More than a Disease: Migration, Militia and Money in the Ebola Response
Millions of displaced persons. Hundreds of rebel groups. Hundreds of millions of dollars in foreign aid. And one disease that continues to ravage the Democratic Republic of Congo. Here’s how it all began, and why the epidemic is so problematic to this day.
What is Ebola and How Did it Get to DRC?
Ebola Virus Disease (EVD), or Ebola, is a fatal virus that has prompted one of the world’s most pressing public health emergencies to date. It gets its notorious name from the Ebola River in Yambuku, Democratic Republic of Congo, where the virus originated in August 1976. The current outbreak in Kivu, which has affected the North Kivu, South Kivu, and Ituri provinces in the DRC is the second-largest Ebola epidemic ever. The disease is deadly. Its death rates range anywhere from 25–90%, with an average of approximately 50%. A high morbidity rate, in combination with a variable, lengthy incubation period of 2–21 days makes the disease incredibly difficult to contain. Like many other infectious diseases, Ebola was originally introduced to the human population from an animal vector. Fruit bats are the primary carriers of the virus, and it is thought that these bats were responsible for the initial case, either directly or indirectly via human fruit consumption.
The Kivu Epidemic began on August 1st, 2018 when four cases in the North Kivu Province tested positive for Ebola.
How did this become the second largest Ebola epidemic in history?
The final layer in the epidemic, which is separate from disease transmission and treatment, is the tremendous lack of stability in the area. North Kivu is currently in the middle of a serious military conflict, with an estimated 70 active rebel groups in the area vying for control and power in the region. The total count could be well over 100, given the difficulties associated with identifying specific factions.
Conflict complicates the disease response because if it’s unsafe to establish health facilities, people suffering from Ebola are helpless. This was true in the first month of the epidemic, when a doctor infected with the virus spread the disease to 97 patients in a conflict zone. Humanitarian aid could not reach these infected individuals because they were entirely surrounded by rebel groups.
The outbreak region in the DRC also shares borders with Uganda and Rwanda, which heightens the possibility of disease transmission — especially considering there is significant movement due to trading activity. In June of this year, the first cross-border victim of Ebola was identified, when a 5-year-old Congolese boy died in Uganda. The added stresses of migration and armed conflict prevents proper health delivery in communities vulnerable to Ebola, and it is likely that major advances in treatment will not be seen until peace can be established.
The April-June timeframe in 2019 was especially problematic for Ebola for a variety of reasons. Dr. Richard Mouzoko Kiboung, a Cameroonian epidemiologist employed by the WHO to fight Ebola, was murdered on April 19th, 2019 at Butembo University Hospital. Two gunmen carried out the attack during the staff meetings, murdering Mouzoko and injuring two other staff. The facility could not treat patients for several days following his death, and the death toll in Butembo increased tremendously over the next two months.
The attack in Butembo was not the only of its kind during the Kivu epidemic, as health workers were targeted before and after Mouzoko’s murder across the DRC. Some experts say it is a sign that there are Congolese who mistrust government, and the presence of foreign health workers. However, given there are 70 militia groups spread throughout the nation, it is difficult to assess who is responsible for the attacks, and why exactly they are staged. The repercussions of the attacks are immense, because violence disrupts efforts to contain and treat the disease.
Another factor that has contributed to the high morbidity across North Kivu is displacement. Estimates suggest that since June 2019, over 400,000 individuals have been displaced due to heightened conflict in the region. According to UNICEF, there are nearly 1.3 million internally displaced persons in the DRC in total. Without permanent homes, Congolese citizens migrate more freely, especially given the proximity to Uganda. In terms of infectious disease management, migration increases the likelihood of transmission because a person suffering from Ebola who is mobile is far more likely to infect a healthy person. Quarantines exist for a reason, and with migration flows that are unpredictable and high in volume, health workers have to be even more attentive to identifying symptoms in vulnerable populations.
Hotspots
Not all health zones in the DRC were created equal. There are certainly some health zones which are more equipped to treat the disease, while others suffer because lack of staffing and location in relation to militant groups. The graph below shows how the health zones compare against one another. Beni and Katwa are by far the most affected of all of the zones, accounting for over 1300 of the 2,907 cases tracked in the data. Beni is located about 40 minutes away from Magina, the origin of the outbreak in August 2018. Butembo has highest death rate of all health zones, defined as the number of deaths divided by the number of cases.
Okay, is there at least some silver lining?
Indeed there is. The DRC is certainly not alone in fighting Ebola, and in fact, US governmental aid to the DRC reached its maximum in August 2019. Countries across the world recognize that public health emergencies like Ebola require coordinated efforts, and with migration and violence complicating the issue, there is all the more urgency to provide effective aid to the DRC.
Worldwide, aid to the DRC has increased from approximately $2.5 million in September 2016, to its maximum of nearly $130 million in April 2019. The future may be uncertain and unstable, but there will continue to be public and private support to fight the Ebola response.
From a treatment point of view, Ebola was officially declared curable in August, as two drugs, REGN-EB3 and mAb114, showed remarkable survival rates. In a clinical trial with nearly 500 subjects, patients taking REGN-EB3 had survival rates of up to 94%, while those taking mAb114 survived 89% of the time. These results demonstrated that effective containment of the disease is possible and that outbreaks can be mitigated if these drugs are properly distributed.
To attack the foundations of the disease, though, a vaccine is imperative. Merck has continued to manufacture the rVSV-ZEBOV Ebola vaccine, which the WHO estimates has a 97.5% efficacy rate compared to patients who are not vaccinated. Since August 8th, over 200,000 individuals have been vaccinated in the Congo. With additional funding and streamlined distribution schemes, the combination of vaccines and drugs have the potential to end the Kivu epidemic as we know it.
Data Visualization Process
To acquire up to date information on the Ebola response by health zone, I utilized data from the Humanitarian Data Exchange. This was a pretty robust data source, and I was impressed that the site generated reports on a daily basis. The data I collected was last updated on 9/1/2019. I combined this information with a shape file that created the health zone boundaries, so I could create maps for the metrics. Once these datasets were joined by health zone, I created all visualizations in Tableau.
Closing Thoughts
The Kivu epidemic is a testament to the fact that there cannot be a one-size-fits-all solution to eliminate Ebola. In the coming days, months, and years, a coordinated effort between peacekeeping, infectious disease management, foreign aid, and government protections will be integral to seeing the end of Ebola in DRC. Ebola aside, the circumstances in DRC remind those of us working in international aid and development to consider the complexity of issues that can contribute to a particular problem. By unraveling this complexity, we can begin to see the potential for effective solutions.
