Fears of Ebola spread in East Africa will grow

Analysis

DRC's ongoing Ebola epidemic continues to worsen.

Since the onset of the epidemic near Beni, North Kivu, in August 2018, there have now been 2,489 cases (2,395 confirmed and 94 suspected) and at least 1,665 deaths.

This is already the second-largest outbreak of Ebola (after the 2013-16 West Africa epidemic, which resulted in 28,000 cases and 11,000 deaths), and has one of the highest case fatality rates ever recorded for any disease epidemic (at around 67%).

In addition, the rate of both new cases and deaths has accelerated over recent months (see CONGO-KINSHASA: Ebola outbreak may accelerate further - April 3, 2019).

Complicating factors

The public health response has been hampered by a range of factors:

• To date, the worst-affected areas have been in remote, rural locations, some of which are inaccessible by road.
• The affected area faces long-standing challenges of insecurity, with dozens of different armed groups operating in the Beni area alone.
• Deep-seated public distrust of authorities -- including health authorities -- has been fuelled by politicised rumours, contributing to widespread community resistance to containment efforts.
• Disputes over management of the response -- in particular, the government's insistence on coordinating all interventions -- have drawn allegations of inefficiency and even corruption (see CONGO-KINSHASA: Ebola response faces critical juncture - June 4, 2019).

Officials from the World Health Organization (WHO) have described the outbreak as a "perfect storm" and "one of the most complex health emergencies" the world has ever seen.

Nevertheless, WHO's Emergency Committee has on three separate occasions decided not to upgrade the epidemic's status to a 'public health emergency of international concern' (PHEIC) (most recently on June 14).

Such a designation would not only place increased pressure on donors to increase their funding for the emergency, but it would also place them under increased political and moral pressure to allow their national agencies or NGOs to upscale their response, despite security risks.

It would also increase the attention and support given to preparations being made by neighbouring countries.

Uganda

The outbreak has already crossed into Uganda.

In early June, health authorities confirmed three cases -- two children and their grandmother -- in Kasese District, Western Uganda. Two of the three later died from the disease.

The victims were all members of a Ugandan-Congolese family, who had recently travelled back into the DRC to attend the burial of their grandfather -- who had himself died of Ebola.

Details of the case highlight just how serious the risk is of the virus spreading to Uganda. Subsequent investigations revealed that, of the 14 family members who had travelled to the burial, five had crossed into DRC informally -- an everyday occurrence along this notoriously porous border.

The border is also a major throughput for refugees. In 2018 alone, 120,000 Congolese refugees crossed into Uganda; a fresh outbreak of violence in Ituri Province since June has seen thousands more cross (see CONGO-KINSHASA: Ituri faces risk of chronic unrest - July 10, 2019).

This suggests that further crossings of infected persons into Uganda are almost inevitable.

Nevertheless, Uganda's Ministry of Health is quite well-prepared. It has enacted a sophisticated emergency health plan, including the vaccination of at least 4,700 health workers across 165 facilities, and the rollout of 'barrier measures', including handwashing and shoe-scrubbing stations using chlorine solution, throughout the border zones.

Memories of Uganda's own Ebola epidemic of 2000-01 (at the time, the largest ever Ebola outbreak, with 425 cases and 224 deaths) are still fresh and have focused minds on the current situation.

More importantly, in the years since 2001, the government has made significant investments in public health emergency planning. Consequently, it is probably the best-prepared regional nation to respond to a new Ebola epidemic.

Even so, it is one thing to contain the outbreak within remote rural areas, quite another to respond to it in an urban context. Were the epidemic to reach major northern towns such as Gulu or Lira, or, worse still, the megacity of Kampala, the situation could deteriorate significantly and rapidly.

Rwanda

Rwanda is also at risk, especially through the gateway city of Goma, which abuts the Rwandan town of Gisenyi.

As with Uganda, Rwanda has invested heavily in disaster preparedness in recent years. Although much of this effort has focused on agricultural and nutrition-related emergencies, following a series of weather-related crises, the Ministry of Disaster Preparedness is well-placed to respond to a health-related crisis too.

In early July, Rwanda hosted a major international conference on 'Health and Humanitarian Logistics', which focused on precisely these issues.

Once again, however, containment efforts would be severely tested were the outbreak to reach Kigali.

Trade and human movements between Goma and Kigali have always been high but have increased further amid a political dispute between Rwanda and Uganda since early 2019, which has resulted in border closures and massive disruptions to bilateral trade. This has resulted in higher trade volumes between Kigali and Goma (see RWANDA/UGANDA: Tensions will rise and fall - April 2, 2019).

South Sudan

However, the real 'doomsday scenario' would be if the epidemic were to reach South Sudan.

Although the current outbreak remains centred around Beni, far from South Sudan, it is also moving slowly northwards -- as the recent case in Ariwara highlights.

There is also a risk that it might become established in the massive camps for South Sudanese refugees in Uganda's West Nile region, which could in turn form a bridgehead into South Sudan.

Were this to happen, the public health emergency would deepen significantly.

South Sudanese populations are more widely distributed across remote areas and generally more mobile than on the Congolese side. Moreover, cultural beliefs about the need to wash bodies of the dead ritually -- a major transmission vector -- are arguably more deep-seated.

In addition, five years of civil war have essentially destroyed the extremely limited health care system that existed before the war.

Almost all health care interventions are undertaken by humanitarian agencies, but South Sudan has become one of the world's most difficult operating environments for aid agencies, both because of enormous logistical challenges (including extremely high costs), as well as insecurity, including frequent attacks against humanitarian workers and facilities.

Mounting any large-scale public health response to an Ebola epidemic in South Sudan would be extremely challenging indeed.