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Two attacks on Ebola treatment centers at the epicenter of the outbreak in the Democratic Republic of Congo forced an international medical aid organization to put some of its humanitarian efforts on hold. Doctors Without Borders experienced an attack in Katwa on February 24 and another Wednesday in Butembo, the organization reported last week.

Congo’s Ministry of Health reported that the Butembo Ebola Treatment Center reopened Saturday and is now managed by the ministry in collaboration with WHO and UNICEF, while reconstruction work will soon be launched in Katwa.

Despite suspending its activities in Butembo and Katwa, in North Kivu province, Doctors Without Borders said Thursday that it will continue Ebola-related activities in the towns of Goma, Kayna and Lubéru, also in North Kivu, and in Bwanasura and Bunia in neighboring Ituri province. The two provinces are among the most populous in the nation and border Uganda, Rwanda and South Sudan.

After the second attack, the World Health Organization said in a statement, “Such attacks are deplorable for their immediate impact on lives and for the risk of spreading the disease further.”

Since the outbreak began in August, there have been 897 cases, with 563 deaths and 304 people healed, Congo’s Ministry of Health reported Monday. Additionally, 85,226 people have been inoculated with an experimental vaccine approved by the nation’s Ethics Committee and made by pharmaceutical giant Merck.

On average, Ebola – which causes fever, severe headache and in some cases hemorrhaging – kills about half of those infected. The latest outbreak has a case fatality rate of 60%.

Outbreak complications

Not only is North Kivu experiencing a deadly Ebola outbreak, but long-term conflict smolders there, with 50 armed groups causing intermittent violence, according to WHO. The UN public health agency estimates that more than a million refugees and internally displaced people are traveling through and out of North Kivu and Ituri, and this movement is a potential risk factor for the spread of Ebola.

Other complicating factors include a surge in malaria cases in the affected region, political unrest related to a controversial December presidential election and media allegations of sexual misconduct at some of treatment centers.

WHO spokesman Tarik Jašarević wrote in an email that “the recent attacks on Ebola treatment centres in Katwa and Butembo indicate a major deterioration of security in the region.” The “first such large-scale and organized attacks targeted directly at the Ebola response,” he noted, “they are of a different order of magnitude to episodes of mistrust in communities or dangers of being caught in crossfire as fighting parties engaged.”

Disruption caused by the attacks will probably lead to increased spread and more people becoming sick, he added.

Tariq Roland Riebel, Ebola response director for the International Rescue Committee, a not-for-profit humanitarian aid organization working on the ground in Congo, wrote in an email on Monday that he “denounces the recent acts of violence in the Butembo region, which has led to the decision to suspend our work in the area.”

View from the ground

In late January, Dr. Stacey Mearns, Ebola Response Program director for the International Rescue Committee, described the outbreak as “incredibly complex” due to conflict in the region.

“The insecurity that we see with the ongoing attacks by rebel groups and ongoing violence basically means we have periods where movement of essential response workers has to stop, and that could be your vaccination teams, your safe burial teams, your surveillance team,” Mearns said. In the first six months of response, her organization “certainly had periods where, days at a time, we’ve had to suspend programming and response.”

Mearns is no stranger to Ebola outbreaks on the African continent, having worked in Sierra Leone during the West African outbreak of 2014-15 and in Congo during a smaller outbreak early last year. The West African outbreak, the largest in history, killed more than 11,000 people, according to WHO.

Mearns believes that people in the affected areas of Congo are experiencing “justifiable frustration” at the “chronic emergency” of insecurity in the region “for the last 20 years.”

“A lot of attention and resources have come in for Ebola, but there’s been little focus on the underlying insecurity and displacement that the population are seeing as well.”

Mearns said regional violence has been a major deterrent and a major obstacle for her organization, which is seeking “to control the outbreak in ways we have done before. It’s tough. The insecurity is tough. There are days where everyone here is worried about their safety and security,” she said.

“So far, I’ve been lucky, but it’s still at the forefront of our minds,” she said. “There are roads that I travel on quite a lot where we’ve had people kidnapped; we’ve had shooting at vehicles; we’ve had stones thrown at vehicles.

“We have to constantly adapt our approaches, because one day, we can’t get to this area or we have to evacuate the team,” she explained. “It just makes everything a lot more complex than it needs to be in what is already a complex situation.”

In January, she also speculated that there was “a very high risk that this will go to Goma.” In the Ministry of Health’s most recent report, three suspected cases have been recorded in that city. She also believes that “there is a very high risk that this will cross borders, be that into Uganda or Rwanda.”

“You need more resources and partners on the ground to be able to manage such a dispersed response,” said Mearns, whose own team is about 130 people.

Riebel said the International Rescue Committee is “currently holding meetings with community members to listen to and address their concerns, better explain our infection prevention programming and work with them to strengthen the response.” To stop the spread of Ebola in North Kivu, he added, “all actors must make community engagement an integral part of the response.”

Six months into the outbreak

Dr. Anthony Fauci, director of US National Institute of Allergy and Infectious Diseases, described the current outbreak as a “unique situation” compared with past epidemics.

“The security issue is really having a major negative impact on the ability to respond in an appropriate way, in the classic way that you respond to an Ebola outbreak, to be able to essentially get to the point where you diminish it, diminish it, diminish it, and then it’s gone,” he said in late January.

In general, Congo, where the hemorrhagic virus remains endemic since its discovery in 1976 near the Ebola River, has been very good at containing outbreaks of Ebola, Fauci said: “From a historic standpoint, they generally have the capability of doing what it takes to curtail and contain the outbreaks as they occur. They essentially have a complete ability to identify, isolate and trace contacts.”

“The problem is that more than half of the new infections that are coming into the Ebola treatment units are individuals who have no connection to any contact. So we don’t know where or how they got infected,” he said. This is “very concerning, because that means you don’t have control over the containment of the outbreak.”

On the positive side, he believes that the experimental vaccine is probably why the outbreak hasn’t “really exploded.”

“So the good news is that we have a tool we didn’t have in the West African outbreak. The sobering news is that we’re not able to implement it as extensively as we want to because we don’t have access to all the contacts of the contacts of the contacts, because new cases are coming in that we can’t trace to any known case,” Fauci said.

He also noted that a randomized trial of four experimental drugs is underway in the region, with the Ministry of Health running the clinical trial as trained by US National Institutes of Health scientists.

In October, the WHO International Health Regulations Emergency Committee decided that the outbreak did not meet the criteria for a public health emergency of international concern.

Some experts disagreed with this decision, including Lawrence O. Gostin, a professor and faculty director of the O’Neill Institute for National and Global Health Law at Georgetown Law. More recently, Gostin said that he believes the situation in Congo “met all the legal criteria for an emergency even then, but since that time, everything has escalated. The violence has escalated; the public distrust has escalated. And the epidemic is really skyrocketing.”

In a February article in the journal The Lancet, he repeated his call for WHO to “sound a global alarm.”

“If it weren’t for the vaccines, it’s very likely that this would have surpassed the West African epidemic,” Gostin said. “It’s already the second largest Ebola epidemic in the history of the world.”

Renewed calls for an international response

“Every time they have a concussive violent attack, there is a huge spike in cases,” Gostin said, adding that there is a “very, very high risk that it could spread to Uganda and even to South Sudan, which would really simply devastate things.”

For this and other reasons, he and his co-authors are asking WHO “to reconvene the emergency committee.”

“And we suggest a number of concrete actions that the UN and WHO should take, such as martialing diplomatic peacekeeping resources as well as a surge of funding and a surge of personnel to the region,” he said. “Without it, we’ve basically got a silent epidemic where we don’t know the extent that is occurring and basically the international community has been asleep at the wheel, including and maybe even particularly the US.”

In October, shortly after WHO’s announcement that the outbreak did not constitute a public health emergency of international concern, the US State Department pulled US government personnel from the region.

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Jašarević said that “a risk assessment is done every month, which looks at a range of factors” and based on this, WHO’s director-general can assess whether any of its emergency committees needs to reconvene. As of Monday, though, the director-general had not set a date for any meetings.

“In light of the violence, some partners have understandably put their operations in Katwa and Butembo on standby as they assess the risks. We continue to work with them in other affected areas,” Jašarević said.

Gostin believes that currently there is a “huge health risk to the region.”

“There’s a huge economic risk to already fragile, unstable countries, and then ultimately, it’s not unthinkable that a case could show up in the US, Europe or other advanced economies because of air travel,” Gostin added. “So I’m worried about the economics, I’m worried about the health, and I’m worried about global complacency.”