Public health officials are worried that the year-old Ebola epidemic is spiraling out of control, and that the international response lacks either the urgency or funding to contain rampant transmission.
Thursday marks a year since the latest outbreak in the Democratic Republic of the Congo, which began with the death of a 65-year-old woman in a remote province. In the intervening months, the virus has since spread across an international border at least twice and to the city of Goma, the regional capital.
Earlier this week, the World Health Organization (WHO) had identified at least 2,671 cases, and 1,782 people have died.
“The situation is extremely concerning. We’re one year into the outbreak and we’re not where we’d like to have been,” said Trish Newport, deputy director of the Doctors Without Borders response team in the region.
But the actual number of infected people, and deaths, is likely higher than the number reported by the WHO. Between one-third and one-half of cases in recent weeks have come from people who are not known contacts of Ebola patients, meaning the virus is spreading through chains of transmission that public health officials have not detected.
Years of violence in the region has left more than 1 million people displaced from their homes. A stark disconnect between communities in northeastern Congo and the far-off federal government in Kinshasa has bred mistrust and antipathy, and outsiders are viewed with suspicion. Terrorist attacks and assaults on health workers have at times brought the response to a standstill.
“It’s a war zone. That’s one of the reasons why we haven’t been fully able to contain the outbreak,” said Tedros Adhanom Ghebreyesus, the WHO’s director-general. “When there is a security problem, the response gets disrupted. And when the response is disrupted, the virus propagates.”
The virus has spread across two provinces in waves, beginning in Beni, a town of about 250,000 residents. It then migrated south to the twin cities of Butembo and Katwa, where several health centers were attacked by mobs, and where several health workers were killed.
Just as the virus came under control there, it broke out again in Beni, where more than 140 people have been infected in the past three weeks.
“It was really quiet for a few months, and now the number of cases have been enormous,” Newport said. “Everyone got complacent and they put their focus elsewhere. But the rest of the population in that area moves elsewhere.”
The spread of the Ebola virus to Uganda, where a family crossed an informal border, and to Goma, where an infected pastor died earlier this month, illustrates the danger posed by a highly transient population in an area where more than a million people have been displaced from their homes. After those two events, the WHO declared a Public Health Emergency of International Concern -- only the fifth time it has made such a declaration.
“This area is a gas can waiting for an Ebola match to hit it,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “Failure is not an option here. I worry every day that it’s going to basically jump out of this area that it’s in now and make problems dramatically worse.”
Public health experts credit the WHO, and the non-governmental organizations operating in the region, for mounting a response far more quickly than in the past. But they say those groups alone do not have the resources necessary to muster a full-scale response that includes addressing underlying political issues in a region wracked by ethnic violence and strife.
“It’s not that someone’s not doing their job in [Congo]. It’s that we don’t quite know what the job to do is anymore,” Osterholm said. “What’s happening here is we’ve got a lot of people who have answers, but I’m not sure they have the right questions.”
A new vaccine, developed by the U.S. government and produced by Merck, has reached more than 170,000 people in the region since the outbreak began. But supplies are running low, and the WHO is now considering whether it is safe to use lower doses in order to conserve the supply that remains.
The United Nations has appointed Mark Lowcock, the under-secretary general for humanitarian affairs and emergency relief coordinator, to oversee the response. But the Congolese health minister resigned abruptly last week, after Congo’s president took control of the national response efforts.
“This [outbreak] is in the setting of a decades-long humanitarian disaster. And what seems to be missing from the narrative here is I do not see a dialogue among the political scientists. You hear people talking about health, but you don’t hear the political scientists and the diplomats talking about peace development and security,” said David Brett-Major, an infectious disease expert who worked in Sierra Leone and Guinea during an outbreak in West Africa in 2014-2015 that killed more than 11,300 people.
The WHO has said it has spent nearly $250 million on the response already. It has asked international donors for millions more; the U.S. Agency for International Development said last week it would provide an additional $38 million, on top of the $98 million it had already sent to agencies including the WHO.
Without a vastly scaled-up response, public health officials worry the Ebola virus will become endemic to northeastern Congo — and become a perpetual threat to neighboring countries like Uganda, Rwanda and South Sudan.
“We really haven’t made a lot of progress reducing the risk of the next Ebola,” said Tom Frieden, the former director of the Centers for Disease Control and Prevention. “We keep getting taken by surprise, partly because we assume things are in the past, and they’re not. The infectious diseases are not dead.”