Battling An Ebola Outbreak In A War Zone
An outbreak of Ebola has killed over a thousand people in the North Kivu province in the eastern region of the Democratic Republic of Congo. This is the second largest recorded outbreak of Ebola. More than 111,000 people have been vaccinated in the country since the outbreak started in August. But the outbreak is happening against the backdrop of a conflict zone. The violence has spread to healthcare clinics and responders working to vaccinate and care for patients; political instability, misinformation, and distrust of the government and healthcare workers has led to 131 attacks on clinics in the region.
Nurse practitioner John Johnson, who is the Emergency Coordinator for Doctors Without Borders based in Goma, Democratic Republic of Congo, and journalist Laurie Garrett, author of The Coming Plague: Newly Emerging Diseases in a World Out of Balance, discuss the vaccination strategy in this outbreak and how healthcare workers are working to organize in a war zone.
Laurie Garrett is a journalist and author with the Anthropos Initiative in New York, New York.
John Johnson is an Emergency Coordinator for Doctors Without Borders, based in Goma, Democratic Republic of Congo.
IRA FLATOW: This is Science Friday. I’m Ira Flatow. The second-largest Ebola outbreak has killed over 1,000 people in Africa, sweeping through the north Kivu region in the Northeastern part of the Democratic Republic of the Congo. During the last outbreak in West Africa, the question was, could enough vaccine be produced?
Well, for this outbreak, the good news is over 100,000 people have been vaccinated in the area. The bad news? This outbreak comes amidst a background of political unrest in the area, and the violence is spilling over into clinics responding to the outbreak. There have been 131 attacks on clinics.
So how do you contain an outbreak in a war zone? That’s what we’re going to be talking about. Let me introduce my guest.
John Johnson is the emergency coordinator for Doctors Without Borders based in Goma Democratic Republic of the Congo. He joins us from the field. Welcome to Science Friday.
JOHN JOHNSON: Thank you, Ira. How are you?
IRA FLATOW: Nice to have you with us. Laurie Garrett is a Pulitzer Prize-winning journalist and author. She’s founder of the Anthropos Initiative based in New York. Good to have you back, Laurie.
LAURIE GARRETT: Hi, Ira.
IRA FLATOW: Let’s talk about the outbreak. There was another outbreak, Laurie, earlier this year in the DR Congo that is now under control. But this one in the Northwest is more difficult. Can you give us a brief overview of what’s going on in the country that’s affecting this Ebola outbreak?
LAURIE GARRETT: Well, no country in the world has had more experience with Ebola than the Democratic Republic of Congo. The first known cases were in 1976 in the country when it was called Zaire. And as recently as last summer and spring, there was an outbreak in a very different part of the country.
And all the resources mobilized quickly. DRC showed tremendous competence and capability and brought it under control in just a few months. But one week after they were able to declare that that first 2018 outbreak was under control, boom. A new outbreak, clear on the other side of the country. A very, very different situation.
And this one now has been unfolding since August 1, 2018, so we’re in 10 months of outbreak. We’re approaching 1,900 identified cases. And at any given moment, you have to assume there are many more cases that have not been identified, because fewer and fewer people are actually coming forward to the medical system to be diagnosed and treated. And 1,241 have died so far.
IRA FLATOW: Hmm. And what is the cause of all this distrust that’s going on there? And the attacks on the clinics?
LAURIE GARRETT: I think there are many sources of it. But the bottom line is, nobody has ever tried to fight this disease– frankly, any really frightening hemorrhagic disease with a high mortality rate, in a war zone. And certainly not in a war zone the likes of this one.
In 1994, we had the tremendous genocide in Rwanda, and the population that had been responsible for the genocide– much of it fled. About a million people into this region– into North Kivu of the Democratic Republic of Congo. And it started a cycle that has continued ever since.
We’ve had war in here that has involved as many as nine other nations’ armies. At any given time, the number of militias or armed organizations operating in this area can be counted– certainly well over 30, and some security estimates put it as high as 130. They range from small groups of armed, almost bandit-like groups, all the way to very sophisticated armed forces. And they are, some of them, quite well-funded, based on resources available in the area to exploit, to mine, and also won support from neighbor governments.
It’s a border area. It’s an extremely porous border. And the whole epidemic is lapping at the edges of Goma, which has, for decades, been an explosive center for the entire region, because it’s a major trading area, mining area– you name it. It affects Uganda, Rwanda, Burundi, Tanzania, Democratic Republic of Congo. So it’s all quite volatile.
And honestly, looking at it from a distance and having been in three Ebola epidemics myself, but not this one, I would say that we’ve rarely seen performance from WHO any better than what we’re seeing today. And the courage shown has been tremendous. And for the first time, we have an African CDC that is on the ground, and a lot of African expertise from all over the continent. But the forces should be with us.
IRA FLATOW: Yeah.
LAURIE GARRETT: We have a vaccine. And yet, the violence is really disrupting everything.
IRA FLATOW: Let me talk to John Johnson, who is there with Doctors Without Borders. How are you doing? Laurie Garrett talks about just how despicable the conditions are.
How are you doing? Are you safe? Give us an idea of what it looks like and how you are working, despite the turmoil there.
JOHN JOHNSON: So, yeah. Like Laurie said, this is an area that’s had a long history of violence over the past 20 or so years. It’s nothing new.
And what you see probably as the most effective use of resources and the people that are making the most ground are the local doctors and nurses and health centers that are able to keep working. And they’re the ones that should be really appreciated. The Ministry of Health– they’ve done an excellent job, continuing despite the ongoing attacks.
I think, like you said, the count is something like 130 attacks between August 1 and now. But every time there is an attack on a health center or on the Ebola response, that certainly slows us down. And you see a several day lag where contact tracing is no longer being carried out– where vaccination get stopped because of insecurity.
And that really hampers the outbreak response. What we’re doing is we are picking things back up and moving back in as soon as we can. But certainly, these attacks on health centers make it very, very difficult to work.
IRA FLATOW: Do you need more medicine or equipment, or is that not the problem in this case?
JOHN JOHNSON: The treatment for a contagious disease is really– it’s two things. It’s the prevention and treatment. And what we have right now is, for the prevention, everything that always goes along with that. Hygiene, prevention in health centers from spreading those nosocomial infections– the vaccination is a huge tool for preventing [AUDIO OUT] And again, now we’ve vaccinated over 114,000 people in this epidemic.
And then the treatment is actually better than it’s ever been. We’re testing new drugs in Ebola response under the Compassionate Use protocol, and they’re randomized clinical trials. Some of them are very, very promising. And so from a technical point of view, these things are actually going quite, quite well. Your question about what do we need more of, do we have enough drugs– we’re not [AUDIO OUT]
Between August 1 and today, we’re talking about 1,888 cases. It’s not the quantity of drugs. On the other hand, the number of vaccines is actually quite [AUDIO OUT]
–does have a very positive effect, that it does prevent Ebola. And it certainly prevents your risk of death if you’re vaccinated. And that is not produced today in quantities sufficient to do a large mass vaccination campaign. So we’re limited to vaccinating contacts and people at high risk for Ebola.
IRA FLATOW: John Johnson on the ground there with Doctors Without Borders, coming to us directly from the Democratic Republic of Congo. Adding, I guess, to your problems is the fact that there is a distrust about the treatment and the aid workers, correct? What approach are you taking to get people treated? How do you engage them so they’re not fearful to work with you?
JOHN JOHNSON: Yeah. So this is something you’ve seen in other Ebola outbreaks in the past. It’s certainly normal that [AUDIO OUT] to you’re in different communities. It’s a very lethal disease. Over 50% of people that catch Ebola will die. So we’ve seen, historically, lots of resistance.
And really, the problem that we have is that the disease spreads faster than we can spread the message about it. And really, the way to go about it is to engage with community leaders, pastors, members of the civil society, politicians, people that have groups of youth or women’s groups. And really begin to work with them and let them buy into the response, and let it be their community that’s the turning response and not me.
I’m from the United States. It’s not that the outsiders that come in should be in charge of this, but we need that the local community should buy back the response for themselves and be in charge of their own prevention and stopping this epidemic. And that’s where we saw things turn around in 2014.
IRA FLATOW: Well, speaking of past outbreaks, in the past, health workers would go to homes and find and treat people there. Can you do that here?
JOHN JOHNSON: Absolutely. It’s nothing new. In fact, Congo is probably the place where this has been done the most in different outbreaks like [INAUDIBLE]. People have actually been successfully taken care of at home.
Today, we are not at that stage, but we’re looking at how we can propose new strategies to be as decentralized as possible. Because up until now, the response, like I said, it’s just been very successful from a technical point of view, but we haven’t been able to expand as fast as the epidemic is. And what we need to look at now, after 10 months where it’s covering a very large geographic zone, is to think of this endemic aspect of this response and how we need to be able to respond in local health centers as much as possible.
And that’s going to be a very decentralized approach. This is something that needs to be discussed and brought into OC as well by the Minister of Health. But these are things we’re working on.
IRA FLATOW: Laurie Garrett, the US’s Center for Disease Control has withdrawn its workers from country because of fear of safety concerns. So is the US doing anything? What is the US doing in terms of this outbreak?
LAURIE GARRETT: Well, I want to correct you. They haven’t withdrawn from the country. But Secretary of State Mike Pompeo ordered back in August when the outbreak was spotted in North Kivu, said look. This is a high security area. We’re not allowing US government personnel on site. And so about a dozen CDC personnel are like 1,500 miles away in the country’s capital, Kinshasa. And this is a real loss, because there is a tremendous depth of bench at CDC of people who have been in multiple Ebola outbreaks.
Many, well over 1,000 CDC personnel, were on the ground in West Africa in 2014-2015, even into 2016, working at the country on local level. And many of the things that are questionable– what works, what doesn’t work, what are the worst sites of infection and contagion, how lethal is a dead body compared to a living person with the virus– these are the kinds of things that the CDC was right smack dab in the middle of and has a very, very deep bench of expertise. But they’re not permitted by the US government to go in.
And then on top of it all, so far, the US has only committed $11.7 million to the entire response, which is a pittance compared to the well over $1 billion that we put in to West Africa in 2014-2015. And there is a giant, yawning funding gap for WHO alone in this response– nearly $60 million short of its need to cover its on-the-ground activities. I think the most important thing that was learned in West African experience was that, first of all, the body of a recently deceased individual for up to three or four days has more virus on the outside of the body than is on the outside, and potentially contagious, of a living Ebola patient.
So the body burials are absolutely crucial– interrupting the funerals, safe burial of bodies. But this is very sensitive without war, without mass suspicion, without a contested war zone. I’ve been to multiple burials of people who had succumbed to Ebola, and families and relatives don’t like it any better than you would if your father were dragged out of your home, put in a plastic bag, and buried by people wearing security gear that look like outer spacemen.
IRA FLATOW: I have to interrupt to remind everybody that this is Science Friday from WNYC Studios.
LAURIE GARRETT: So just to continue, Ira, the problem is, these are always going to be difficult interventions to make– necessary. Pulling people out and putting them in quarantine– necessary. But they’re always sensitive– culturally sensitive and politically.
Now you add to it active disinformation campaigns– active lying claims that there’s no such thing as Ebola, or claims that the foreigners are injecting Ebola into people. And then you add one more layer on top of it. And that is a stolen national election.
It’s no coincidence that this surge in violence, which started the surge in cases, starting roughly in mid-March, comes right on the heels of the final announcement of the election results, when the Catholic church of Congo said, without a doubt, one individual took about 70% of the vote. But Kabila, the former dictator of the country, engineered a deal whereby the guy who actually came in third was named the president.
IRA FLATOW: OK. Go–
LAURIE GARRETT: And this region–
IRA FLATOW: I’m running–
LAURIE GARRETT: –was forbidden to vote.
IRA FLATOW: All right, Laurie. I’m running out of time.
LAURIE GARRETT: They were never allowed to vote.
IRA FLATOW: I’m running out of time. I want ask John Johnson before our line goes down, are you feeling optimistic about the outcome, John, on the ground there in the Congo?
JOHN JOHNSON: Well, I think we have a long ways to go. Optimistic that it’s going to end quickly? I don’t think so. I think we still have quite a long time and quite a lot of work ahead of us. But I am optimistic about the response, about the technicity of it, about the new strategies that are being proposed, and the fact that everybody’s really been working together quite well to move forward.
But it is right now at its worst period. The last two months have been the worst two months of the epidemic. Each week we’ve had more cases than any other week in the epidemic. And this poses a lot of problems for us. And we’re hoping to see that the peak of the epidemic is behind us and we’re going downhill. But at this point, it’s still going up.
IRA FLATOW: All right. Thank you. Thank you so much for taking the time to be with us today, John Johnson. Stay safe. John Johnson, Emergency Coordinator for Doctors Without Borders based in Goma, Democratic Republic of the Congo.
JOHN JOHNSON: Thank you.
IRA FLATOW: Good luck to you. And thank you, Laurie. Laurie Garrett, Pulitzer Prize-winning journalist and author who covers epidemics, and founder of the Anthropos Initiative, based in New York.