Democratic Republic of Congo

The health minister of the Democratic Republic of the Congo (DRC) announced six Ebola cases in the city of Mbandaka in Equateur Province in northwestern DRC. As of June 1, four of the six victims have died. These recent cases of Ebola represent DRC’s eleventh such outbreak since the disease first appeared in 1976. Like most other countries, the DRC is also dealing with the COVID-19 pandemic, though with a relatively a small number of reported cases (about 3,500) and deaths (75) as of June 3. The two diseases are not related. Ebola is deadlier, but spreads less easily than COVID-19. The director general of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, tweeted “This outbreak is a reminder that #COVID19 is not the only health threat people face." In the far east of the country, about 750 miles away, an Ebola outbreak that began in August 2018 is close to being declared over, but efforts to snuff it out are complicated by ongoing security crises. A deadly measles outbreak has taken the lives of over 6,000 people since 2019. WHO already had a presence in Mbandaka owing to a 2018 Ebola outbreak that killed thirty-three people there. With the latest outbreak, the WHO team is already involved in testing for Ebola and tracing the contacts of the victims of the disease. WHO states it is augmenting its personnel in Mbandaka in the next few days.  Mbandaka is a trading city on the Congo river. Estimates of the population are around one million (official figures of little credibility are as low as three hundred thousand). Like many other African cities, the population has grown rapidly, with necessary infrastructure construction lagging far behind. Ebola is endemic in the rain forest, which is receding in the face of population pressure. Hence, regular recurrence of the disease, pending the success of vaccines, would seem to be inevitable.  This latest Ebola outbreak is a reminder of the crucial role played by the WHO is responding to disease in Africa. The DRC is one of the world's poorest countries, and parts of it are wracked by violence associated with warlordism. It is dependent on international assistance through the WHO in controlling Ebola. Whatever the organization's shortcomings, it plays an indispensable role in providing health care to people in the DRC and elsewhere.

CFR Senior Fellow for Africa Michelle Gavin interviews President of the Citizenship and Development Party in the Democratic Republic of Congo Martin Fayulu.

CFR Senior Fellow for Africa Michelle Gavin interviews President of the Citizenship and Development Party in the Democratic Republic of Congo Martin Fayulu.

Officials from Democratic Republic of the Congo (DRC) and the World Health Organization (WHO) announced that the last Ebola patient has been discharged from a hospital in Beni. The patient’s discharge follows two weeks in which no new cases of Ebola have been reported. However, forty-six of those that had been in contact with the last Ebola patient remain in quarantine. Once there has been no new cases for forty-two days, the outbreak can be officially declared over. This threshold has already been met in certain areas, which are now “non-active zones.” The current Ebola outbreak in the eastern DRC started in August 2018. Some 3,300 fell ill from the virus and about two-thirds of those died. There have been ten outbreaks total since the disease emerged in 1976. The Eastern Congo outbreak was the second-deadliest, with the first being the 2014–2016 Ebola outbreak in West Africa, during which 28,652 people contracted the disease and 11,325 died from it.  The Eastern Congo outbreak was the first time Ebola emerged in a war zone. Fighting the disease was especially difficult given the high levels of distrust among the local population of officials from the government or international organizations, and the poor security situation. Hence, the apparent end of the current Ebola outbreak is a major achievement of the international organizations, non-governmental organizations, and Congolese authorities.  While there are experimental vaccines and pharmaceutical treatments, there was no “silver bullet” that ensured success. It appears to have been overcome through a slog involving quarantining the sick, tracing the contacts of those with the disease, the rigorous application of hygiene, especially hand-washing, and the use of protective clothing.  Success against Ebola gives hope that the eastern Congo will respond well against the new threat of the new coronavirus. DRC was one of twelve other countries identified as most at risk of coronavirus because of its close travel links with China. Officials from the UN Population Fund commented that eastern Congo may be better prepared against coronavirus because of the procedures learned from Ebola. After all, measures such as quarantine, contact-tracing, and hygiene are applicable to both diseases. 

The number of cases of Ebola in the eastern Congo continues to fall, and there had been speculation that the World Health Organization’s Emergency Committee would remove the designation of Public Health Emergency of International Concern (PHEIC) from the outbreak. However, at its February 12 meeting, the Committee voted unanimously to keep the designation. The original designation was made on July 17, 2019.  In its report, the committee put the Ebola risk as high at the national and regional levels, but low at the global level. The committee noted that sustained progress is dependent on improvement in the security situation, and security incidents had actually increased in recent months. The poor security situation and deep distrust of outsiders by locals has made this Ebola outbreak particularly difficult to tackle. The meeting also noted that outbreaks of other infectious diseases, notably measles and cholera, continue in the Democratic Republic of Congo and merit international attention and support. From the beginning of the current outbreak to February 10, the WHO states 3,308 confirmed and probable Ebola cases in eastern Congo, and that 2,253 people had died, about two-thirds. The WHO estimates the death rate from the coronavirus is about 2 percent, but cautions that it is too early to be definitive. Nevertheless, it is clear that Ebola is vastly more deadly, if still largely confined to eastern Congo. 

Twenty years ago, I was catching my breath after a whirlwind trip through central and southern Africa. I had been traveling with my boss, Senator Russ Feingold, whose expertise on African affairs eventually led to his appointment as a special envoy to the Great Lakes in the Obama Administration. Senator Feingold had agreed to join then-U.S. Ambassador to the United Nations Richard Holbrooke on a mission to bolster the prospects for peace in the Democratic Republic of the Congo. The United Nations had just voted to send 500 military observers to the DRC, beginning what would become one of the world’s largest and most complex peacekeeping missions. First known as MONUC (the United Nations Organization Mission in the Democratic Republic of the Congo), and later as MONUSCO (The United Nations Organization Stabilization Mission in the Democratic Republic of the Congo), that mission persists today, despite the desire of many UN member states to wind it down. The trip—with stops in Angola, Namibia, South Africa, Zimbabwe, Zambia, Rwanda, Uganda, and the Democratic Republic of the Congo itself—was unforgettable, in part because of the spectacle of watching Holbrooke operate. Holbrooke was capable of inspiring respectful admiration and appalled discomfort within the same hour, and people who knew him far better than I have written insightfully about his character and legacy.  At his best, he used his formidable intensity and relentlessness to push momentum forward in the most unlikely circumstances.  He did not have a deep background in the region, but he did have a clear set of core convictions about how to achieve his mission. First, he was convinced that without inclusive political dialogue and genuine political progress, no force on earth could bring an end to the costly conflict that had already taken such a devastating toll on Congo.  He made this point again and again at each stop, including in a speech he delivered in Pretoria, where he stressed that, “we cannot expect that alone, outside peacekeepers will deliver a peace that is lasting and just.” Populations, governments, and rebel groups had to commit to the hard work of addressing the tensions and interests that had led to the violence.  He knew that tough political issues could not be papered over or ignored, or else there would be no peace to keep. That point was especially important to him, because he understood that the United States had to be invested in the credibility of the United Nations, and he knew that American interests were best served by a UN that the world could believe in.  He had no desire to see the United States help bankroll a peacekeeping mission that was destined to fail. His commitment to American leadership, and to a vision of foreign policy far more ambitious than a set of ephemeral transactions, was the driving force behind his efforts to make the United Nations effective and to create an enabling environment for the Congo mission’s success. Finally, Holbrooke understood that for U.S. partnerships in the region to work effectively over time, the United States needed to stay attuned to the most pressing priorities of partner states. For all his bluster, he did quite a lot of listening, and came away from the trip convinced that the HIV/AIDS crisis required urgent attention at the highest levels. His conviction was not grounded only in compassion—although he seemed genuinely moved by the human cost of the disease—but in a sense that present and future partners of the United States were at risk of being hollowed out entirely.  Within a month he was chairing the first United Nations Security Council session on the crisis, reframing it as a security issue. Two decades later, political progress today too often means elite accommodation while overall conditions on the ground are neglected. The world has ignored violations of the Congolese people’s civil and political rights in the hopes that looking away will promote stability. The U.N. mission has come under attack from civilians angered by its failures, which are in part a result of a dysfunctional relationship with the government in Kinshasa. That mission is now in the unenviable position of being simultaneously ineffective, indispensable, and terribly expensive.  The vulnerabilities and aspirations of the populations affected by Congo’s instability seem increasingly remote from the policy discourse in capitals.  It is unsurprising that the Economist predicts more trouble ahead. Soon, some stock-taking will be required, and the policymakers around the world could do worse than to return to Richard Holbrooke’s core convictions to help find a way forward.

Protests that began last week in and around Beni in eastern Democratic Republic of the Congo have continued into this week, claiming several lives. Civilians on the ground, frustrated and frightened by yet another spike in insecurity, have channeled their anger toward the United Nations’ peacekeepers in their midst, demanding that they leave since they are unable to protect civilians.  Just over a month ago, the Congolese defense forces launched a campaign against the Allied Democratic Forces (ADF), one of the misleadingly-named armed groups that have terrorized eastern Congo for years. The campaign was not coordinated with UN forces on the ground, one of many examples of the dysfunctional relationship between the state and the long-serving UN presence in the country. The ADF, in turn, has stepped up its attacks on civilians in response to increased military pressure, brutally murdering over 100 people and displacing thousands more. All of this is occurring in the same part of the DRC that has been coping with an Ebola outbreak for over a year, and where hundreds of attacks on those trying to fight the virus have added to the already daunting challenge of responding to the outbreak. From a distance, it can be perplexing to read that international peacekeepers sent to provide stability are the focus of local wrath, or that health workers trying to stop the spread of Ebola are vilified and attacked. Indeed, UN Under-Secretary General for Peace Operations Jean-Pierre Lacroix urged people to “make no mistake about who the enemies are” during his visit to the troubled region. But on the ground, these populations have experienced decades of insecurity, dozens of armed groups with murky agendas, failures and in some instances a total absence of governance. They see enemies everywhere, and most of the time it is impossible for citizens to hold them to account.  The mistrust manifest in the reports out of Beni is tragic and self-defeating, but not incomprehensible. Whether the protests and attacks are orchestrated or encouraged or not, rage and suspicion are understandable reactions to life in eastern Congo. Rejecting well-intentioned interventions seems like a very human attempt to assert some element of control over a situation that has long been chaotic, to reject the external forces that have for generations brought suffering to the Congolese people, and to find an immediate and tangible scapegoat to blame for years of suffering. 

On September 8, a woman in her mid-thirties died in Tanzania of apparently Ebola-like symptoms. Tanzanian health officials conducted an autopsy, but ruled that Ebola was not the cause of death. The problem for many, however, is that Tanzanian authorities have reportedly not been entirely forthcoming with information about the woman’s death. According to the World Health Organization, Tanzania is refusing to share test samples related to the woman’s death and other information on what could be a case of Ebola. The American and British governments have issued travel advisories for Tanzania calling for the exercise of increased caution due to health issues. American Secretary of Health and Human Services Alex Azar has also criticized the Tanzanian government for not sharing information.  Officials are right to be suspicious. Tanzanian President John Magufuli is cracking down on dissent and is restricting access to information. A new law criminalizes the distribution of information that contradicts the government. This fuels concerns about a Tanzanian cover-up of the possible presence of Ebola. Yet, if Ebola is in fact present in Tanzania, the sooner preemptive measures are taken, especially vaccination, the stronger the likelihood of controlling the outbreak.  Like other African countries, Tanzania is urbanizing rapidly. The population of Dar es Salaam, where the victim died, is estimated to be about five million. But 70 percent of its residents are estimated to live in informal communities, and it is the ninth-fasted-growing city in the world. Hence, there is concern that if Ebola spreads to urban areas, the rate of transmission will increase, as happened in Eastern Congo. Tanzania borders Uganda, which, in June, reported its first cases of Ebola, ostensibly spillover from the outbreak in Eastern Congo.   Meanwhile in Eastern Congo, Ebola continues unabated, where by mid-September there had been some three thousand cases and two thousand deaths. There are disagreements over vaccination strategies between the World Health Organization and Doctors Without Borders. Health workers continue to be attacked by armed groups and public trust in such workers is low.

The proliferation of disinformation online amidst the DRC’s outbreak of the Ebola virus is a serious threat to global health. Efforts to curb bad information and conspiracy theories on social media about the disease and other health issues have been no more successful in health than in other contexts.

In a world awash in troubles, nothing less than catastrophe will spur policymakers to forceful action on global health. Unfortunately, concerted action could come too late to prevent local crises from becoming global emergencies.

In Foreign Policy, Shannon Kellman and Mark Lagon of the Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, make the point that disease outbreaks in states with weak governance and high rates of poverty often spread to other countries. With respect to eastern Congo’s Ebola outbreak, they highlight the fact that the disease has spread out of eastern Congo to the border with Rwanda and into Uganda. The World Health Organization has designated the outbreak as a “public health emergency of international concern.”  Disease outbreaks like Ebola also exacerbate other health issues in weak states; in Congo’s North Kivu province where the Ebola outbreak started, they cite an eight-fold increase in the incidence malaria. In addition to Ebola, eastern Congo faces myriad other issues, including endemic militia activity that is often hostile to government and widespread distrust of medical professionals trying to bring Ebola under control. The authors advocate increased international health assistance to fragile states such as Congo, especially by the United States. Though the Trump administration has proposed cuts, they highlight bipartisan congressional support for global health assistance. They suggest that increased assistance has the potential to improve governance and stability in affected areas, both of which are in the interest of the United States. In fact, it is likely that U.S. funding for global health could be increased, as it was last year. The authors argue that such health crises should be seen in the context of combating state fragility, the spread of terrorism, and of improving governance.  The outbreak has become a security issue that is already affecting Congo’s neighbors. Like the Ebola epidemic in West Africa in 2014, Congo’s outbreak could lead to disruptions to international travel and trade, and its knock-on effects in health and security could threaten the stability of an already unstable region. However distant the outbreak may seem at present, its far-reaching effects are yet more reason why aggressive and substantial support for disease-fighting efforts must be advanced.  

The recent designation of Ebola as a “public health emergency of international concern” by the World Health Organization (WHO) is a positive development in efforts to contain the disease. The decision highlights the importance of containing the disease to an international audience; the WHO’s designation is being widely carried by the international media.  It will likely unlock badly needed international assistance, though WHO is careful to say that designation is not a fundraising strategy. The WHO states that it has received only $49 million in donations since February, about half of the amount it needs. Representative Karen Bass, the top Democrat on the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations, welcomed the designation. In June, she introduced legislation to expand the amount and type of resources the U.S. is authorized to commit to fighting Ebola. Meanwhile, the pharmaceutical giant Merck has donated 195,000 doses of the apparently effective vaccine. Much more is needed, but it takes a year to produce the vaccine. There is a second vaccine, developed by Johnson and Johnson, which the WHO would like to use, but the Congolese authorities have not authorized it because of residual popular suspicion of all vaccines that has led to attacks on health workers. According to the New York Times, there are ongoing discussions between the WHO and Congolese authorities.  The WHO moved because the disease has been present for twelve months and continues to spread, most recently to Goma, a city of more than two million people on the border with Rwanda and near Uganda, raising the possibility that the disease could spread internationally. Congolese officials are reportedly concerned that international hysteria could lead to travel and trade restrictions. Given the hysteria in the United States (among other places) during the 2014 Ebola outbreak in West Africa, with calls for such restrictions, those officials’ concerns are not misplaced. Fear of disease can translate into a political cause that is easily exploitable for domestic political purposes in many countries. Thus far, the eastern Congo Ebola outbreak has infected 2,512 people, with 1,676 deaths in the twelve months of the outbreak. The eastern Congo is riddled with competition among militias for, among other things, access to minerals, resources, and tax revenue amid a breakdown of governmental and societal structures. Many people in the affected region do not trust the government in Kinshasa; anybody apparently associated with it, including health workers, can be at risk of violence. As recently as last week, two health workers were murdered in their homes.   

An outbreak in the DRC has spread to neighboring Uganda, and conflict and mistrust of health workers is impeding international efforts to contain the disease.

The Ebola vaccine is proving highly effective, but distrust of health workers, skepticism of the disease’s existence or provenance, and attacks on medical facilities are stymying progress. Popular suspicion of government authority is an old song in sub-Saharan Africa. Governments are often seen as exploiters that operate for the benefit of a tiny elite, deliver few services, and levy arbitrary taxes. In Nigeria, for example, critics will say that they still live in a “colonial state,” with the British having been replaced by a tiny, local elite. In general, anti-government suspicion tends to intensify the further the distance from the capital. In many cases, that distrust is not without good reason. But the current Ebola outbreak in the eastern provinces of the Democratic Republic of Congo illustrates the devastating practical consequences of that suspicion for disease control, especially when it is fanned by misinformation spread by social media. A study published in the highly respected British medical journal, The Lancet, reports the findings of a survey in the Ebola-affected parts of the eastern Congo. Less than a third of responders trusted official authorities. More than a quarter believed that Ebola was not real. Ignorance and social-media-fanned misinformation led to a reluctance to seek health care, to accept the Ebola vaccine, and to practice preventive behaviors.  The New Humanitarian explores the specific factors in parts of the eastern Congo that make so many prone to accept social media false information. North Kivu province has a long history of grievances against any government authority. Ostensibly because of the Ebola outbreak, the Kabila government postponed—until after the new president was sworn in—national elections in Ebola-affected areas, further fueling suspicion. There are more than one hundred militant groups fighting the government and each other in the area. Many who accept the reality of the disease believe it is being used by the far-away Kinshasa government to kill them. Efforts to counter Ebola are well-funded by the international community, in contrast to poor indigenous medical facilities. The disparity causes resentment. A consequence of such factors is that victims of the disease do not seek treatment.  On April 28, the authorities in Goma (the largest city in the region) confirmed 27 new cases of Ebola, bringing the total for the week to 126 cases. That time period established a new record since the outbreak started in August 2018. So, Ebola is far from being under control. The tragedy is that the disease can be controlled through vaccines and prevention, and even recovery is increasingly possible. Ebola is a governance issue as well as a medical one.