Citizens of the Democratic Republic of Congo, site of an expanding Ebola outbreak, are set to hear the results of their long-delayed presidential election on Sunday. Violence and instability in the lead-up to the Dec. 30 voting has already interrupted efforts to rein in what is the second-largest Ebola outbreak ever.
Now global health leaders are concerned that controversy and chaos in response to the election results could significantly undercut the response to what the Centers for Disease Control and Prevention is now calling an “epidemic” that so far has produced 613 cases and claimed 371 lives in the DRC.
The DRC, home to over 80 million people, has never had a peaceful democratic transition of power. President Joseph Kabila had delayed last month’s election to choose his successor for two years. The election commission has put off releasing the voting results until at least Jan. 6. In the meantime, both the ruling party and the opposition forces are claiming victory.
Multiple irregularities undercut the integrity of the vote, the opposition and observers say. The ballots from the northeastern cities of Beni and Butembo, both hot spots of the Ebola outbreak as well as opposition strongholds in the northeastern province of North Kivu, will not even be counted until March ― months after the new president is expected to take office. The threat of Ebola was the reason given for officially delaying the vote there, although the citizens then organized their own vote.
Electoral protests turned violent in Beni, with people burning an Ebola transit center and scattering the patients waiting for test results there on Dec. 27, as well as vandalizing several other health facilities. That violence and other election protests, which focused on Ebola facilities after the government blamed the epidemic for the voting delays, led several non-governmental organizations to temporarily stop operations in the region over the last two weeks. At least five international NGOs that had been offering critical assistance to the World Health Organization and the DRC Ministry of Health ― Mercy Corps, Médecins Sans Frontières, International Medical Corps, Oxfam and the International Rescue Committee ― have at least partially pulled their personnel out, according to the IRC’s new field director for Beni, Dalia Al-Awqati. (HuffPost was able to independently verify all but the IMC by press time.)
The WHO’s operations were notably affected from Dec. 24 through Jan. 1, said Mike Ryan, the agency’s assistant director-general for emergency preparedness and response. He told HuffPost that responders were significantly limited in their ability to get into the field and to track contacts and administer vaccinations.
While the WHO is essentially back up to speed now, other NGOs like the IRC and MSF are still ramping their operations back up. And now they’re working without internet or SMS, since the government has cut them both country-wide, allegedly to preserve public order, since Dec. 31. The IRC’s departing Beni coordinator, Nora Love, said the internet and texting suspension had severely hampered data collection and contact efforts.
Reports of new Ebola cases have been lower in the last couple of days, but Ryan said that was most likely due to the absence of medical personnel, rather than any real turn in the outbreak. The last time there was an extended interruption to the Ebola response ― this September in Beni ― the number of cases surged dramatically afterward.
Rebel attacks in the Ebola-afflicted region and community resistance to outside help have impeded the medical response from the start. Now, “the elections have been the third wave of destabilization,” said J. Stephen Morrison, director of the Global Health Policy Center, a program at the Center for Strategic and International Studies in Washington, D.C. “I think [the responders] are hanging on by a thread.”
Fighting Ebola in a war zone is hard enough without the threat of electoral chaos.
“If there’s anything we need, it’s stability,” Ryan said. “It’s just important we stay the course and that we don’t lose confidence we can finish this.”
A senior U.S. government official actively involved in the Ebola response, who requested anonymity in order to be candid, also raised the alarm. “Personally, we’re all incredibly concerned what we’re seeing now and what the potential impact is going to be over the next weeks for additional transmission of disease,” the official said.
And while the current case count is a fraction of the devastation of the 2014 West Africa Ebola outbreak ― which killed 11,300 people and infected over 28,600 ― the threat of surging numbers or cross-border spread continues, Ryan said.
“It’s on the epidemiological knife’s edge at the moment.”
Fighting Without ‘Your Best Allies’
There’s no question that the WHO and the medical workers still on the ground are working around the clock to stop the outbreak, said Ron Klain, the former Ebola czar under President Barack Obama. But he argues, and many global health experts HuffPost spoke to agree, that they need more help.
The U.S. has come under fire for its decision to pull CDC personnel from Beni back to the DRC capital of Kinshasa many hundreds of miles away in August, citing security concerns. On Dec. 14, the U.S. State Department evacuated all non-essential government employees from the DRC due to the threat of election violence. Only two CDC workers remain in country.
The CDC is currently making preparations to set up a training center for DRC Ministry of Health workers in Goma, the capital of North Kivu south of Beni and Butembo. Vaccination of frontline health care workers has begun in the heavily populated area, which lies on the Rwandan border. The CDC said the Ministry of Health is also considering moving its Ebola response operations there. However, the U.S. agency would need clearance from the State Department to re-enter North Kivu. It’s unclear when ― or if ― that will happen.
“Clearly we’d love to have CDC. It’s difficult to fight a war without your best allies in the field,” Ryan said, noting however that the U.S. has offered massive financial and technical aid.
Some wonder if the Ebola outbreak would have been smaller if the CDC’s vast knowledge of epidemic surveillance and related activities had been brought to bear more fully.
“I think many of us feel that if more people had been in the area earlier that we could potentially be in a better place today,” the anonymous U.S. official told HuffPost. “But I don’t do security assessments; I do public health assessments.”
“It’s an imbalance between what is needed for this far-flung, difficult-to-control outbreak and what’s available.”
Regardless of what could have been done before, more resources are needed now, said Dr. Thomas Inglesby, director of the Johns Hopkins Center for Health Security.
“It’s an imbalance between what is needed for this far-flung, difficult-to-control outbreak and what’s available,” Inglesby said, especially in light of the current NGO pullouts and possible mass disruptions due to the election. “The only obvious new source of resources and finance and people for the response will come from countries ― including the U.S.”
In a STAT interview published Friday, WHO Director-General Tedros Adhanom Ghebreyesus said the criticism of the U.S. wasn’t entirely warranted given that other countries had also cited security as a reason for not sending government employees. And Morrison said that he doubted the CDC’s on-the-ground presence would have been a total “show-changer.”
“The bigger picture is that in the era of Brexit and the era of EU disarray and the era of Trump Washington, there’s not a lot of leadership at the major power level that’s focused on anything like this,” Morrison said. “WHO is out there alone.”
Under Rising Pressure
For Ryan, the trouble in the DRC has highlighted a broader problem: an escalating rise in the most dangerous kinds of disease outbreaks in the most insecure of situations. At the WHO, he’s in talks to expand the outbreak response team, as well as fortify in-country surveillance systems and increase in-country expert training.
“We need to scale this up for the future as the pattern of high-impact outbreaks is intensifying,” Ryan told HuffPost. “We are constantly at full operational level and we need to be able to leverage a much larger workforce to be able to [expand more] than we are currently.”
That constant deployment is taxing on response workers, as they’re going nonstop 24/7 with little relief, said Jeremy Konyndyk, a senior policy fellow for the Washington-based Center for Global Development who led parts of the 2014 Ebola response for the Obama administration.
Morrison points to the two recent Ebola outbreaks in the DRC as powerful examples of large-scale health crises amid significant security threats. “[The world has] asked WHO to play a major role along with other UN agencies but none of them are fully able to deal with security or high diplomacy demands, so what’s the strategy going to be for the future?” he asked.
“For four years, I have been advocating the creation of a ‘white helmet’ battalion of security forces that could operate globally to protect infectious disease responders. What is going on now in the DRC shows the need for such a force.”
The increasing number of worst-case crises is also driving NGOs to pull back, citing the costs and dangers to their own staff, Morrison warned ― and leaving other NGOs and the WHO to shoulder a greater burden.
The global health community may need a new security solution, Klain said. While Ryan argues that the United Nations security force, known as MONUSCO, has been protecting WHO workers and other responders on top of its peacekeeping mission in the area, Klain is pushing for a separate force dedicated solely to protecting public health responders.
“For four years, I have been advocating the creation of a ‘white helmet’ battalion of security forces that could operate globally to protect infectious disease responders. What is going on now in the DRC shows the need for such a force,” Klain said.
After The Election
For now, global health leaders are waiting to see what the DRC election results could set off. Community reaction in North Kivu will be key, with a special eye on what happens to the self-run voting from Beni and Butembo.
“It’s hard to predict how they will react if people feel like their voices are not heard,” Konyndyk said.
Meanwhile, the Ebola outbreak’s other challenges rage on, Ryan said. While rebel attacks have subsided, he stressed they don’t know how long that respite could last. Community resistance persists, especially in new areas of the outbreak. A vaccination team was violently set upon in the past week. Patient contacts are still resisting follow-up, and the outbreak is being fought on widespread fronts.
And the threat of a WHO pullout, which could be triggered by targeted attacks on or killings of the organization’s workers, remains. That would be an “utter humanitarian disaster,” said Morrison.
“Thank God that Tedros is out there in the thick of all of this and doing what he’s doing to rally his troops and put himself in the midst of all of this,” Morrison said, citing a trip that the director-general made to the outbreak area over the new year. “That’s pretty extraordinary leadership and evidence of how imperiled and vulnerable they feel.”
The global health response will have cost an estimated $129 million by the end of January, and with the outbreak expected to last months after that, they will need tens of millions more.
“Unless the disease is checked, the risk of an explosive turn in the outbreak remains: spread to a larger city in the region, or to other countries, or to refugee camps in Sudan, or even to Kinshasa,” Klain said. “That would be a catastrophe.”
The WHO will see this through, Ryan said.
“There’s no other option. We stay and deliver and support the vulnerable people that are affected by this outbreak, but we also stay and deliver as the world has to be protected from disease like this.”
An earlier version of this story indicated per the International Rescue Committee’s field director for Beni that Medair was one of the NGOs that pulled at least some of its people out of the Ebola conflict zone in late December. Medair has since told HuffPost that none of its personnel were pulled out.