The Democratic Republic of Congo’s Ebola outbreak – which has killed more than 2,200 people in the conflict-torn country since August 2018 – was supposed to be at an end.
The last known person with Ebola was discharged from the hospital in early March. The country then went 40 days with no new diagnosed cases.
But on Friday, a new case was confirmed in the city of Beni – two days before the World Health Organization was prepared to declare the outbreak at an end.
Even as Ebola has waned in the Democratic Republic of Congo, Covid-19 has been on the rise. The country’s Ministry of Health announced 215 cases, primarily in the capital city of Kinshasa, on Thursday, along with 20 deaths.
Trish Newport, who works on the ground in the Democratic Republic of Congo, is concerned that Ebola has devastated the country’s public health system, making it harder for it to fight off the encroachment of Covid-19 – along with other diseases like measles, malaria, and cholera, that kill many Congolese people.
“Land of outbreaks”
“Congo is the land of outbreaks. There’s a malaria season. There’s a cholera season. There’s a measles outbreak,” Newport, a program coordinator for Doctors Without Borders, explained.
“It’s a place where the health care system is already stretched to the limits, so the Ebola outbreak just added to the pressure.”
For people in the affected northeastern part of the country, Ebola is just one of many concerns. The DRC has been roiled by a series of conflicts that are still ongoing , driving many into displacement camps.
At one point, Newport said, as many as 6 out of every 10,000 children were dying, every day, in those camps, primarily due to what she calls the three “classics” – diarrhea, malaria, and respiratory infections – rather than Ebola.
Newport described an interview with a woman who had seen three children die as a result of malaria and whose husband had been killed in a massacre, and who wanted more security and access to healthcare: “Ebola wasn’t her priority.”
But for many responders – including a number of international NGOs – Ebola was the priority.
Distrust and suspicion
Although the DRC has seen no fewer than 10 Ebola outbreaks, this has been the largest, in part because it occurred in highly mobile urban areas where the population, according to Congolese pandemic response expert Diafuka Saila-Ngita, also an adjunct professor at Tufts University, “is very active economically…very involved in trade.”
This particular area of the DRC had never seen an Ebola outbreak, had no experience dealing with it, and felt mistrustful of the response, Saila-Ngita explained.
The presence of armed escorts, in an area of the country that feels negatively toward the military, compounded the problem, Newport said. In addition, misinformation was rife, and the sometimes mysterious nature of Ebola treatment – patients taken away to containment centers and, if they died, not seen again – disturbed and alienated many Congolese people.
The response by both the government and NGOs did little to change that at first, Newport said.
“The amount of money that came into the Ebola outbreak was huge…[Health workers] could earn more money working in the Ebola outbreak than working in their health center,” she explained. “It meant that people weren’t able to access treatment for diarrhea, malaria, the things that also killed people.”
The international response bred anger and resentment – even suspicion, said Harris Ali, a professor of sociology at York University who was involved in creating community-engagement training workshops to fight Ebola.
“‘Why are you coming just for Ebola?…Is this some sort of government conspiracy?’ These sorts of suspicions were, I think understandably, raised,” he said.
According to Saila-Ngita, even as Ebola has seemingly waned, people in the DRC aren’t celebrating either. “They’re already too busy now stressing with coronavirus. You have no time to breathe, no time to celebrate. People must be exhausted as well,” he said.
But the sources interviewed for this article all agreed: Ebola taught responders valuable lessons for fighting future epidemics like the current Covid-19 pandemic – lessons that are relevant to the DRC and the larger world.
The lessons they outlined weren’t about disease containment strategies or sophisticated technologies. Instead, they were about communication and getting people involved: lessons on how to talk, how to listen, and how to show every person that they have an effective role to play.
Learning to listen
In February of 2019, MSF’s Ebola treatment center in the city of Butembo was attacked by an armed militia who fired their guns on the facility, sending staff and doctors fleeing, before burning it down. The organization was forced to temporarily pull out of the area.
MSF realized that “‘we need to change the way we’re doing this,’” Newport recalled.
After meeting repeatedly with different community groups, they realized something: People weren’t nearly as concerned about Ebola as they were about not having access to water. MSF set about building wells. Then increasing access to basic healthcare.
And then, once some trust had been built up, asking community members what they wanted a local Ebola containment center to look like. In the end, “community members [were] proudly showing us their Ebola isolation center,” Newport said.
When it comes to finding ways to stop to Covid-19, Newport said, “when I’m asked what the answer is, I say ‘I don’t know, I don’t live there.’”
She stressed that listening to a community’s needs isn’t just relevant to the DRC. “I look at vulnerable populations in Europe, in Canada, in the U.S., I look at vulnerable populations on the street,” she said.
Many of these people can’t socially isolate and don’t have reliable access to clean water. Instructions from governments and other entities, telling them to distance themselves and wash their hands, aren’t necessarily relevant.
“When the communities have been involved in the [disease] response, things have tended to go very well,” said Jeremy Rossman, a lecturer at the University of Kent and the director of Research-Aid Networks, a nonprofit organization dedicated to developing more effective humanitarian aid strategies.
At the beginning of the Ebola outbreak, Saila-Ngita said, local communities “were not part of the deal, they were not really involved, and that was a major issue.”
Effective communication doesn’t just mean providing accurate information. Instead, it’s important to “try and make sure the people actually doing the communication…are local, trusted sources,” Rossman said.
It can take time to establish allegiances with a member of the community whose word will be taken seriously, he said, but it’s a productive strategy.”
Transparency – sometimes literally
When Ebola broke out in West Africa, people who contracted the disease were frequently taken to faraway containment centers, Rossman said. If they died, they were often encased in black body bags, so grieving family members couldn’t see their loved ones.
“They started out ahead of the curve in the DRC outbreak, because there was this understanding that burial customs were so important,” he explained.
That wasn’t always the case, as Newport made clear. But some Ebola containment facilities in the DRC were literally transparent, allowing people to see and visit with loved ones from the other side of a clear wall.
“The more open, communicative, and transparent that any disaster response is, the better it’s going to be at gaining community trust…and the easier it’s going to be genuinely helpful and effective,” said Rossman.
While “be transparent” seems like straightforward advice, Rossman said it’s relevant even to his own community. “There hasn’t been a lot of consistent messaging,” he said. “People are resistant to a lot of the recommended precautions because there’s not this community-level communication going on.”
Ultimately, responding to a disease is about community, Ali said. The DRC is a low-income country with a strained health care system, but its current Ebola case count stands at one.
Ali is worried about the West. There’s an “emphasis on liberalism and individual rights, as opposed to collective,” he said. “That will always confound a public health response, because public health…requires a collective response.”