After a surge of 27 additional Ebola cases in the last five days in the Democratic Republic of Congo, global health leaders are growing increasingly concerned that the deadly outbreak could spread beyond their reach.
Experts are blaming the sharp jump in cases ― which had previously slowed to about 10 a week ― on an uptick in rebel and mob violence in the outbreak’s new epicenter of Beni. In recent days, angry community protests and continued local resistance have frequently brought the efforts of emergency health responders to a standstill.
“We said from the beginning this is probably the most difficult context with which [we’ve] ever had to respond to an Ebola outbreak, and we stand by that assessment,” said Dr. Peter Salama, the World Health Organization’s emergency response chief.
The Ebola outbreak ― already the seventh largest of all time ― is close to topping 200 potential cases, including 159 confirmed cases and 35 probable ones as of Wednesday, according to the DRC Ministry of Health. An estimated 122 people have died since July.
Most concerning, an estimated 70 percent of the 27 new cases were not known contacts, said Ray Arthur, the co-lead of the Centers for Disease Control and Prevention’s Ebola coordination team. That means the emergency response team could be losing track of chains of transmission in the community, he said.
Close monitoring is essential for this deadly hemorrhagic fever, which spreads through contact with bodily fluid. When cases start appearing from contacts who are unknown, that’s when such outbreaks begin to spiral out of authorities’ hands, experts say.
“It’s hard to know how big that submerged iceberg is ― is it that one case or is there a line of transmission that was submerged?” said Dr. Thomas Inglesby, director of the Johns Hopkins Center for Health Security.
“The current situation is worse than it’s been since the outbreak began in July of 2018,” the CDC’s Arthur said, pointing to the sharp uptick in unknown contacts.
“The rebel violence ignites social tensions in the community that then affects our efforts. When people feel unsafe because of rebel attacks, they stop caring about our health messages.”
Salama and the DRC Ministry of Health both told HuffPost the rising wave of Ebola cases will continue in the coming days and weeks. The outbreak is now expected to last at least through January, Salama said, necessitating a new infusion of international resources.
Though the numbers are certainly lower than those of the deadly 2014 West Africa outbreak ― which infected 28,600 people and killed 11,300 ― it has some characteristics that warrant the highest levels of concern, according to Nora Love, the emergency field coordinator for the International Rescue Committee based in Beni.
At this point ― several months after the first cases were reported ― the number of new cases should be diminishing, not surging, according to 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.
“The biggest concern from the beginning was the risk that the disease becomes entrenched into some of the no-go areas. And now as violence expands into previously accessible areas, it widens the concern,” he said.
“Based on the security situation and its ability to spread ... it’s not under control,” Love added. “There’s potential for it to explode.”
The Anger Underlying The Rise In Cases
The North Kivu province of DRC ― home to the latest Ebola outbreak in the northeastern part of the country ― has been wracked with conflict for decades. Brutal machete attacks and child-kidnapping are common, as dozens of rebel groups have killed thousands and displaced a million more. While the United Nations has called for a cease-fire, groups such as the Allied Democratic Forces have executed a series of attacks that has left the city of Beni “virtually in a state of siege” since last October, according to the U.N. Refugee Agency.
After a Sept. 22 attack by the ADF that killed 17 civilians in Beni, the city of 200,000 people declared a “ville morte” ― a week of public mourning and demonstrations that disrupted Ebola response activities.
From Sept. 24 until Sept. 26, emergency response teams were unable to trace Ebola patients’ contacts and do other important containment work. Contacts reached by Ebola teams plummeted from the 90 percent range to 20 percent in the day after the attack. As the days went on without access to contacts, the disease spread. People also cared for the sick in their homes without medical supervision, which is part of the reason for the large uptick in cases, Salama and Love said.
“The challenges illustrate a huge gap in our global outbreak response capabilities,” said Ron Klain, who served as Ebola czar under Obama. He advocated for a “white helmet” style battalion that could provide security for emergency health workers to operate in dangerous areas.
The responders’ movements haven’t just been limited by the ville morte. An increase in civic protests and threats of violence has also been disruptive. Even Wednesday, response efforts were on lockdown from 9 a.m. to 2:30 p.m. as student protests closed major roads in Beni, and a protest against a local military official resulted in the deployment of tear gas and live fire, according to Love.
“It’s almost been a daily occurrence over the last couple weeks that we’ve lost hours and days of various teams [due to an] inability to access the people they need to access,” Salama said. “This is now a very different kind of community response, directly tied in with communities being incredibly frustrated that the national and international and regional communities have been unable to ensure over decades their physical security.”
That frustration ― at the lack of safety and security compounded with the sudden foreign international presence over a disease the area has never seen before ― has boiled over into violence against health care workers.
Three volunteer Congolese Red Cross workers in Beni, who were attempting to perform a safe burial, were attacked by a large group on Oct. 2, and two of them remain hospitalized. One is expected to be released next week, according to Jamie LeSueur, head of emergency operations in DRC for the International Federation of the Red Cross. The other, who has injuries that are making it difficult for him to walk, will stay in the hospital.
Safe burials are vital to response efforts because the body is very contagious immediately after death. So far, 37 unsafe burials have taken place because communities either refused safe burial or held the burial before a team could get there, or because of security concerns, the WHO said.
Those attacks are not isolated, he said ― there have been several more, though not of that severity. Salama said health care workers have met with threats of violence and intimidation when trying to work in the community.
“Most of the times people do not get hurt but the material, like cars, get damaged,” a spokesperson for the ministry of health said. “The rebel violence ignites social tensions in the community that then affects our efforts. When people feel unsafe because of rebel attacks, they stop caring about our health messages.”
As one community health worker said in a report published in The Lancet, “Ebola kills, but the rebels kill more.”
The violence also affects Ebola patients. People feel unsafe leaving their own homes to seek treatment or still don’t trust the authorities, which has resulted in several “community deaths” in recent days ― meaning people who died at home rather than in a contained medical facility, potentially exposing their families to the disease and spreading it into the community.
In one recent case, three children who attended school together contracted Ebola, two of whom were in contact with known contacts and one of whom was not. Love worries that the third child could have gotten the disease from the other two at school.
But Salama stressed that the uptick in cases this week could also mean that WHO teams are becoming more adept at finding community cases, meaning a greater proportion of Ebola patients are known to the medical staff. Salama believes that the outbreak, while not contained, has not reached the threshold of being out of control.
“The good sign is we’re starting to see more reporting,” he said, citing WHO and other NGO partnerships with approximately 200 local healers in Beni, whom infected patients are likely to visit first. “They’re starting to see us as more part of the solution, which is critical to stopping this outbreak.”
A Lack Of Trust
Still, the ministry of health says misinformation about Ebola continues to spread. Reports that international health workers have created the outbreak for their own gain, that the virus doesn’t exist or that it’s being used to influence the elections coming up in December spread like their own contagion.
This distrust has caused several people infected with Ebola to evade authorities, hide at home or flee to surrounding rural areas ― upping the spread of the disease. The WHO is still looking for one confirmed case who fled into a “red zone.”
The misinformation is also partially to blame for the attacks on Red Cross workers and the resistance to safe burials. The community trust needed to execute a safe burial ― and also to disinfect the home and burn the dead’s belongings they were most in contact with while ill, such as their mattress ― is threatened when such misinformation continues to spread, LeSueur said.
“Volunteers risk their lives often for this operation to make sure their communities come out of this on top,” he said.
“The current situation is worse than it’s been since the outbreak began in July of 2018.”
In light of the growing resistance and threats of violence, the DRC issued an urban decree in Beni on Tuesday. It ordered that law enforcement teams escort the safe burial teams; that families obtain a death certificate before receiving a burial permit; that all health professionals refer Ebola cases to the authorities or risk losing their ability to practice medicine of any kind; and that anyone hiding Ebola patients face potential jail time.
As of yet, no one has been arrested, the Ministry of Health told HuffPost.
But such severe actions, while meant to curtail resistance and decisions to hide family members, could have the opposite effect, Love said.
“I think there is a lot of controversy around this,” she said. “It’ll probably scare people and so they’ll run into the forest.”
Calling In The A-Team
According to Salama, the current emergency health response needs more money ― the latest estimate was $33 million, of which the WHO has secured $8 million in commitments ― as well as more security and more staff, especially senior epidemiologists and logistics managers.
For Inglesby, the perfect people for the job would be the CDC and the U.S. Agency for International Development’s Disaster Assistance Response Team ― both of which have been deployed to DRC, but are far away in the nation’s capital or across the border shoring up defenses in the neighboring countries of Uganda or Rwanda, where there is a high risk of regional spread.
“This outbreak is occurring in a really highly insecure environment, which complicates the response,” a state department official told HuffPost when asked why the teams had yet to be deployed to the current epicenter. “The U.S. is committed to do its part to help save lives the best we can.”
Inglesby and Konyndyk both argued that the proper security arrangements should be made so that these highly trained U.S. resources would be able to execute what they do best.
“This is where the post-Benghazi hangover of the U.S. government’s risk aversion really bites,” Konyndyk said.
“It’s time to consider it anew. It’d be valuable to bring resources in sooner rather than later,” Inglesby said. “It does seem like this is a time for potential intervention where things can go either way.”