The second largest Ebola outbreak in history has killed more than 1,300 people since it began in August last year and has now spread across the border from the Democratic Republic of Congo to Uganda.
Doctors, aid workers and the government have been unable to contain the virus in the Democratic Republic of the Congo — a country in the midst of civil war. Now two people have died from the Ebola virus in neighboring Uganda, including a 5-year-old boy. The virus has infected more than 2,000 people.
Public health experts at the World Health Organization (WHO) on Friday decided not to declare an international emergency, which if implemented, would require the WHO Director-General to issue temporary recommendations including surveillance measures, travel and trade measures and treatment guidelines, to prevent the spread of the disease.
“In general this has garnered a lot less attention than the 2014 epidemic,” Laurie Garrett, a Pulitzer Prize-winning author and expert on infectious diseases, tells TIME. “On all levels. Political, economic, public health and media.”
This is the third time WHO has gathered to assess whether to declare an emergency or not. At a Friday press conference Dr. Preben Aavitsland , acting chair of the WHO Emergency Committee on Ebola read out their statement.
“The exportation of cases to Uganda is a reminder that as long as this outbreak continues in DR Congo, there will be a risk of spread to neighboring countries,” said Dr Aavitsland. “The risk of spread outside the region remains low,” he said. “It is the committee’s view that the outbreak is a health emergency in the Democratic Republic of Congo and the region, but it does not meet all the three criteria for a public health emergency of international concern.”
“In the past [WHO has] been reluctant for a number of reasons,” Garret says. “The key one is it hasn’t crossed borders. Now a Congolese boy has died on Ugandan soil followed by his grandmother, but they still aren’t Ugandan and there hasn’t been any evidence of person to person transmission inside Uganda.”
The DRC has been at war since 1994 involving complex conflicts internally between rebel groups and externally against neighboring countries. Much of the conflict is concentrated in the eastern part of the DRC, where both militia and official security have been accused of mass violence, leading to a culture of mistrust of officials and outsiders.
More than an estimated 5.4 million civilians have died in the conflicts. Many aid workers on the ground treating Ebola patients have become the target of attacks, forcing several aid centers to close. Misinformation spread by some politicians have also created an air of mistrust in foreign workers and rumors that Ebola doesn’t actually exist. All of these factors have prevented an end to the outbreak.
“It’s not biology, it has nothing to do whatsoever with biology,” Garret says. “This is a 100% military/ political set of obstacles… the issue is that the people trying to stop the epidemic are being shot at.”
When did this Ebola outbreak start?
On August 1, 2018, the Institut National de Recherche Biomédicale confirmed four cases of the Ebola virus in the DRC. It is unclear what started the outbreak in August, according to Garrett, but organizations including the World Health Organization (WHO) immediately declared an outbreak. Further investigations found a concentration of Ebola cases in the North Kivu and Ituri provinces in eastern DRC, bordering Uganda.
The rate of deaths has slowly started to decrease after peaking in April 2019, but containment has proven difficult.
Why has it been so difficult to contain?
No other country in the world has more experience with Ebola than the DRC, Garrett says, and the country has been successful at ending many past epidemics, even ending an outbreak as recent as July 2018. But eastern DRC presents a different set of challenges, where a lot of the country’s conflict and violence is concentrated.
An estimated 4.5 million people are currently displaced in the DRC, according to the International Rescue Committee. The Council on Foreign Relations (CFR) estimates the number of people displaced in 2017 alone was 4.9 million. More than 20,400 peace keepers have also been deployed to the country. CFR estimates the country’s death toll due to war has surpassed 5.4 million, where kidnapping, sexual violence and robbery are common.
“It’s not clear that ramping up the response would make a difference in the context of a war zone,” Garrett, a former senior fellow on global health at CFR, says. She says she believes the epidemic has the potential to turn into an endemic.
To add to the difficulty, some politicians in the DRC have spread rumors that Ebola doesn’t exist, or that it was brought to the DRC by foreigners. A 2018 study found that 25.5% of North Kivu residents didn’t believe Ebola was real.
“Pouring more people in there, especially white-skinned people, Asian people, non-Africans, pouring them in there only can draw more of the conspiracy theories,” Garrett says. “And they can become more targets for the thugs and the armed bands and military groups.”
Yet others, like Nicole Fassina, an Ebola operations coordinator with the International Federation of the Red Cross, remain optimistic.
One way the Red Cross has responded to the spread of false information is by regularly going door-to-door in various communities to collect information on what rumors people are hearing. They counter those rumors in public statements.
“This is a really important part because it allows us to adapt our approach based on what we’re hearing,” Fassina says. “It’s a community-led approach that will end this outbreak.”
A spokesperson for WHO echoes that sentiment.
“We have the people, the tools, the knowledge, and the determination to end this outbreak but what we need is the sustained political commitment of all parties, so we can safely access and work with communities to beat the virus & end the suffering & loss of life,” WHO said in a statement to TIME. “Working closely with communities is the only way we can end the outbreak.”
After a string of fires at aid centers and shootings at aid workers in February 2019, Doctor’s Without Borders was forced to leave the DRC. At least two aid workers were killed and one was kidnapped, according to the U.N. In an earlier incident, 15 U.N. peacekeepers were killed, and 53 others were injured in North Kivu. Attacks have continued at various other centers, causing those who are sick to fear getting help.
“This is unprecedented,” Garrett says.
A lack of funding has also played a role in the rate of cases. WHO’s Dr. Aavitsland called on the international community to step up funding.
“The lack of funding makes the response in DR of Congo and the preparation work — makes it more difficult and may delay the actual stamping out of this outbreak,” he told reporters at a WHO the Friday press conference announcing the international emergency decision.
How many people have died?
A DRC woman and her 5-year-old grandchild have died of Ebola after crossing the border into Uganda. As of Thursday, the Uganda Ministry of Health confirmed a third case.
There’s a 67% fatality rate for those who have contracted the virus in the DRC. The highest fatality rates have been in North Kivu, where more than 1,200 have died.
Nicole Fassina, an Ebola operations coordinator with the International Federation of the Red Cross, is back home in Nairobi, Kenya, after spending four weeks in North Kivu. She describes the situation on the ground as disheartening.
It is still possible for the virus to be contracted after the infected person has died, making mourners especially susceptible to the disease. The Red Cross has implemented a Safe and Dignified Burial system, working with local community members to handle bodies in a way that is culturally respectful.
“If someone is taking away your loved one without being able to say goodbye in a manner that allows you some level of peace of the situation, that can be really difficult,” Fassina says. “We have to make sure that even though this is a medical outbreak, there’s still a very personal element that can’t be forgotten.”
What has the response been?
The international response to the outbreak has been minimal, according to Garrett.
The U.S. State Department issued a do not travel warning to North Kivu, Ituri and several other eastern DRC provinces.
The U.S. Centers for Disease Control announced Wednesday that it would be activating an Emergency Operations Center in Eastern DRC. Since June 11, 187 CDC staff have completed 278 deployments to the DRC, according to a statement by the CDC.
“Through CDC’s command center we are consolidating our public health expertise and logistics planning for a longer term, sustained effort to bring this complex epidemic to an end,” CDC Director Robert R. Redfield said in a statement.
Part of Fassina’s work includes building a rapport and relationship between affected communities and Red Cross aid workers to ensure cultural traditions are respected.
The Red Cross has had a presence in the DRC for nearly 100 years. Other organizations on the ground are WHO, the International Rescue Committee, Human Rights Watch, Africa CDC, various U.N. agencies, and dozens of NGOs and faith-based aid organizations.
“It’s only by being a part of these communities that we can listen to them properly and know how to respond when an outbreak comes up,” Fassina tells TIME.
How does the 2019 Ebola outbreak compare to the 2014 outbreak?
The global response to the 2014 epidemic in western Africa was also slow at first. In March 2014, WHO declared an outbreak after 49 confirmed cases in Guinea, several months after the first case was detected in December 2013. By July 2014, the virus had spread to Sierra Leon and Liberia. In August, after the virus spread to Nigeria, WHO declared an international emergency, 932 deaths later.
The U.S. CDC activated its response centers in west Africa in July 2014 and trained 24,655 healthcare workers. The U.S. Department of Justice also deployed military to west Africa in April 2014. Later in the year, one person in the U.S. was confirmed to have died of Ebola.
The 2014 outbreak is still the worst Ebola epidemic in history. A total of 11,325 died, and there were 28,652 total cases.
What public health considerations should people take?
The Uganda Minister of Health, Dr. Jane Ruth Aceng, called on Ugandans to avoid touching each other, not even handshakes, until the outbreak has been resolved.
WHO has been distributing best practices for those in proximity to the disease, which include minimizing contact with others, and how to properly hydrate a person who is sick. WHO also encourages those who have survived Ebola to play a role in spreading accurate information on the ground, and recommends vaccinations for those on the ground in crisis areas.
The disease spreads through contact with bodily fluids and contact with infected animals and aid workers are highly susceptible to catching the virus.
“I really commend the frontline workers who risk their lives every day to respond,” Fassina says. “The approach and the way forward is clear, and we are prepared for this. But we really need to make sure that we are adapting and listening to those communities and having a community-led response.”