According to the latest estimates from the World Health Organization, an outbreak of Ebola in the Democratic Republic of Congo has killed over 1400 people. This makes it the second worst ebola outbreak in history, following the 2014 outbreak in West Africa that killed over 11,000 people.
The current outbreak in the DRC is so far confined to the eastern part of the country, which has long been beset by insecurity and violence. There were, however, two cases reported over the border of Uganda from a family that contracted the disease while attending a funeral in the DRC. This marked the first time that this outbreak crossed an international border which brought this long festering outbreak back into the news.
On the line to discuss some of the international efforts to halt the spread of ebola is Ambassador John Lange. He is a retired US Ambassador and currently serves as the senior fellow for global health diplomacy at the United Nations Foundation. We kick off discussing why this outbreak has been so hard to contain and then have a broader conversation about strategies the international community, including the World Health Organization, are using to halt this outbreak.
If you have 20 minutes and want to learn why this outbreak is still festering and not under control, have a listen.
The outbreak that is currently going on in the DRC actually began on August 1st of last year. It has not been possible to get it totally under control for two reasons. Firstly, it is the result of insecurity in North Kivu and eastern DRC. Secondly, it is hard to get community acceptance to change burial practices and other traditional factors to control this outbreak.
There have been 174 attacks on health care resulting in five deaths and 51 injuries of health care workers and patients. It is a difficult and tumultuous situation in terms of the different groups involved. The DRC does not have full control over all the districts in that part of the country.
There is a challenge of getting communities in Ebola affected areas to cooperate with health officials. Can you discuss why that element has been lacking?
There was the Ebola outbreak in 2014 in West Africa involving Sierra Leone, Guinea, and Liberia. There are certain community practices that will be followed during an outbreak, like touching the dead body of a loved one. This practice can cause the disease to spread further, so it really must end. Secondly, when someone takes a loved one to an Ebola treatment center they are separated from them. That can be very difficult because it is a human’s natural response to want to be close to a loved one if they are sick or dying. It is not as simple as just explaining these factors in advance to communities in parts of the world where Ebola could break out. Instead, you have to deal with it after Ebola breaks out in a particular situation. The communities tend to focus on their local needs rather than what the government wants them to do. Therefore, WHO and other organizations must work closely with community leaders to bring about change.
What are some of similarities/differences in how the international community is responding now compared to in 2014?
It is totally different. Prior to 2014, WHO was not expected to have a robust emergency response capacity. By August of 2014, it was clear the world needed a stronger emergency response capability. There have since been massive changes, first under Director-General Margaret Chan, and now under Director Tedros.
How is that being manifested on the ground in the DRC?
They now have an Assistant Director-General based in the DRC. They also have around 670 people on the ground working there. Dr. Tedros himself, just Saturday, was in Butembo. He has visited several times to point out that WHO needs the funding to meet those needs, and boost morale. The Secretary of Health and Human Services, Dr. Alex Azar, was speaking positively about the response of WHO and Dr. Tedros.
Can you talk about the role of the vaccine and how it is being deployed?
It is still experimental but it has proven to be highly effective with a 97.5% efficacy rate. WHO has vaccinated 32,000 health care and front line workers and over 39,500 children. The total number of individuals they have vaccinated is over 133,000. They use what is known as a ring vaccination. So, the way you deal with Ebola is to talk to the affected person, find out all of that person’s contacts who also could have been infected, and then talk to those contact’s contacts. You end up bringing the number of cases gradually down to zero.
One wonders if vaccine campaigns are the answer to the challenge of community engagement.
All of the cases except three have been in the DRC, and the three in Uganda were a family that crossed the border from DRC.
One of the few parts of international law that involves global health is the international health regulations approved in 2005 (in response to the SARS outbreak). The idea was to ensure countries were transparent when they had infectious disease outbreaks that could become global. The decision that was made by an emergency review committee not to declare a public health emergency of international concern was a decision that could have gone either way. It certainly meets one of the criteria that the outbreak an extraordinary event. The other criteria is there must be international spread, and the committee did not believe it constituted a threat beyond the immediate region.
There is a robust response, not just from the WHO, but also the UN. They have just announced that David Gressly will be the UN Emergency Ebola Response Coordinator in the Ebola affected areas of the DRC. WHO is the technical lead, while the UN has a broader role. Other UN agencies, like UNICEF, the World Food Program, and many NGO’s have been involved as well. Declaring this a public health emergency of international concern would not necessarily have enforced a more robust response.
There is still a funding gap, can you talk about that?
You can tell an international organization, “you need to create a robust emergency response capacity, we can’t risk a global Ebola outbreak.” Then the organization tries to create that and the money is not forthcoming at the levels needed. WHO requested 98.4 million dollars but there is a still a gap for over 50%. On the whole, the international community has not fully funded this effort. There is not a choice, we cannot risk a global outbreak. The longer it goes on, the greater that risk is.
The fear of Ebola can be so distorting to policy. In 2014 there were US governors who undermined the global Ebola response by quarantining nurses and doctors when they arrived back in the US. Now the concern is that if an emergency is declared there may be travel bans which can deter the robust response required to confront this crisis.
Exactly. If you closed US borders you would only gain about one week in terms of an advantage prior to the time a vaccine could be created. Modelling has shown that even if you close your borders it won’t make much difference, yet that is the natural inclination of people in government leadership positions. One of the fears, if this were to be declared a public health emergency of international concern, is that countries would close their borders rather than monitor the potential people who could be infected. Closing the border does more harm than good.
What sort of indicators will you be looking toward that will suggest if this outbreak is trending in the right direction?
The goal is to get to zero. To get there, you have to reduce the number of cases each week. The idea is to look community by community.