Lessons from Ebola as DRC grapples with conflict, measles, and covid-19

Learnings

WHO highlighted the key role of contact tracing, infection prevention through public awareness, access to clean water, and promotion of hygienic practices, as well as isolating both confirmed patients and suspected cases. These are now also at the core of DRC’s covid-19 response.

But ultimately, the best defence against any outbreak is investing in a stronger health system as the foundation for universal health coverage, said Tedros Adhanom, director general of WHO at a press briefing, adding that only half of DRC’s health facilities have access to clean water.

Even before Ebola, the country’s health system was dysfunctional owing to collapse of the state and the economy, leaving over 70% of the population, including health workers, impoverished. Health financing became almost totally dependent on out-of-pocket payments and external aid. With no public funding and weak national leadership, regulation of the health sector evaporated.3 The situation is compounded by the country’s ongoing civil conflicts. Throughout the recent Ebola epidemic, violence real and threatened slowed down relief efforts and medical aid, making contact tracing difficult and leaving health workers vulnerable to both attack and infection.

In a post-outbreak analysis, Médecins Sans Frontières said that residents of the region became suspicious of the motive of the high number of international experts prioritising Ebola control over other challenges they face on a daily basis.4 DRC has one of the highest number of unvaccinated children, for example, with immunisation coverage of 50%, well below the global average of 80%.5 The Ebola-centric approach initially adopted to contain the outbreak ignored these other issues and was one of the reasons for the response’s failure to earn the trust of the communities, Médecins Sans Frontières says.

Writing in The Conversation,6 Yap Boum, a professor in the Faculty of Medicine at Uganda’s Mbarara University of Science and Technology, said that DRC was prioritising the strengthening of its health system instead of choosing to focus on a disease at a specific time. “DRC has begun to make this shift in mindset. Community engagement, research, and testing capacity that has been strengthened during the recent outbreaks has put the country in a better position to respond simultaneously to the most recent Ebola outbreak, as well as the measles outbreak and covid-19.”

Eteni Longondo, DRC’s minister of public health, said that the country’s response to covid-19 and measles and to future outbreaks will benefit from ongoing government efforts. These efforts include strengthening surveillance and building up laboratory diagnostic capacity. The government has also beefed up a survivor care programme that follows up those who have recovered for at least 18 months.

The next outbreak

Although the 2018 epidemic is over, DRC is not in the clear. On 31 May, another active Ebola outbreak was declared in the country’s west lying Équateur province, the opposite side of the country to North Kivu.7 Genetic analysis has confirmed that the cases reported in Équateur are different, representing a completely separate outbreak.

DRC has been here before—Jean-Jacques Muyembe-Tamfum, director general of DRC’s National Institute of Biomedical Research (INRB), said that the end of the last Ebola outbreak in Équateur province coincided with the start of the Kivu one, with response workers leaving the region perhaps too soon. “Everybody had gone [to Kivu] therefore leaving the Équateur province without any follow-up. We did learn a huge lesson from that experience because now we are going to make sure the local community has the necessary capacity.”

The good news is that the chances of it spreading as far as the now cleared Kivu region are slim. Moeti said that not only are the outbreaks far apart, but a flight ban in place due to covid-19 would further limit the spread. DRC’s poor transport infrastructure may be its saviour. “When the epidemic occurred in Kivu, we had to fly from Kinshasa to Kikwit because we couldn’t go by road,” Oyewale Tomori, professor of virology at Nigeria’s Redeemer’s University, told The BMJ, “Many parts of DRC are like that. No roads and jungles all over the place. It makes it quite difficult for people to move around and spread the disease.”

Muyembe-Tamfum said that the major problem in outbreak response is reaching scattered cases, “The eastern region of Kivu is not densely populated but the cases are dispersing in villages that are not accessible by car or bike.”

For covid-19, DRC has secured a $363m (£289m; €318m) loan from the International Monetary Fund,8 alongside $47m from the World Bank9 and $40m emergency funding from the United Nations10 to shore up the country’s economy and strengthen the medical response. Muyembe-Tamfum told the World Bank that DRC had implemented a plan valued at $135m for covid-19, almost 75% of which had already been mobilised.11 “We have proposed a plan that will be based primarily on subsidies to access such basic social services as health and food, and microcredits to support the informal sector, which accounts for more than 80% of the Congolese economy,” he said.

Tomori reiterated the need for African countries to invest their own resources in strengthening their individual health systems to withstand the burden of infectious diseases. He said that the minister of public health had promised that the government would provide budget to continue the work being done at the INRB. He has also, however, raised concerns about maintaining laboratories should overseas funding come to an end. The Japan International Cooperation Agency, for example, had granted a 30 month $21m grant to upgrade the INRB. The Japanese embassy in DRC released a statement on 2 July 2020 reaffirming Japan’s support for the DRC during and beyond the covid-19 pandemic.12

Tomori said that he doesn’t see foreign partners leaving it entirely to the DRC government anytime soon, “They have their own national health security interest in ensuring that the outbreak is controlled and does not spread to foreign countries.”