Ebola has been raging in DRC for 12 months: why is it proving so hard to control?

The spread of Ebola to a city of one million people in the Democratic Republic of Congo is a sure sign that the outbreak - first declared last August - is far from over.

The news broke as the major partners in the response - the World Health Organization, the United Nations, the DRC ministry of health, major aid agencies and representatives from the UK and US governments - met in Geneva to declare the outbreak an "international emergency" for the first time.

This is DRC’s ninth known Ebola outbreak and is by far the biggest, with nearly 2,500 cases and 1,600 deaths. So why is this outbreak proving so intractable?

Conflict and violence
This is the first time that an Ebola outbreak has taken place in a conflict zone - ethnic and tribal tensions which have been ongoing for many years mean there are more than 100 armed groups operating in this part of DRC.

As well as coming under direct attack, responders have also been subject to curfews and lockdowns, preventing them from going out and doing their job - every time there is a pause in the response due to security fears there is a spike in cases.

An outbreak of fighting in neighbouring Ituri province last week underlined the fragile security situation and the possibility it could escalate further. The only way out for those fleeing violence in Ituri is through the Ebola zone, risking further spread of the disease.

The Ebola responders themselves have also come under attack for a variety of reasons. Clinics and treatment centres have been torched and a WHO epidemiologist from Cameroon - Richard Valery Mouzoko Kiboung - was killed in April. Since January there have been nearly 200 separate attacks on staff and clinics and seven staff have been killed in total.

Just this weekend two Ebola workers were killed in their homes, both of whom had been subject to threats since December. The ministry of health says neighbours were jealous that they had found employment in the Ebola response.

Lack of trust
To bring the outbreak under control experts say that 70 per cent of patients should be treated within three days of displaying symptoms. Treatment times are currently nowhere near this because people are still not coming forward quickly enough - and this is mainly due to a lack of trust.

The disease is raging in poor and remote areas and local people are suspicious of  the influx of people and money to an area which has been neglected for many years. Since January, 2000 children have died from measles alone in DRC, leading local people to wonder why Ebola is the focus of such attention.

A survey carried out by researchers from Harvard University earlier this year showed that one in four people in the worst affected areas thought the virus was fake and a third thought the outbreak was fabricated for either financial gain or to destabilise the region.

Dr Tedros Adhanom Ghebreyesus, director general of WHO, acknowledges these frustrations, saying he was embarrassed to come to the region and just talk about Ebola.

"To build trust we must demonstrate we are not parachuting in to deal with Ebola and leaving once it's finished," he told yesterday's meeting in Geneva.

In March, Médecins sans Frontières president Joanne Liu was highly critical of the “militarised” public health response to the outbreak. She said that heavy-handed tactics - which included the police and army forcing people to attend treatment centres - were not only unethical but also counter-productive as they discouraged people from coming forward.

In recent weeks there is some evidence that the strategy has changed, with more Congolese leading the response. New tactics such as the use of Ebola survivors, who have immunity to the disease, to care for patients, act as ambulance drivers and to help with community engagement should go some way to resolving this.

But, as the attacks this weekend show, employing some locals also risks driving a further wedge between communities - with those not employed in the response jealous of their neighbours' new-found income.

At the meeting in Geneva international development secretary Rory Stewart urged other G7 countries such as France and Japan to do more to respond to the crisis. The UK and US governments have been generous - with the UK pledging a further £50 million. But other richer nations have not responded in the same way that they did to the West Africa Ebola outbreak of 2014-15.

So far, WHO has received less than half the funds it says it needs. It requested $98.4m for the period February to July but has received just $43.6m, leaving a funding shortfall of $54.8m.

The spread of the disease to Goma, which is on the border with Rwanda, has prompted the WHO to convene another meeting of its emergency committee which will decide whether the outbreak constitutes an international health emergency.

So far it has pulled back from doing this three times, despite the emergence of the disease in Uganda last month. Making such a declaration would trigger more funding from the UN but it would also put trade and travel restrictions on DRC, something that WHO is reluctant to do.

Coordination and dialogue
WHO has been the outside agency leading the response but it cannot act alone. It can lead on public health but security and a broader co-ordinating role is not in its remit.

A new UN emergency coordinator, David Gressley, was appointed at the end of May and was given the task of taking the response closer to the community and giving it a more “humane” face.

Tariq Riebl, International Rescue Committee’s emergency response coordinator for Ebola in DRC, said that “community engagement and continued demilitarisation” must be the top priorities of any new strategy agreed by the major partners.

Excluding local people from decision making has been an ongoing criticism. At a conference convened by aid agency Tearfund last month, attended by local faith, civic and even armed group leaders, members of the community came up with a set of recommendations for WHO and other responders.

These included ensuring that loved ones can attend their relatives’ funerals – a particular flashpoint – and the appointment of a local person in every village to ensure dialogue between the community and the official responders.

What’s working?
The outbreak has been confined to the North Kivu province of DRC and international spread to Uganda last month was quickly contained.

Most experts believe that without the vaccine - which has been given to 160,000 people as a prevention tool - there would have been many more cases. However, there are only 450,000 doses so there are fears that it could run out.

The DRC government has ruled out the deployment of a second vaccine developed by Johnson & Johnson, to the dismay of some who believe that responders need everything at their disposal to bring the outbreak to a close. The government said there was not enough information on the vaccine's safety and efficacy for it to be confident to introduce it.

As well as experimental treatments not available in previous outbreaks, the care of patients is much improved. Survival rates for those in treatment centres are at around 70 per cent. There is also some evidence that if you have the virus the vaccine can reduce the symptoms.

Other less hi-tech innovations include body bags with a transparent window to enable people to see their loved ones. Burials have been a source of anger because local custom is for people to touch and wash their dead - but dead bodies can still be contagious.

Another innovation is US NGO Alima’s Ebola cube - a tent with transparent walls so patients can be monitored from the outside without the need for staff to put on cumbersome protective equipment. It also means family members can see their loved ones being cared for.

Dr Tedros described the outbreak as more than just a health emergency and "one of the most challenging humanitarian emergencies any of us have ever faced". It is clear this outbreak is far from over.

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