The world thought it knew how to deal with Ebola outbreaks—but it’s never dealt with one like this before.
The signs of a coming Ebola crisis are mounting. The disease is spreading rapidly in a region of the Democratic Republic of the Congo where health care workers have been facing unprecedented violent attacks, both by insurgent militants and anxious locals.
Nevertheless, World Health Organization Director-General Tedros Adhanom Ghebreyesus made the confounding announcement on Wednesday that he will not declare the outbreak a “public health emergency of international concern.” Such a designation would have triggered a response across the United Nations, mobilizing multiple agencies, funding, and personnel—in other words, the sort of global response that belatedly resolved the epidemics in Liberia, Sierra Leone, and Guinea in 2014 and 2015.
Addressing journalists from all over the world from WHO headquarters in Geneva, Tedros acknowledged a tough situation is unfolding in the North Kivu region of Congo, near the borders of Uganda, South Sudan, and Rwanda, where an estimated 60 different armed groups, a 16,600-strong U.N. peacekeeping force, and government soldiers have clashed for years. The epicenter of this latest Ebola virus outbreak is smack in the center of local military clashes, in and around the town of Beni.
“The situation is this,” Tedros said. “Some 216 people have been infected” with the hemorrhagic virus, leaving “139 dead, 57 recovered. Government leadership is still strong.” This is Congo’s 10th battle with Ebola, and its Ministry of Public Health has many seasoned veterans of skirmishes with the virus. So far, Tedros said, more than 18,000 people in the North Kivu area have been immunized with an experimental Ebola vaccine, and a 250-strong WHO team is on the ground, finding infected people, bringing them into quarantine, and trying to control the outbreak. A committee of the WHO’s scientific advisors concluded that the government of President Joseph Kabila, with existing international support and expertise, is capable of handling the crisis.
The view from the United States is different. Last week, the U.S. State Department deemed the security situation on the ground in the outbreak so dangerous that teams of U.S. Centers for Disease Control and Prevention experts were pulled back more than 1,000 miles away to the Congolese capital of Kinshasa. On Sept. 28, the WHO warned that the epidemic had reached a “critical juncture,” amid widening reports of violence, including the recent killing of 17 people inside the city of Beni. This year, more than half a million people have been displaced from their homes in the region by military activity, and 13,000 fled homes around Beni in August.
The fear, anger, and violent rivalries have spilled over into the Ebola response. On Oct. 2, for example, a Red Cross team came under attack by a village mob as the team tried to bury a woman who died from Ebola, following safe practices that eliminate physical contact between the body and mourners. The body was stolen, and Red Cross volunteers fled for safety. In another incident, an Ebola Treatment Center was attacked by a gang of young men. Although Tedros and the WHO decided there is no need to declare an international emergency at this time, forestalling the delivery of additional medical and public health personnel and logistic and supplies support from multiple U.N. agencies, there is reason to be deeply concerned about this situation. It is the first Ebola outbreak in a war zone. On Oct. 3, Tedros himself admitted as much, requesting from the U.N. Security Council a marked increase in security support from MONUSCO, the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo, which has more than 16,000 military personnel drawn from armies all over the world and is supported by more than 4,000 civilian staff members.
The conflict in the Kivu region, moreover, is especially complex. At least 2.5 million people, mostly civilians, were killed in Northern and Northeastern Congo between 1998 and 2002, and the area is still rife with ethnic hatred, including elements of the Hutu versus Tutsi blood hatred that was at the root of the 1994 Rwandan genocide. The dozens of militias are well armed, filled with ranks of seasoned, often brutal soldiers, many of whom have waged war for more than two decades. The allegiances and wealth of the militias are also complex, as many fill their ranks with combatants from outside Congo and finance their campaigns with diamonds, gold, and other gem and mineral wealth extracted from Congo. Ebola responders have had to negotiate free passage privileges with local militias and armies to track down infected individuals and trace the possible spread of the virus via their contacts.
Because they can’t move about freely, the Ebola responders—including international nongovernmental organizations such as Doctors Without Borders and the International Red Cross—can’t deploy tactics that have succeeded in halting prior epidemics, including scouring homes and villages for people who had contact with known Ebola victims, testing family members for infection, creating rings of vaccination to form social barriers to disease spread, and stopping all normal funeral procedures to prevent mourners’ contact with highly contagious cadavers.
The constant presence of MONUSCO alongside the health care workers only exacerbates rumors and distrust among local people, who are already on edge about violence and view the national army as a repressive force. A Congolese Ministry of Public Health team questioned local civilians, finding, “The Government is criticized for not doing enough to make it safe. The UN is judged to be complicit in the massacres here, and for not protecting the population except for a few battalions. And NGOs, people think they are here just to make money.”
A source from ALIMA, a humanitarian doctors’ group now treating patients around Beni, told me that the thermometers used to test people for possible Ebola fevers have led to outcries; because Ebola is so contagious, mouth thermometers cannot be used, so “fever guns,” as many call them, are pointed at individuals’ heads to give a quick temperature read. Many people believe the foreigners are using these fever guns to read their minds, discovering how they intend to vote in the upcoming elections. It is also widely rumored that foreigners made the Ebola virus and released it, for a variety of alleged purposes. Still more people think the scale of the Ebola response is disproportionate to the far greater likelihood that local residents will be raped, tortured, or murdered by rival militias. As one local community health worker put it to an enquiring anthropologist recently, “We think it would be good that as much effort be put into mobilizing teams to end the insecurity. Ebola kills, but the rebels kill more.”