With more than 2,577 confirmed cases and more than 1,803 confirmed deaths, the outbreak in the eastern Democratic Republic of the Congo (DRC) is the second largest in history. It has a 67 per cent fatality rate and case numbers are still escalating, even 11 months after it began. It is disproportionately affecting women (55 per cent of cases) and children (28 per cent).
The World Health Organisation (WHO) declared the outbreak an international public health emergency in July 2019. The same month saw the the first diagnosis of a case in Goma, a city of two million people, which is a transport hub on the border with Rwanda. In early August, Rwanda announced that it was closing its border with the DRC .
The WHO has long said that the national and regional risk levels are very high and containment of the spread to North Kivu and Ituri provinces was unlikely, unless a break in fighting made it safe for health workers.
Ebola hemorrhagic fever is caused by a virus that has a reservoir among forest animals, including monkeys and bats. It is spread through body fluids, which is why carers – mostly female relatives and nursing staff – are particularly at risk. It causes fever, aches and diarrhoea and attacks the immune system, causing blood clotting cells to malfunction so that victims bleed extensively and die if their immune system cannot fight off the viral infection.
Drugs are still experimental. Patients are isolated (left alone) and treated by nurses wearing full protective body suits and masks who try to boost their immune response. Friends and relatives are quarantined (or kept alone, away from the public) for 21 days. Patients have their temperatures taken every day because a rise beyond 37.5C is the first sign of infection. Prevention measures include washing hands at every opportunity and safe burial practices, with no touching or washing of the body, as is traditional in some cultures.
The 2013 and 2016 outbreaks in Sierra Leone, Liberia and Guinea spread for months through forest regions in west Africa, where Ebola was unknown before the emergency was recognised. It escalated when it emerged in towns and cities, with 28,600 cases and 11,300 deaths.
The DRC successfully stamped out nine previous Ebola outbreaks in rural areas within a matter of a few months. There was concern that the previous outbreak between May and July 2018 in Équateur province might spread to towns via the Congo river, but it stopped after 53 cases and 29 deaths.
Aid agencies, infectious disease experts and the WHO say it will be very hard to bring this outbreak under control, even though they have had vaccines and experimental drugs from the outset.
There is almost no functioning state in much of eastern DRC. There is an almost total lack of basic services such as power, education, roads, healthcare, and the authority of the government only extends to the edges of urban areas.
The president, national assembly and other institutions in Kinshasa are a four-hour flight away.
Most people in the region live hand to mouth, growing their own vegetables or scraping enough to make a living from day labour, gathering wood for charcoal and a small amount of trade. Police are corrupt, predatory and violent. In rural zones, militia and armed bands provide security and employment opportunities but also steal, rape and kill at will. It is one of the most hostile environments faced by aid and health workers anywhere in the world.
Mistrust of officials and foreigners is harming efforts to tackle the disease and conspiracy theories are rampant. Some believe the outbreak is fake news spread by non-governmental organisations and the United Nations to justify their presence in the country and allow the extraction of valuable mineral resources. Others believe the outbreak was deliberately created for the same reason. Some locals wonder why money is poured into fighting Ebola when many more people die each year of malaria without any similar international interest.
Many people also fear going to Ebola treatment centres, choosing instead to stay at home and risk transmitting the disease to carers and neighbours. Insecurity also has prevented vaccination teams from getting to some areas, further limiting the health response.