging. U.S. attention and resources were ultimately pivotal to ramping up the global response. And still, that epidemic killed 11,300 and infected 28,600 more.
Morrison hopes that global leaders aren’t fretting away the time like they did from February to August 2014 before taking definitive action.
At The Ebola Epicenter
In the epicenter of the outbreak, the city of Beni, the spread of Ebola has been driven by transmission of the illness in the “tradi-modern” facilities, according to Salama. Practices in these 300 or so health care centers, which combine traditional healing with modern medicine, are not optimal. Workers are reusing needles and there are no records of whom they treat.
A concurrent malaria outbreak is driving many ― especially children ― to the health centers. The WHO theory is that there they come into contact with infectious Ebola patients or are given injectables with the same needles used on Ebola patients. Without records, tracing contacts among the population of those exposed through the tradi-modern system is extremely difficult.
That’s a critical insight about the spread of the disease, but the WHO first suggested it almost a month ago to STAT. Given all the other challenges of fighting Ebola in an unstable urban community of 200,000 people, it’s not clear this theory is enough to quell the outbreak anytime soon.
Klain said it also sounds like something he’s spotted over the last few weeks in the WHO’s public statements: “the beginning of a hint of excuse-making.” That’s a shame, he said, considering the organization has made massive strides since its fatally slow response in 2014 and that until recently it “should be commended” for its forthrightness about the severity of the DRC situation.
The bottom line is that this Ebola outbreak is still expanding, not contracting, into new areas ― a total of 14 health zones of significant geographic size, as of Wednesday’s Ministry of Health report ― and infecting new, unidentified people.
“Right now, the position of global public health authorities should be we have an outbreak that is spreading in every conceivable way it can spread and we don’t have a grip on it,” Klain said. “And until you have a grip on it, you just don’t.”
CORRECTION: An earlier version of this article said there had been 219 deaths in the recent Ebola outbreak. There have been 215.