The ongoing Ebola epidemic in the Democratic Republic of the Congo (DRC) is the second largest outbreak of its kind since the 2014-2016 West Africa outbreak, which killed 11,000 people. The current epidemic – which has caused over 1500 recorded deaths, has recently spread into neighbouring Uganda, and looks to be infiltrating the South Sudan border – is the first outbreak of the disease in an active warzone. This has contributed to what medical organisation Médecins sans Frontières (MSF) have described as ‘a climate of deepening community mistrust’. As the epidemic nears its one-year anniversary, this long-read blog, developed through desk research and discussion with organisations operating in the country, explores some of the interwoven factors behind the hostilities.
The DRC’s Ebola response takes place in a highly insecure setting and is being led by two contentious agencies; the World Health Organization (WHO) and the National Ministry of Health (MoH). Combined with the historical experience of many DRC Congolese, a less-than firm foundation has been laid for humanitarian actors to control the spread of the disease. More than this, a number of external challenges, including political influences and myth-spreading, are shaking the already precarious response. This piece unpacks the hostile environment in DRC by exploring these factors, and outlines some of the groundwork that can be done by the sector to improve both the security of aid workers and the quality of the response.
Building on shaky ground
During the official Congolese wars of 1996 – 2003, up to 6 million people lost their lives due either to conflict or to disease and malnutrition. The wars required a United Nations (UN) military to maintain order, and, while militias in the east have continued fighting, UN peacekeepers have maintained their largest presence in the world.
The experiences of many residents of Ebola-affected areas in DRC – in the provinces of North Kivu and Ituri – have led to long-standing associations between civil unrest and the people present during these times of crisis. Over the years, where there has been war, conflict, famine and disease, a host of external actors – police, military bodies, rebel groups and militias, the UN, medics and aid workers – have appeared in locals’ towns. Existing alongside persistent neglect from the government in Kinshasa, for many locals the end result of the external presence has been displacement and destruction. As the current climate in DRC illustrates, it’s not easy to break the conflation between the pain they have suffered and the co-occurring presence of the same external actors. For humanitarian responders, it is unfortunate that such trauma is rarely mindful enough to filter those with good intentions from the mass.
“We have a striking contradiction: on the one hand a rapid and large outbreak response with new medical tools… and on the other hand, people with Ebola are dying in their communities, and do not trust the Ebola response enough to come forward.”
Dr Joanne Liu, International President of Médecins Sans Frontières (MSF)
A serious concern in the current Ebola response is the amount of new cases that are not linked to any previously known chains of transmission. According to MSF, which runs some of its largest programmes in DRC, this makes it more difficult to trace contacts and control the evolution of the outbreak. The trend of Ebola-sufferers remaining in their communities and avoiding medical attention – even until the point of death – is a clear indication of the level of mistrust felt in the humanitarian medical effort.
An insecure setting
“I was speaking with some colleagues yesterday who have 35-40 years in the industry. And it was unanimous: this is the most complex humanitarian situation that they’ve ever been on, we’re tackling an Ebola crisis in a war zone.”
Jamie LeSueur, Head of Ebola Operations for the International Federation of Red Cross and Red Crescent Societies (IFRC)
For decades the Democratic Republic of the Congo has been wracked with violence, civil war and corruption. While the 5-year conflict involving the DRC, Angola, Namibia, Zimbabwe, Rwanda and Uganda officially ended in 2003, Eastern DRC in particular has experienced little respite. Over the years, multiple groups have sought to bring down the country’s government. In 2009 a peace deal was formed following the storming of Goma the year before by the National Congress for the Defense of the People (CNDP). Multiple militias including the CNDP agreed to disband and join the national army, which received strong public support and contributed to Joseph Kabila’s re-election as president in 2011.
In early 2012, following the President’s decision to extradite leaders of the CNDP, thousands in the national army defected to their original cause and formed the group ‘M23’. In the years since, M23 have worked to destabilise eastern DRC, committing atrocious human rights violations. Although the Force Intervention Brigade (FIB) – created by the UN Security Council in the place of peacekeepers – was seen to have succeeded in neutralising armed insurgencies, instability in the area persists at an alarming rate.
The enduring conflict in the DRC probably makes this Ebola response the most complex to-date. Violence and insecurity have pushed people to leave their homes, causing hundreds of thousands of internally-displaced persons (IDPs). In the Ituri province, it is estimated that around 400,000 persons are currently living in dire conditions across displacement sites and informal camps. As well as these domestic threats, those opting to leave the country have created an international countdown to cross-border contamination. This finally ended in June 2019 when cases began to be reported in Uganda and, more recently, on the South Sudan border.
“Humanitarian actors urgently need access to provide assistance and prevent further massive displacement. We are increasingly concerned that rising displacement creates fertile ground for the spread of disease – most worryingly Ebola – in Ituri province.”
Fabien Sambussy, International Organization for Migration Chief of Mission in DRC
Within DRC, war creates vast access constraints that continue to challenge the ability of those responding to contain the disease. Whether due directly to fighting, or to communities reluctant to trust outsiders when their towns are attacked on a regular basis, access constraints make response activities extremely difficult. This is particularly true of more invasive humanitarian activities like burials, which, irrespective of war and insecurity, are habitually met with resistance.
A fractured response
The WHO is co-leading the response to the DRC’s 10th Ebola epidemic, in partnership with the DRC’s Health Ministry. Since the latter is a government body, the leadership of the response effort is not perceived as neutral. Associations with such partisan bodies make it difficult for humanitarian responders to gain trust among communities in eastern DRC. For a long time, many citizens have received little from central government, and in some cases have experienced violence at the hands of its security forces.
Since response efforts began last year, treatment centres – and, more recently, health workers – have been the targets of attacks. WHO recently warned that containing the epidemic may not be possible if such incidents continue. Following a violent attack on a burial team on 3 May 2019 that forced WHO to close its activities for five days, on 8 May a treatment centre in Butembo was attacked. In April a hospital in the same city was raided, resulting in the death of a Cameroonian doctor working for WHO. In February, unidentified attackers torched two MSF treatment facilities in North Kivu, prompting the organisation to suspend operations in the area.
‘It is the first Ebola outbreak where health workers have had to wear steel helmets and bulletproof vests, and have had to have the protection of armed escorts when moving into insecure areas.’
Davis Nordeen and Tyler Marshall, International Medical Corps
Targeted violence has led to the response leaders hardening security around medical operations, which has included enforcing a police presence outside treatment centres and NGOs’ offices. Calling for choices to be given back to patients, MSF stated in March that ‘the use of police and armed forces to compel people to comply with health measures against Ebola is leading to further alienation of the community and is counterproductive to controlling the epidemic.’ The medical organisation continued; ‘using coercion for activities such as safe burials, tracking of contacts and admission into treatment centres discourages people from coming forward and pushes them into hiding.’
Rejecting MSF’s claims, WHO Director-General Tedros Adhanom Ghebreyesus stated that the organisation are ‘working hard to strike a balance between protecting health workers and patients and securing the trust of communities.’ Meanwhile, a spokeswoman for the MoH, Jessica Ilunga, dubbed MSF’s claims ‘a gross exaggeration of the situation’. Given local perceptions of NGOs as players in an ongoing exploitation process, MSF’s claims may carry more weight than the response leaders are willing to acknowledge. Even if claims of coercion are indeed false, the enforced police and military presence around healthcare facilities contributes to the conflation of being contained in treatment facilities with being detained by government forces. These types of fear can add to the trauma experienced by Ebola-sufferers and their families, and are detrimental to humanitarians’ hard-won acceptance.
“You have a window of time in which treatment is effective. Wait too long, the patient dies anyway, and people lose confidence”.
Natalie Roberts, emergency operations coordinator for MSF
In terms of NGOs themselves, in addition to the conflation of aid workers with current and historic exploitation processes, locals are experiencing very real fatigue with the current humanitarian presence. Those in North Kivu and Ituri complain of a multitude of bothersome issues, including increased market prices due to aid workers’ higher salaries, NGO workers throwing loud parties at night, cars being driven too fast through towns, and rental properties being taken up by aid workers. Such behaviours are clearly not to blame for attacks on treatment facilities and health workers, but they certainly fuel negative perceptions of humanitarians.
Alongside all of these factors, a multitude of political influences are working against the Ebola response. In 2018, over a million citizens of three opposition areas were stripped of their ballots when voting was postponed by three months until March 2019. According to a Human Rights Watch report, even more were left disenfranchised by the last-minute closure of over 1,000 polling stations in Kinshasha, electronic difficulties and stations across the country opening late. Following this, the government closed lines of communications throughout the country when it shut down Internet and text messaging and cut the signal for Radio France Internationale (RFI).
December’s events followed two years of delayed elections, during which then-President Joseph Kabila was permitted to remain in office well beyond the two-term limit mandated in the national constitution. In a bid to deflect fault, however, authorities publicly blamed these final delays on insecurity and the Ebola outbreak. Whether knowingly or not, this announcement contributed to furthering the disease’s status as a key political pawn.
Ebola conspiracy theories exist across DRC, with some rejecting that the disease exists, others claiming it is a biological weapon, and even more believing that the Ebola outbreak was fabricated for financial gains or to destabilise the region. Given the effective awareness-raising activities being run by non-profits around the country, with widespread access to well-written, translated resources on Ebola it seems unlikely that those sceptical about the Ebola response have reached these understandings on their own. Whilst the country’s political climate is clearly complex, it seems probable that disillusioned power-players are manipulating existing tensions to spread fear about the Ebola outbreak in order to regain their seats at the political table.
When it comes to acceptance in DRC, negative perceptions of aid workers appear to win out over the Ebola response. Together with the fractured past and shaky present of both the country and the humanitarian interventions it sees, defamatory rhetoric and the ensuing violence look set to collapse the Ebola response. Given that the disease seems to be taking more lives and crossing more borders each week, an imminent solution is urgently required.
To be effective, a common acceptance strategy will have to prove NGOs’ neutrality, reliability and transparency, place community needs at the forefront, be implemented consistently across the sector, and extend past myth-busting about the disease to include the response effort itself. Beyond these basic principles, what an effective acceptance strategy in DRC will look like is going to have to be ascertained through focused, inter-agency coordination between responders at all levels.
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