Ebola could become endemic in the DRC

In 2014, we came far closer to losing control of Ebola than most people realize. We witnessed impossible choices daily, such as watching treatment centers turning away infected patients because there were no beds left.

The epidemic eventually receded, but not because anyone had mastered Ebola. It ended because of extraordinary international cooperation, local adaptations, and no small measure of luck.

Today, as a new Ebola outbreak unfolds in eastern Democratic Republic of Congo, most of those conditions are absent. The greatest risk is not that this outbreak spreads. It is that it never ends.

In the past, the possibility of endemic Ebola was unthinkable, and the international community was aligned and deeply committed. Much of that is untrue today. Global health capacity has become fractured and underfunded with a terrifying corresponding shift in approach to disease containment. In previous outbreaks, outbreak control and eradication strategies included contact tracing, case tracking, geo-mapping, vaccination, treatment (to the extent it is possible and available),  and local adaptation of core cultural essentials, such as safe and dignified burial practices. The goal was to contain, meaning stop, the outbreak.

Today, the politics of containment focus upon the long-disproven idea that you can control an outbreak by fencing it off and closing the borders. It has never worked, and it won’t work in the DRC.

Historically, Ebola emerged periodically from the forest to ravage a few isolated villages at a time. It’s met by counter measures and/or peters itself out, mostly by being denied access to more human hosts.

This time is different. The current outbreak is occurring in one of the densest areas of population in Africa. Further, the economics within even small African villages have changed. Cellphones are ubiquitous and have become the basis of economic progress. People are more connected, with relatively more resources, and commerce is highly mobile. Travel between villages used to be mostly on foot. Now every village has one or more inexpensive Chinese motorcycles that enable people, products, and services to move. They can also allow sick or potentially infectious people to flee outbreaks to populated areas quickly seeking help. 

Superimpose these new mobility capabilities against a global health infrastructure where every layer of defense has been weakened, and the very real possibility of an outbreak that is never contained emerges. There are no proven medical countermeasures for the Bundibugyo strain. The World Health Organization and Centers for Disease Control and Prevention are operating at greatly reduced capacity. The ongoing conflict makes it unsafe for outbreak responders to travel freely and be where they need to be to be most effective. Trust has been deeply damaged by the “Ebola business” that has profited from and exploited previous outbreaks. Add to this the lack of lessons learned from prior outbreaks.

The announcement by the U.S. government of a highly controversial and currently on-hold quarantine and treatment center in Kenya defines the approach: “Let’s protect ourselves rather than stop the outbreak.” Highly specialized treatment facilities in the United States remain unutilized, and global health budgets have been cut with huge amounts of resources shifted toward border protection and immigration control. While not new, the appetite for isolationism as a core response is once again politically popular. It’s equally uninformed. Since the Middle Ages, borders against infectious diseases have failed when upstream control has failed. Yet that is the bet being placed here.

In the DRC, the effectiveness of border containment is particularly unlikely because the mineral riches of the area are essential to the global economy.

There’s a mostly undeclared war in Eastern DRC driven by the staggering mineral wealth of the region. Internal factions and neighboring countries continue to relentlessly tussle over the resources of the Kivus. That conflict is currently running quite a bit hotter than it was in 2019, which exacerbates the difficulty of accessing communities in need of care. The Kivus are no longer the site of a local insurgency. They have become the arena for a regional conflict involving Congo, Rwanda, Burundi, Uganda, and dozens of armed groups competing for power, security, and control of some of the world’s most valuable mineral deposits. Spread into any or all those countries by infected actors is possible or even probable in an uncontained epidemic.

Again, in 2014-2016, our focus was stopping, not merely containing, the epidemic in western Africa. This may not be possible in such an opaque proxy war including so much area and such large actors. 

If the outbreak isn’t extinguished, it could burn for decades and pose an ongoing threat to the entire world. Containment will not be effective in preventing enormous suffering and global destabilization. The greatest risk is not another or more Ebola epidemics. It is the emergence of a permanent Ebola frontier via an outbreak that never truly ends — an endemic disease that continually threatens millions in Central Africa while periodically casting sparks into the rest of the world. Once that future arrives, containment will become a recurring expense and control will be impossible.

The question is whether the world still possesses the capacity, and the resolve, to stop that from happening.

Ivan Buendia Gayton is a technologist and humanitarian adviser with more than 15 years of experience with Médecins Sans Frontières, serving in roles including head of mission, field logistician, humanitarian affairs officer, and GIS and technological innovation adviser, and as a member of the board of directors of MSF Canada. He is currently product innovation manager and humanitarian adviser with the Humanitarian OpenStreetMap Team. Eric D. Perakslis, Ph.D., M.S., is an engineer, scientist, and former strategic adviser for innovation for Médecins Sans Frontières who served in West Africa during the 2014–2016 Ebola outbreak and supported Ebola response efforts in the Democratic Republic of the Congo during the 2018–2020 outbreaks. He has also worked in humanitarian response and capacity development across the Middle East, North Africa, and Bangladesh.