More than 900 people have been sickened by the Ebola virus since it began spreading in the Democratic Republic of the Congo (DRC) in early August. The outbreak, now the second-largest ever recorded, shows no sign of slowing—fuelled, aid workers and government officials say, by a toxic cocktail of violence and mistrust.

Conflict in the northeastern DRC, the centre of the Ebola outbreak, has surged in recent months. Political protesters robbed and burned an Ebola-treatment facility in Beni in late December, after the DRC government blocked more than one million people in areas stricken by Ebola from voting in the country’s presidential election. And last month, armed assailants torched treatment centres in Butembo and Katwa. Front-line Ebola responders in those cities—who disseminate health messages, track down potential cases and bury the dead—face threats and assaults nearly every day.

The constant violence has hampered efforts to contain the virus. “There’s so many armed groups in this place that you don’t know where the next problem will happen,” says one front-line responder, who asked for anonymity because he is not authorized to speak to the press. “We are thrown into the fire.”

Just as worrisome, epidemiologists say, are recent data from the World Health Organization (WHO) that suggest the virus is spreading undetected. During the last three weeks of February, 43% of the people who died from Ebola in Katwa and Butembo were found dead in their communities—not isolated in hospitals in the late stages of the illness, when the disease is most infectious. And three-quarters of those diagnosed with Ebola had not previously been identified as contacts of people who had contracted the virus.

Taken together, the statistics suggest that the virus is spreading outside known chains of transmission, making it harder to contain and driving up the mortality rate compared to previous outbreaks. The current death rate of about 60% is higher than it was during the much larger 2014–16 Ebola crisis in West Africa, despite improvements since then in how people with Ebola are cared for, including the introduction of several experimental drugs.

“We can have the best treatments in the world, but it won’t decrease mortality if patients don’t come in or come in too late,” says Chiara Montaldo, medical coordinator for aid group Médecins Sans Frontières (MSF, also known as Doctors Without Borders) in the DRC’s North Kivu province.

Uncharted territory

This Ebola outbreak is the tenth in the DRC since the virus was discovered there in 1976. It is by far the largest and longest ever to strike the country, with an estimated 907 cases and 569 deaths, as of 5 March (see 'Advancing outbreak'). Unlike earlier epidemics, this one began in war-torn northeastern DRC, where waves of conflict have killed up to six million people since 1997.

The region is home to dozens of armed groups, and is also a stronghold for opponents of the DRC’s ruling political party. Many residents are suspicious of the effort to stamp out the Ebola outbreak, because they see it as intertwined with the government’s treatment of its political foes. The decision last year by former president Joseph Kabila to block people in the cities of Beni, Butembo and Yumbi from voting—to prevent Ebola's spread—exacerbated those suspicions.

A sustained response from the DRC Ministry of Health, the WHO and MSF, among other groups, has curtailed the outbreak in the communities where the virus first emerged, such as Mabalako, Komanda and Beni. But as people move, so does Ebola. The virus has spread into new areas, including Butembo and Katwa.

Credit: Nature, March 8 2019; Source: World Health Organization

Ongoing violence prompted MSF to suspend its activities in the two cities on 28 February. Leading public-health agencies outside the DRC, such as the US Centers for Disease Control and Prevention, have deemed North Kivu province—where Butembo and Katwa are located—too risky to enter. Instead, epidemiologists from the United States and other Western countries are monitoring the situation from afar.

The WHO has kept its staff in place, but is considering whether to use United Nations peacekeeping troops to help secure the clinics and compounds where its employees work. “We are worried for our people,” says Ibrahima Socé-Fall, the WHO’s assistant director-general for emergency response, who is based in Brazzaville in the Republic of the Congo, just across a river from the DRC. In the meantime, the WHO has stepped up discussions with community leaders and is preparing residents to help carry out the Ebola response. “We want to reduce the dependency on international partners,” Socé-Fall says.

Sounding the alarm

To help halt Ebola’s spread, some health-policy analysts want the WHO to designate the DRC outbreak a public-health emergency of international concern. That could increase international cooperation and mobilize aid, as it did when the WHO declared a public emergency seven months into the West African Ebola epidemic of 2014-16.

The WHO estimates the cost of stamping out the current Ebola outbreak in the DRC at US$148 million. As of 26 February, WHO member countries had committed less than $10 million, according to the agency’s director-general, Tedros Adhanom Ghebreyesus.

“If this isn’t a global health emergency, what is?” says Lawrence Gostin, a health-law and policy specialist at Georgetown University in Washington DC. The ongoing conflict in the northeastern DRC makes the outbreak extraordinary, he says, and the thousands of people regularly passing from the northeastern DRC into South Sudan, Uganda and Rwanda increases the risk that the virus will spread.

Proponents of an emergency declaration say that it would enable the WHO to denounce government actions that could harm the Ebola response, such as the DRC’s voting restrictions last year or the United States' decision to stay out of the outbreak zone. A declaration could also put pressure on the DRC to improve health services and security in communities traumatized by Ebola and violence, says Oyewale Tomori, an independent virologist in Ibadan, Nigeria.

Since October, the WHO has repeatedly decided against declaring a public-health emergency, saying that Ebola is unlikely to spread globally and that aid groups are providing sufficient help to limit the outbreak. Some specialists in global health speculate that the WHO’s reluctance to declare an emergency is influenced by geopolitical issues, too. Declaring an emergency might trigger countries around the DRC to block border checkpoints, for example, which could depress the region’s economy and make it harder to know when people with Ebola enter other countries.

And David Heymann, an epidemiologist at the London School of Hygiene and Tropical Medicine, says that leaders of armed groups in the region might use an emergency declaration as leverage to negotiate for territory, resources or power, in exchange for allowing Ebola responders to do their jobs. “Infectious agents can be held hostage,” he says.

Then there’s the issue of whether an emergency declaration does anything at all. Adia Benton, an anthropologist at Northwestern University in Evanston, Illinois, says that the turning point in the West Africa epidemic may not have been the decision to declare an emergency, but the news of a handful of cases of Ebola in the United States. Whether or not the WHO sounds the alarm in the current outbreak, she fears that it will continue to fester—just as the world has largely ignored arson, starvation and violence in the DRC for a quarter-century.

This article is reproduced with permission and was first published on March 8, 2019.