The reality of a new virus outbreak is a threat especially in fragile environments. We spoke to two MSF advisors, Caroline Voûte, Health Policy Advisor and Maria Guevera, Advocacy Advisor, about the situation in the Democratic Republic of Congo where the last Ebola epidemic ended on the 4th of April and where Covid-19 will probably disproportionately affect the most vulnerable.
Why is this important? The eradication of a disease such as Ebola in the DRC does not mean the country will not face other outbreaks. It shows how difficult it is to contain an epidemic in an already fragile and complex environment. Last Friday, The Vaccine Alliance said Covid-19 could have devastating effects on the world’s least-developed countries and could further overwhelm their already weakened health systems. “At least 13.5 million people could miss out on vaccinations due to the postponement of campaigns and interruptions in routine vaccinations,” which could lead to an even higher death tolls.
A never-ending battle. Although Ebola first developed in 1976, most of the illnesses the DRC is facing today – including cholera, measles, meningitis, plague, diphtheria, yellow fever and seasonal malaria- have been around for centuries. “It’s a never-ending battle, over and over again, every year in the same places, which is good because they know how to mount a response but also disheartening because it keeps happening”, said MSF’s Caroline Voûte.
The country deals with back to back outbreaks. When the last Ebola outbreak started last year in North Kivu, the DRC was fighting the biggest measles epidemic to date. The “end” of an epidemic does not mean other outbreaks will not occur. “When I worked as a Medical Coordinator for MSF in the DRC in 2007, there were constant outbreaks on the front lines and in the camps. Cholera was constantly breaking out in Goma, on top of which was a suspected Ebola outbreak at the border,” recalls Maria Guevara, Advocacy Advisor at MSF.
An unstable political context. The region’s instability and the ever-changing borders add another layer of complexity: the double burden of fighting a disease amid conflict and insecurity. It makes it difficult to respond to an epidemic successfully and to avoid its spread by tracking, tracing, isolating and setting up health facilities.
“With Ebola, there was a triple threat: biosecurity -a highly infectious and fatal disease-, sanitary security and physical security because of the conflict,” highlighted Guevara. “During the 2018 October outbreak, people were moving around in constant displacement in the conflict areas and also to note that the area of Butembo is a huge commercial route/hub.”
The area between Guinea, Sierra Leone, and Liberia also experiences a lot of migration, and the poorest people need to be mobile to survive. Urbanized areas intensify the spread of the disease in West Africa.
Huge geographical areas and a lack of access. “You have infected cases in the middle of the woods, eight hours away by motorbike. It’s very difficult to get around and reach patients, to bring medicine in and out and to set up a surveillance system”, says Voûte. If remoteness can sometimes be a way to prevent an outbreak for two to three months in a rural village, it can also backfire on the population if medicine cannot get in fast enough.
Low resource settings. Countries with lower resource settings may have an advantage in the sense that they know how to deal with an epidemic and their health systems are used to adapting to epidemic response systems. Having said that, “No one can be 100 per cent ready with Covid-19 (148 cases have currently been declared in the DRC). It’s new for everybody”, admitted Voûte. Especially in low resource settings. African countries often have densely populated areas like slums, detention centers or refugee camps. They have struggling health systems, overrun with people who need care, and overlapping emergencies. “The ability to move, to keep social distance or quarantine and to wash your hands: this is not a reality for large portions of the world. If they don’t have water, if they don’t have soap and live in a detention center with 120 other people in their cell, it makes it very difficult to apply basic guidelines”, says Voûte.
People are already dying from normal diseases, giving birth is an issue, malaria cannot always be controlled, there are cases of malnutrition and the question of regular routine polio, measles or meningitis vaccination. “They have been trying to work on that campaign, and catch up, but when you are in a conflict area, that does not always happen,” emphasizes Guevara.
Cultural dynamic. African countries’ medical systems are influenced by traditional medicine. There is an important component of education and communication with the local community and building trust with them about outbreak responses. “When you throw in our biomedical way of thinking coming from “white men”, you naturally have a reticence. People are suspicious,” highlights Guevara.
Ebola was seen as a foreign disease, even though it originated in Africa. “White men’s organisations are coming in zipped suits, all gowned up, looking like aliens putting your loved ones in isolation units, and you never see them again because they die. That is one of the reasons for which one of our clinics in West Africa was stoned and our staff attacked,” recalled Guevara.
Epidemic after epidemic. In theory, the last Ebola outbreak ended last Saturday. But measles is still affecting over 300,000 people since it began in 2019, with more than 6,000 deaths in several countries. The DRC is the world’s most significantly affected, according to The Vaccine Alliance. With ongoing cholera and malaria outbreaks, the question is how the country will manage this overlap of epidemics. “How do you expect them to survive when you throw a new virus on top of that, and all the resources are aimed at controlling it? The other diseases are left out and new breakouts are allowed,” said Guevara.
“There is a lot of international attention going towards Covid-19, like there was for Ebola. It tends to make people and governments focus more on that, despite the fact that we have higher death tolls from malaria and measles,” Voûte noted.
Number of Covid-19 cases by country: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200405-sitrep-76-covid-19.pdf?sfvrsn=6ecf0977_2
Caroline Voûte has worked with MSF since 2010 on many different epidemic responses mostly in Africa. She was in North East DRC in 2012, in the North of Liberia and Monrovia in 2015 and again in North Kivu and Goma in 2018-2019 during Ebola outbreaks.
Maria Guevara has worked with MSF since 2004. She was in DRC in 2007-2008 and in North Kivu in October 2018 during the second Ebola outbreak, in Nigeria during the massive cholera outbreak along with measles and meningitis in 2009.