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

The current Ebola outbreak in the Democratic Republic of Congo (DRC), which began in July 2018, is now the largest in that country’s history and the second largest ever recorded. According to the country’s health ministry, as of January 15, 2019 there have been 663 cases and 407 deaths in the outbreak, which is centered in 2 northeastern provinces. No cases have yet been identified outside DRC, though cross-border transmission remains a risk as does concern about exposure for international travelers and responders. In late December 2018, for example, an American doctor working in the outbreak zone was flown to a specialized clinic in Nebraska for monitoring after possible exposure to Ebola, although he was subsequently released after officials determined he was not infected.

Violence and unrest continue to hinder efforts to control the Ebola outbreak in the Democratic Republic of Congo. Here’s a look at the impact on the international response, including the limited role played by the U.S.

Despite improvements in the global capacity to respond to Ebola that have come since the major 2014 West African Ebola epidemic (outlined in our previous brief), the current outbreak has proven especially challenging because the virus is being transmitted in an active conflict zone. In 2014, the US played a major leadership role, mobilizing an unprecedented amount of resources and personnel to support the Ebola response in West Africa. In the current outbreak, though, the U.S. role has been more limited, with American personnel restricted from working directly in the hardest hit areas due to security concerns. This has led some calls 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), 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 in DRC Render Response Difficult and Risky

Conflict in the Ebola-affected provinces predates the current outbreak, and has impeded the response from the start. The long-standing violence in the region coupled with Ebola prompted the UN Security Council in October 2018 to raise concerns and call on armed groups to respect the humanitarian worker engaged in the Ebola response.

Long-standing conflicts in the Ebola-affected provinces have now been exacerbated further by unrest and violence stemming from the recent, contested national elections. Voting took place on December 30, but prior to that date the government decided to bar voting in the two provinces with Ebola transmission, citing the outbreak as the reason. These two provinces also happen to be centers of opposition to the current ruling political party. After the vote, the government postponed reporting the results, originally scheduled for release on January 6, and shut down internet and messaging capability nationwide for several days, reportedly in an attempt to prevent dissemination of “false” election results. When the government finally announced provisional results on January 9, it declared a winner, but many in the country including the Catholic Church, along with outside analysts and observers, have called the results fraudulent. Subsequent protests and violent demonstrations have left over 150 dead nationwide.

Armed group activity in and around cities and villages with Ebola transmission has impeded access for responders and made communities less receptive and, at times, even hostile to public health responders. Ongoing violence has frequently interrupted core activities such as identifying and isolating contacts of infected individuals and vaccinating at-risk populations. The post-election unrest and spread of misinformation has often exacerbated the difficulties for authorities. In the Ebola-affected province of Beni, for example, people vandalized clinics and burned an Ebola transit center (where patients await testing results), which led to the scattering and loss to follow up of people potentially infected with the virus. In response to the growing post-election insecurity, a number of major NGOs involved in the Ebola response reduced staff or stopped operations entirely.  In recent days, access has been regained and operations have resumed but the threat of violence and interruptions in response remain.

WHO and DRC Government Lead the Response

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. There have been notable successes so far, including vaccinating over 60,000 individuals and likely saving hundreds if not thousands of lives already. To date, the response has cost the international community an estimated $120 million, with more expected to be needed as the epidemic grinds on. Unlike in 2014, the WHO International Health Regulations (IHR) Emergency Committee (EC) has so far decided against declaring the DRC outbreak a “public health emergency of international concern”, though if the virus spreads across borders or a large increase in cases occurs, the WHO may revisit this decision.

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 from U.S. personnel has been curtailed due to the security situation, with U.S. officials pulling Centers for Disease Control and Prevention (CDC) staff back from the front lines of the response over safety concerns. Reportedly, about a dozen U.S. personnel comprise a Disaster Assistance Response Team in country – including staff from the U.S. Agency for International Development (USAID) and CDC – but are based in the capital Kinshasa about 1,000 miles from the epicenter of the outbreak. Other CDC workers have deployed to WHO headquarters, as well as to neighboring countries such as Uganda to assist in their preparedness and response activities should the virus cross borders.

The contentious national elections in DRC have only heightened the security concerns for U.S. personnel. On Dec. 14, 2018, the U.S. State Department evacuated all non-essential government employees from the DRC due to the threat of election violence. On January 4, 2019 President Trump announced the deployment of 80 US Armed Forces personnel to nearby Gabon “in response to the possibility that violent demonstrations may occur” in the wake of the DRC elections. These deployed personnel will remain in the region until “their presence is no longer needed”.

Given ongoing transmission and interruptions to the response, some 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 USG will deviate from its current policy of keeping U.S. personnel out of those regions, especially in light of the increased risk of violence in the post-election period. Little information is being provided by the U.S. government about its strategy for the Ebola response in DRC going forward, particularly regarding if and how it might change with a large increase in cases or if Ebola transitions to a long-term problem in a region that remains inaccessible for U.S. personnel.  Further exacerbating the lack of communication about and attention to the events in DRC is the ongoing partial U.S. government shutdown – now going on more than 26 days. While it has not directly affected responders yet, it could have snowballing negative effects the longer it continues.

Uncertainty Ahead

For its part, WHO believes it can work effectively with its existing partners, even without the presence of the US in the affected provinces, to contain the outbreak. Still, 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 at least 6 more months to contain it. Despite an increased global capacity to address Ebola generally, the outbreak in DRC remains extremely concerning and has potential to get worse.