Using Guinea’s Approach to Contain Ebola in the DRC
The Bundibugyo Ebola outbreak in the eastern Democratic Republic of Congo (DRC) has registered more than 3,000 confirmed cases and over 1,400 deaths in an area beset by conflict, displacement, and high mobility from mining and cross-border trade. The outbreak threatens to become a regional crisis rivaling the 2014–16 West African Ebola epidemic, which began in Guinea and quickly reached neighboring Liberia and Sierra Leone, causing more than 28,600 infections and 11,300 deaths.
The interventions needed to control the outbreak—even without approved treatments or vaccines for Bundibugyo virus—are well established. Deploying them effectively requires a coordinated, systematic response calibrated to the complex dynamics of the affected areas. We faced a similar challenge during the West African epidemic, when Guinea’s president enlisted us to help build the national response. That experience offers insights into the organizational challenge this response now faces amid more difficult conditions, including creating a robust response system, negotiating access in areas affected by armed conflict, and building trust with communities.
Control Requires a System
Each intervention seems straightforward to implement but works only if executed in tight orchestration with other countermeasures. Community engagement should pave the way for safe burials, case reporting, and contact tracing, which should connect seamlessly to transport, testing, isolation, and treatment. Weakness in any link results in communities unwilling to cooperate, infected contacts being missed, and transmission persisting.
Aligning everyone meant solving a Rubik’s cube of organizational politics
Where health systems are strong, these response capabilities can be layered on quickly, as Rwanda did during a recent Marburg virus outbreak. However, similar to Guinea in 2014, health systems in eastern DRC are underdeveloped or absent. In Guinea, we had to build—at great cost and amount of time—a parallel response system from scratch. That same undertaking is unfolding now in eastern DRC under more challenging circumstances and resource constraints.
Building that system is complicated by the need to coordinate it across numerous organizations. In Guinea, more than 30 global, nongovernmental, and aid organizations were involved in the response. Most funding flowed directly to these organizations, yet only the government had the authority and legitimacy to lead. Initially, some groups were duplicating efforts in the same places even while other areas and needs went neglected.
Aligning everyone meant solving a Rubik’s cube of organizational politics. The government ultimately set an overarching strategy into which all partners had to integrate with clear delineation of the “4 Ws”: who would do what, where, and by when. That structure turned a crowded field of activities into a coherent, unified response under a single chain of command.
In this outbreak, the Africa Centres for Disease Control and Prevention (Africa CDC) and the World Health Organization (WHO) have led a unified global and regional response from the outset. Nationally, DRC is well equipped to lead, with expertise from 16 prior Ebola outbreaks. Translating that into coordinated action, however, is challenging in areas contested by warring militias. Amid a polarizing election cycle, Guinea suffered bursts of political violence, and Ebola itself was heavily politicized. External diplomatic mediation [PDF] was frequently needed to achieve enough cross-party support for response activities to ultimately control the epidemic. Even so, Guinea remained at relative peace with a government to work through.
In eastern DRC, implementation requires, at minimum, negotiating safe passage for responders and ideally brokering truces. WHO and Africa CDC, however, work through national governments, and DRC’s government is itself seen by some as a party to the conflict. The security that the response needs may require regional bodies like the African Union’s Peace and Security Council or the International Conference on the Great Lakes Region to mediate cooperation, and local intermediaries, faith leaders, and community representatives to ensure compliance. The response economy itself should be managed carefully, as the massive injection of resources can become a subject of conflict and deepen distrust if it appears to be captured by any one faction.
Epidemic of Multiple Outbreaks
A major factor shaping how hard an outbreak is to control is the number of distinct sites of transmission. The West African epidemic was better understood as an “epidemic of outbreaks.” In Guinea, 32 of 34 jurisdictions in the country were affected by Ebola transmission at some point in the epidemic, and as many as 17 prefectures were active at the same time, some with multiple hotspots. Each site required its own ground game: contact tracers, burial teams, vehicles, alert systems, local leaders, and strategy tailored to local dynamics and transmission patterns. Resources had to be constantly rerouted as transmission faded in one place and flared in another.
In this outbreak, more than 40 health zones spread across hundreds of miles are currently active, some of which may be difficult to manage because of insecurity, poor roads, dense forest, and constant population movement.
Once the core interventions were in place in Guinea, managing the epidemic became a matter of continually finding and closing gaps. This work runs on a delay. With an incubation period of up to 21 days, infections surfacing today reflect transmission from weeks earlier, so the effect of any fix or gap shows up only after the same lag.
Every new case prompted an “epidemiological autopsy,” a process of systematically working back from an infection to pinpoint why response measures were unable to prevent it and what had to change to close that gap. The “autopsy” included questions like was the person never listed as a contact? Was their name withheld out of stigma due to insufficient community engagement? Is there a hidden chain of transmission spreading entirely off the radar? In the current outbreak, where most transmission is hidden, contact tracing—which works outward from known cases—may not be enough, and finding these infections may require new strategies, such as using rapid tests to screen more widely in areas of active transmission.
The reason why response measures had failed was often mundane. In one area, families were still burying their dead themselves, resulting in new infections. The problem was not the community’s refusal to call safe-burial teams but, instead, delays in those teams arriving in time because of fuel shortages. Funds were reallocated to ensure adequate fuel and eliminate that gap.
This process is constant and relentless. Control demands that efforts be sustained long enough to definitively drive down transmission. Any lapse can allow resurgent spread to wipe away weeks of hard-fought progress. In December 2014, just as cases in Guinea were declining, one funeral seeded 85 infections that took weeks to contain.
Trust Is Political and Historical
Trust is often treated as a messaging problem. In our experience, the question was not whether communities understood the message but whether their history gave them reason to believe it. In Guinea, transmission persisted in communities skeptical of government after decades of dictatorship, and of international organizations perceived as complicit or absent during that period, and only now arriving in hazmat suits to take relatives away, often for good. This led people to secretly bury the deceased at night, hide infected persons, question whether Ebola was real, and even attack response workers.
We eventually deployed anthropologists from the region to sit with communities one by one, hear grievances, and build relationships. It was slow and imperfect. Earning trust fast in an emergency is hard, and some communities opened up only after suffering catastrophic levels of transmission and death.
In eastern DRC, distrust may be the most foreboding challenge. Communities have lived through decades of violence and displacement, and WHO personnel were themselves implicated in sexual misconduct during the 2018–20 outbreak in some of the same areas now affected. Where responders risk attack or kidnapping, deploying anthropologists or contact tracing may not be tenable. The response may have to be creative and lean on communities to interrupt transmission themselves, as we ultimately did in Guinea by working through village leaders to limit movement in and out of active areas.
This outbreak is already large and unfolding in punishing conditions. Controlling it will require a response that can knit interventions together across agencies, narrow pathways for persistent transmission, and earn the trust needed to reach communities. The conditions in eastern DRC—daunting compared to what we faced in Guinea—may test what even a well-coordinated response can achieve. That is all the more reason to press now, at full force, before the outbreak entrenches or expands further.
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