This outbreak’s trajectory underscores the imperative to understand the complex interplay of biologic and social factors against the backdrop of a longer ecologic and political history.
Although other outbreaks have occurred in conflict zones,the events in eastern DRC illustrate the difficulties that can be generated by national, regional, and local politics and various power-holding groups, as the MOH and WHO strive to control EVD amid layers of armed, political, and social violence.
Violence associated with community resistance, which may be defused by careful community engagement, must be distinguished from organized attacks on highly visible symbols of the response.
Attacks by armed groups targeting health facilities and medical personnel in settings of armed conflicts are a clear violation of the protection of health care provided under international humanitarian law.
Humanitarian space, which is necessary to operate in war zones, is generated by international humanitarian law governing the conduct of warring parties, in combination with the humanitarian principles laid out by the International Federation of Red Cross and Red Crescent Societies.
Compounding community resistance, these attacks have had a catastrophic effect on transmission and control.
Early treatment with isolation is the most effective way to stop transmission.
Attacks targeting Ebola treatment centers result in contagious patients fleeing to areas inaccessible for follow-up and vaccination.
Fear of further attacks reduces the likelihood of new patients presenting for health care.
The loss of operational capacity is further compromised by threats and violence directed against human resources.
The consequences of such attacks in the DRC were recognized by the U.N. Security Council in October 2018, in Resolution 2439.
This resolution reaffirmed UNSC 2286, which specifically condemned attacks on medical facilities and personnel in armed conflicts.
Medical personnel already at risk for contracting EVD are now faced with the risk of direct violence. With a density of 0.05 doctors per 1000 population, the DRC cannot afford to lose any more medical personnel.
Distrust and militarization of the response breed further violence, engendering a vicious cycle.
Contextual factors, local and regional interests, and the variable degree of community distance all play a role in explaining both the successes of the internationally supported national response in containing the epidemic and the worrisome failure to curb transmission.
Compliance with control measures premised on an understanding of basic biosafety and public health cannot be assumed.
Investigational treatments and vaccination are no substitute for culturally appropriate, endogenous social responses that support early detection and treatment.
Even the best biomedical advances require social traction to work.
The third strategic response plan for this outbreak, covering mid-February through July 2019, emphasizes that a successful response must be anchored in the community.
Although the immediate goal is to end this outbreak, it is unlikely to be the DRC’s last, and the plan provides pragmatic opportunities to address other global concerns such as malaria and antimicrobial resistance.
Community-based surveillance of EVD could benefit from the training of community health workers in the diagnosis of malaria using rapid diagnostic tests and in compliance with correct antimalarial regimens to reduce deaths from malaria and the risk of antimicrobial resistance.
Such actions could also reduce the number of alerts for safe and dignified burials, decrease nosocomial spread, address popular concerns about meeting other health care needs, and build trust, engagement, and outbreak preparedness.
