Ebola Spreads amid Violence in the Democratic Republic of Congo, and U.S. Role Remains Limited

Updated on May 20, 2019. Originally published on Jan. 18, 2019.

The current Ebola outbreak in the Democratic Republic of Congo (DRC), which began in July 2018, is the largest in that country’s history and the second largest ever recorded. According to the country’s health ministry, as of May 19, 2019 there have been 1,816 cases and 1,209 deaths in the outbreak, which is centered in 2 northeastern provinces. No cases linked to the outbreak have yet been identified outside DRC, though cross-border transmission remains a risk as does concern about exposure for international travelers and responders.

Despite improvements in the global capacity to respond to Ebola that have come since the major 2014 West African Ebola epidemic (outlined in a previous brief), the current outbreak has proven especially difficult to contain because the virus is being transmitted amid conflict, in communities mistrustful of the government and of outside responders. Over the last few months an increasing number of violent incidents, including many direct attacks on response personnel, health care providers, and clinics involved in caring for Ebola patients, have made the response effort even more challenging.

In the 2014 West African outbreak, the US played a major leadership role, mobilizing an unprecedented amount of resources and personnel to support the Ebola response. In the current outbreak, though, the U.S. role has been more limited and mainly in support of other leading actors, providing fewer resources and with American personnel restricted from working directly in the hardest hit areas due to security concerns. Given the worsening nature of the epidemic, some have called for the U.S. to increase its engagement and to take on a more prominent, leading role in the response alongside the World Health Organization (WHO), the DRC government, and other key responders.

In this Issue Brief, we summarize available information about why the outbreak continues, describe the ongoing U.S. role in response, and discuss what might come next.

Conditions Have Become Much More Difficult and Risky for Responders and Affected Communities

Conflict in the Ebola-affected provinces predates the current outbreak, and has impeded the response from the start. Long-standing conflicts in the areas affected by Ebola were exacerbated by unrest and violence stemming from a contested national election late last year, the results of which were challenged as illegitimate and fraudulent. The new President, Felix Tshisekedi, is still in the process of forming a government and naming his cabinet. He visited the Ebola-affected regions in April and called for local communities to trust the health workers involved in the Ebola response, and for disarmament of warring factions in the region.

Even so, it appears community mistrust and violence remain powerful, mutually re-enforcing factors greatly impeding the Ebola response. People in the affected areas have suffered from years of instability and violent attacks, which has engendered widespread suspicion of the motives of external parties including Ebola responders, be they from the national government, international organizations like WHO, or non-governmental organizations. Studies find that many in the affected areas believe the Ebola outbreak is not real, that it is a hoax perpetrated by the government or other outside parties. Violence linked to armed group activity in these areas continues, frequently interrupting core response activities such as identifying and isolating contacts of infected individuals and vaccinating at-risk populations. Perhaps most troubling is the trend of armed groups increasingly focusing their attacks directly on Ebola responders and the clinics where patients are being cared for. Over 100 violent attacks have occurred in the region since the start of the outbreak, including the murder of a WHO epidemiologist in April, and 42 separate attacks on health care facilities. These risks to come on top of the risks that workers face from Ebola itself, as over 100 health care workers have been infected during this outbreak so far, and 34 have died. This unique combination of factors has made responding to this outbreak a much more difficult challenge compared with previous outbreaks in the DRC.

WHO and DRC Government Lead the Response; More Financial Support Needed from Donors

The WHO and the DRC Ministry of Health, with other partners including UNICEF, the International Red Cross/Red Crescent, and key international NGOs such as MSF (Doctors without Borders) and International Medical Corps (IMC), lead the current Ebola response in the country. In February, the DRC government launched the third iteration of its Ebola response plan, covering planned activities from February to July 2019. In February, WHO said fully implementing the new plan requires $148 million. While donors have provided some assistance, including $80 million from the World Bank, as of early May WHO reports there is still an urgent $54 million funding gap yet to be filled.

There have been notable successes in the response so far, including vaccinating over 110,000 individuals, which has likely saved hundreds if not thousands of lives. In fact, WHO is now recommending an expansion of the use of the vaccine in the response as a way to address the epidemic. A WHO International Health Regulations Emergency Committee has met three times during the course of the outbreak (most recently in April) and has so far decided against declaring the DRC outbreak a “public health emergency of international concern” given that it primarily remains a threat that is contained within the eastern Congo region. If the virus spreads across borders, or if there is a very large increase in cases in other areas within the country, however, the WHO decision may be revisited yet again and an emergency declared. While some experts have called for such a declaration given the challenging situation in eastern Congo, others believe that declaring an emergency would not make much difference or may actually even make the situation worse.

U.S. Support Continues, Though Limited and Restricted

The U.S., along with other countries, continues to contribute to the response, providing technical assistance and expertise along with funding and other support. Direct engagement in the response in affected communities by U.S. personnel has been curtailed due to the security situation. Citing safety concerns, U.S. officials have decided to keep Centers for Disease Control and Prevention (CDC) and other staff away from the front lines of the response. Currently, there are a number of US personnel in the country as part of a Disaster Assistance Response Team, including over a dozen CDC employees, most of whom are based in the capital Kinshasa – about 1,000 miles from the epicenter of the outbreak. Other CDC workers have deployed to WHO headquarters, and to neighboring countries such as Uganda to assist in preparedness and response activities should the virus cross borders.

Donor funding information is limited, but according to data from the United Nations, of the $70.6 million provided by donors for the DRC Ebola response in 2018, $11.7 million (16%) came from the United States. Comparable figures for 2019 donor flows are not available. The U.S. assistance for the Ebola response is part of a broader set of humanitarian and development efforts it supports in the country.

Given ongoing transmission, growing numbers of cases, and continued interruptions to the response, outside experts have made repeated calls for increased U.S. engagement, including returning CDC staff to affected areas to assist more directly and ramping up political pressure to mount an effort to reduce the violence in the affected regions. So far though, there is little indication that the US government will deviate from its current policy of keeping U.S. personnel out of those regions. Little information is being provided by the U.S. government about its strategy for the Ebola response in DRC going forward, though there are indications that a new U.S. effort is being planned to address the affected communities’ mistrust in response. Some in Congress are concerned that expanding support for Ebola in DRC may be restricted by existing U.S. laws that place limits on assistance to countries linked to human trafficking, and have introduced legislation to clear the way on any such impediments.

Uncertainty Ahead

Earlier this year, WHO had stated it believed it could work effectively with its existing partners, even without the presence of the US in the affected provinces, to contain the outbreak. Most recently, though, WHO officials have sounded much more concerned about the state of the outbreak, with the WHO Director-General saying he is “profoundly worried” and asking for additional support from the U.S. and other donors. The security situation that has driven the spread of this outbreak shows no sign of abating and those leading the response estimate it will take many more months to contain it even under the best of circumstances. Despite an increased global capacity to address Ebola generally, the outbreak in DRC remains extremely concerning and has potential to get worse.