GENEVA – An Ebola epidemic called by experts calling "exceptionally dangerous" is taking place in the Democratic Republic of Congo.…
GENEVA – An Ebola epidemic called by experts calling “exceptionally dangerous” is taking place in the Democratic Republic of Congo.
So far, there have been more than 420 cases and 240 deaths, making it the biggest outbreak of Ebola since the outbreak of West Africa 2014-2016, which killed 11,000. It is also the second largest Ebola outbreak on record.
People have been messing with the Ebola virus for centuries with deadly results. But until five months ago, Ebola had never appeared in an active war zone.
On August 1, the World Health Organization declared an outbreak of Ebola in the Democratic Republic of Congo. The virus had begun spreading in cities in northern Kivu, an unstable province in Central African countries, where the fighting between several rebel and militia groups has repeatedly interrupted the disarmed work of health workers who came to respond to the outbreak.
Although Ebola respondents have never had so many tools at their disposal to fight the virus ̵
1; experimental vaccines and treatments that have shown promise – the incidence of the disease has more than doubled since September. Even worse, many of the newly diagnosed cases can not be linked to other known cases. This means that there are still people spreading the disease that health officials have not yet identified.
Due to the ongoing conflict in the region, the US government has decided it is too dangerous to let its highest Ebola experts work at the outbreak epicenter. The United States has maintained this position even though there is concern from public health professionals who say the US does not do enough to help.
To unravel how the outbreak became so bad, and what the WHO needs right now, I sat down with Peter Salama, head of the WHO healthcare program. His team was created in 2016 as a direct response to the WHO fumbling of the West Africa Ebola eruption. This year he has helped the organization respond to 50 health situations in 47 countries.
But the Ebola eruption in the DRC is something else, Salama said. Sits at his office in Geneva, in front of a map of the Democratic Republic of Congo – as he holds before him “to remind me that I have to focus on this in a minute” – he went through the extra complexity of trying to throw an Ebola- outbursts in a war zone and why the WHO can use the world’s best Ebola senses right now. Our conversation has been edited for length and clarity.
The United States pulled out their centers of disease control and preventive workers from Beni, the outbreak center, in early September. They decided it was too dangerous for America’s best Ebola experts to be there – and it sounds like they will not be back anytime soon. Can the United States do more? Do WHO need these experts now?
As we go more and more into the outbreak, we are taxing all our abilities, so we must allow staff to take a short break at some point and update. We have to look at rotating staff – because people work 20 hours a day here in Geneva and [in DRC]. We do not want people so exhausted they burn out. So we need people. We have people coming in and for some countries, not just the US, they have security concerns.
But I understand Canada, Great Britain, also ideal with American staff, sending people, and you have hundreds of WHO officials deployed. Is the US government an outlier?
The US government is the most important country that has had limitations. But others have asked many questions, need security, and are limited in their respondents.
What kind of people do you need right now?
Some of the most important areas where people are not easily found are the most common viral haemorrhagic epidemiologists, those who specialize in viral haemorrhagic fever. [We need] Medical Logistics but not just General Logistics – People Know How to Set Up the Cooling Chain at Negative 60-80 Degrees Celsius [to keep the vaccine cold] and Ensure Its Integrity to Beni. So it’s not just the average humanitarian worker we need.
What about money? The WHO Health Fund has never received $ 100 million from donors, including the United States, requested it. How do you work in this constant state of underfunding?
We asked for $ 100 million initial capital when we started three years ago. We never got 100 million dollars. But because it is constantly used and constantly filled, it’s not the end of the world. Over the past two years, we have spent about $ 60 million to respond to 70 events. This year we have received nearly $ 40 million with further promises. So that has been good support.
I would like to come to a more formal system in place where, for example, the G20 country says that we guarantee this fund, as it is so important for global security, will never fall below $ 50 million. That’s where I would like to come to.
The DRC had seen nine Ebola eruptions since the virus was discovered in 1976. What does this 10th outbreak differ?
It is an outbreak that I describe as a perfect storm – a combination of this fatal disease in one of the most difficult long-standing crises we have around the world.
In northern Kivu there is a long civil conflict, close to many international borders – Uganda, Rwanda and South Sudan – and a population constantly on the road with 1 million displaced people from  million inhabitants. It is also a population that is very traumatized, especially in and around Beni [the outbreak epicenter]. People have been subject to a huge number of serious attacks consistently since 2014 but date back to even the Rwandan genocide [in 1994].
The population is so traumatized that everything for them is seen through the lens of mistrust of authority, physical uncertainty, and the inability of the world to protect them. These viruses manage to exploit social vulnerabilities and fatalities. That is what we see in this Ebola outbreak strongly.
A cause cited for the ongoing Ebola spread is the distrust caused by this violence and instability in northern Kivu – that it contributes to the spread of Ebola when people do not go to treatment centers or work with responders. What does the WHO do to overcome it?
The most important thing we can do is understand what societal perceptions and behaviors are related to the outbreak. We have sociologists and anthropologists – both local and international – work close together with the WHO. So we ask questions to those we want to know.
Once we entered North Kivu, we wanted to understand more about the political economy. It’s a mineral rich part of DRC: 60 percent of the world’s cobalt, the critical ingredient of electric car batteries. Mineral wealth has a lot to do with why it’s so unstable. Anthropologist a gave us an introductory briefing to help set the response from the WHO.
Since then, we have asked them more everyday but critical questions – about important funerals, the ongoing perception of the Ebola response. Some of the feedback we received was fascinating. Everyone thought that this was the 10th outbreak of Ebola in the DRC, that there would be great knowledge and awareness about Ebola. But consciousness was abysmal, among healthcare professionals.
It was an interesting Lancet study once again showing that people in the DRC trust the Ebola vaccine but would not send their family to healthcare centers. Is that still the case?
Awareness and Knowledge [about Ebola treatment is changing]. There is a much more sophisticated understanding of how this Ebola response fits into the concerns of the people about protection and security. The constant refrain has been: “Look, we think the Ebola response is very important and supports it as a community, but we want you to give at least equal to no more attention to our physical protection and security. We do not want to survive Ebola to die of physical violence. “Women’s groups, youth groups – they are very articulate about it. They send a message to the international community.
It seems like a much bigger challenge than your device or WHO can deal with.
We have 300 employees and every night I lose sleep thinking that they are in the line of fire. Two weeks ago, there was a big event in Beni. There were bullet holes through several of our staff’s walls. They sent us pictures. We temporarily moved staff who felt the effects of being in the fire. An ordnance landed on their boarding house. It did not explode, but if so, they probably had all died.
] This violence and insecurity – would you still say that it is the biggest obstacle to get this outbreak under control?
The most important challenge here has always been this confusion of really violent security incidents and constant attacks. Beni, the epicenter, has had more than 20 serious attacks since the eruption was declared on August 1, so it is constant. On the other hand, we know it’s a bad bike with the community’s mistrust. Then they go together.
But people accept the vaccine?
When you look at the ring vaccination you will find a confirmed case and contacts around the bag and vaccinate them. We may have made 240 rings around confirmed cases. With over 90 percent of these rings, we achieve between 95 and 100 percent of coverage. So that’s overwhelming acceptance.
But what happens more is that people question why the vaccine is not used to a much greater extent – so they do not understand this ring vaccination strategy.
It’s not an easy question to answer. We must explain that it is a specific strategy that worked to eradicate a disease [smallpox] and it has worked in earlier Ebola responses. We also do not have a licensed product and we have a limited amount so we have to use a vaccination strategy that preserves the vaccine.
We do not vaccinate the majority of our staff. They are not imminent risk unless they participate in funeral or clinical care. So I have not been vaccinated because I do not do direct clinical care.
WHO now gives the vaccine prevention in Uganda – but considering everything you’ve described, it’s surprising that it has not already spread across borders.
There has been a lot of understanding in this eruption, things that have never been done before. One of them is the use of this experimental Ebola vaccine on this scale. We have more than 37,000 people vaccinated.
We know that vaccination has an important impact. In [outbreaks] we speak of something called reproduction number [or the number of people one sick person can infect]. Also for Beni is the reproduction number 1. When Ebola is very hot it can get up to 2 to 4.
Many observers talk about this Ebola outbreak as the main test for your health emergency unit. Has it caused you to think about how you work or structure?
This is probably the biggest test for all public health institutions or knowledge regarding an outbreak of Ebola. This is the most difficult context we have seen, and we have people who have been involved in Ebola since the 80’s. So it’s a test for everyone, including the WHO.
We are very convinced that we have the right people and systems. The question really is the context – an outbreak that is this volatile requires us to regularly review strategies. We keep open and make sure we listen to experts from different advisory groups.
We use it [advice] to continue challenging all assumptions and revising our strategies. There will be no point when we say, “Let’s change everything and start over.”
We know that these strategies – traditional public health and breakthroughs such as vaccines and therapy – help us to stop the outbreak. But the minimum requirement from this point, according to the epidemic curve, is that it takes at least six months [to stop the outbreak].
] I In the month there are elections in Congo. This is a moment of real excitement given the sharp political environment. Is there concern that the choice could prevent the answer and what does the WHO do about it?
The election is scheduled for December 23 and we are very vigilant to make sure that Ebola is not used as a political issue in connection with the election.
It’s difficult – we have to engage all community leaders, regardless of whether it’s governor in Kivu, mayor of Beni, opposition parties – to make everyone understand that this is beyond the table. We do not want to use Ebola for that purpose. So far, they have been susceptible to it. But it is a constant awareness and education process. It is important to have society behind us in this.
I remember to learn early as a health reporter that Ebola was a virus that no one thought would go epidemic because it was so difficult to transfer – people became so sick and died so fast. But it was knowledge of rural outbreaks, and since it has appeared in urban areas, we have seen Ebola’s true mortal potential. What is the big removal here from an outbreak response?
Over the last two years since I’ve been here, 80 percent of our major outbreaks have been in conflict-affected areas. This is the question of the future.
The issue of urban outbreaks of highly threatened pathogens is really a matter of our generation. I do not think we are full of it. Now with yellow fever, plague, with Ebola, we begin to see these patterns. All efforts are gone [in terms of] Thinking we know about transmission of diseases due to what happened in rural outbreaks in the past. It is completely different now.