Almost a year after the second-worst Ebola outbreak in history began in the Democratic Republic of Congo, the World Health Organization finally declared the crisis a “public health emergency of international concern” (or PHEIC for short)—a label that it has only used four times before. The decision was made at an emergency meeting yesterday, on the recommendations of a panel of independent experts.
More than 2,500 people have become infected since the outbreak was officially declared on August 1, 2018. Almost 1,700 of those have died, while more than 700 have been cured. A few hundred cases are still being investigated, and new ones arise on an almost daily basis. These numbers make the outbreak worse than all of the Congo’s nine past encounters with Ebola put together, although they are still well below the scale of the West African epidemic of 2014 to 2016, which infected 28,000 people and killed 11,000.
Ebola was first discovered within the Congo’s borders in 1976 by Jean-Jacques Muyembe—then the country’s only virologist and now the director-general of its National Institute for Biomedical Research. The disease has reared its head repeatedly, more so in recent years. But the Congo is arguably the most experienced nation in the world at dealing with Ebola. The eighth outbreak in 2017 was contained in just 42 days. The ninth was over in three months (almost exactly as Muyembe predicted at the time).
But the tenth and current outbreak is different. While the previous ones took place in the Congo’s northern and western regions, this one had the grave misfortune to spark up in the eastern provinces of North Kivu and Ituri. These regions abut Rwanda and Uganda, and are active war zones full of displaced refugees.
To control Ebola, health workers need to find infected people, track whomever they had contact with, deploy vaccines, and convince people to forgo deeply held burial practices that put them in touch with the virus-ridden bodily fluids of their dead loved ones. All of that becomes infinitely harder in regions plagued by armed conflict, where people are distrustful of health workers.
Those workers have come under attack themselves. Hospitals, treatment centers, and operational facilities have been pelted with stones, set on fire, and stormed by armed assailants. Volunteers have been attacked while trying to bury Ebola victims. Two Ebola workers were murdered in their homes. Small wonder that the outbreak has proved unusually hard to contain.
The WHO hopes that the PHEIC declaration will act as a rallying cry. “I urge the international community to step up and put its full support behind the Ebola response,” said Matshidiso Moeti, the WHO regional director for Africa, on Twitter. The PHEIC declaration is “an opportunity to ensure the international community does not turn its gaze, but rallies to support DRC and Africa in the fight to end the Ebola outbreak.”
But for many parties involved in the outbreak response, the PHEIC decision came bafflingly late. “Finally after 1600 deaths?” Marc Yambayamba from the Kinshasa School of Public Health said on Twitter. “Almost all international legal and policy experts agree that the conditions for declaring a public health emergency of international concern were met long ago,” added Rebecca Katz, who directs Georgetown University’s Center for Global Health Science and Security, in a statement.
The PHEIC label was created in 2009, as part of international regulations to which the WHO’s member states must adhere. It’s an alarm bell, to be rung when the world must collectively mobilize against “an extraordinary event” that involves “the international spread of disease” and “may require immediate international action.” Until now, only four events have met that criteria: the swine-flu pandemic of 2009, the resurgence of polio in 2014, the West African Ebola outbreak, and the Zika epidemic of 2016.
The WHO had previously convened three emergency meetings to discuss whether the current Congolese outbreak also warranted PHEIC status. Thrice, the committee said that it didn’t, arguing that a declaration would do little to improve matters. For example, a PHEIC allows the WHO to compel the affected countries to disclose information that would be relevant to responders—but the Congo has been very transparent. A declaration also carries risks, as other countries might react by imposing trade and travel bans that would paradoxically stanch the flow of support and make the outbreak even harder to stop.
The calculus shifted slightly in June, when two children and their grandmother carried the virus into Uganda. All three died, but fortunately, the virus didn’t spread any further. Once again, the WHO ruled against a PHEIC. (Uganda also has a strong track record of controlling Ebola; its robust surveillance network means that most of the outbreaks that have been detected in the past decade have been limited to a handful of cases.)
Then, on July 14, a pastor brought Ebola to Goma, a big city that directly borders Rwanda and has an international airport. (Depending on the source, Goma is home to either 1 or 2 million people.) That event finally swayed the WHO’s emergency committee, although the chairman, Robert Steffen, emphasized that states should not use the PHEIC “as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region.”
The Congo’s Ministry of Health accepted the WHO’s decision, but released a somewhat barbed statement in their daily update. “The Ministry hopes that this decision is not the result of many pressures from different stakeholder groups who wanted to use this statement as an opportunity to raise funds for humanitarian actors despite the potentially harmful and unintended consequences for the affected communities dependent on significant cross-border trade for survival,” the ministry said. “While the Government continues to openly share with partners and donors how it uses the funds received, we hope there will be greater transparency and accountability of humanitarian actors in relation to their use of funds to meet this Ebola outbreak.”
“A public health emergency of international concern is not for fundraising, it’s for preventing the spread of disease,” said Tedros Adhanom Ghebreyesus, the director-general of the WHO, on Twitter. “The WHO is not aware of any donor that has withheld funding because the emergency had not been declared. But if that was the excuse, it can no longer be used.”