At a press conference in Geneva yesterday, Doctors Without Borders (MSF)—a group with a long history of treating hundreds of patients in Ebola outbreaks—warned that the response in the DRC is losing the upper hand owing to deepening community mistrust.
In other developments, the Democratic Republic of the Congo (DRC) health ministry today reported seven new Ebola cases and responded to concerns about the response, which today included a visit from top World Health Organization (WHO) officials.
MSF: Community grievances increasing
During the briefing, MSF officials said that, since the first of the year, 40% of the newly reported cases are people who died from Ebola in their communities and that in the current epicenter of Katwa and Butembo, 43% of the patients confirmed with the virus in the past 3 weeks have no known links to other cases, a sign of undetected transmission chains, which is bad news.
MSF recently pulled its staff from Kawta and Butembo following violent attacks on its Ebola treatment centers (ETCs), but it has maintained its operations in other parts of North Kivu province and in neighboring Ituri province.
MSF International President Joanne Liu, MD, said, "We have a striking contradiction: On the one hand a rapid and large outbreak response with new medical tools such as vaccines and treatments that show promising outcomes when people come early—and on the other hand, people with Ebola are dying in their communities, and do not trust the Ebola response enough to come forward."
Regarding the attacks on the two ETCs, MSF said it doesn't know the motives or identities of the attackers, but the violence follows escalating tensions in the outbreak area that have also included dozens of security incidents against response efforts in February.
"While the causes of these acts are not all the same, it is clear that various political, social and economic grievances are increasingly crystallising around the response," MSF said in a press release today.
Underlying issues fueling the tensions include a massive influx of financing focused only on Ebola in neglected areas suffering from long-standing conflict, violence, and healthcare gaps, postponed elections in the outbreak-hit area, and suspicions that Ebola is a political ploy.
Police and armed forces are being used to compel cooperation with Ebola response steps, such as safe burials, contact tracing, and treatment center admission, which MSF says further alienates the community and is counterproductive.
DRC health officials have stepped up community talks in Butembo to better understand the gap between health workers and community members, and Health Minister Oly Ilunga Kalenga, MD, has acknowledged that using response teams accompanied by police in less secure areas has been perceived with suspicion. In an update today, the ministry also said it has gotten the message that community members want partners not only to fight Ebola, but also to improve general living conditions.
MSF said the Ebola response must change direction, and it had several suggestions, including giving disease management choices back to patients and their families, addressing communities' other dire health needs, and avoiding coercion tactics. And it urged even wider use of the vaccine, which has been administered to more than 86,000 people in the DRC.
Liu said Ebola is a brutal disease that breeds fear and isolation to patients, families, and health providers. "The Ebola response needs to become patient and community centred. Patients must be treated as patients, and not as some kind of biothreat."
DRC offials respond to criticisms
In its daily update, the DRC health ministry reported 7 new cases, including 5 in Katwa, 1 in Butembo, and 1 in Kyondo. The new illnesses lift the overall outbreak total to 913, which includes 848 confirmed and 65 probable cases.
Six more people died from their infections, including 3 in the community and 3 in ETCs, boosting the outbreak's fatality count to 574.
Also in the update, the health ministry pushed back on and clarified some perceptions of the outbreak. It said there's a misunderstanding about the role of law enforcement in the outbreak areas and that police and military are not involved in response activities and their role has never been to force compliance with sanitary measures.
Given numerous security incidents, the ministry said it asked the country's interior ministry to ensure the security of goods, services, and people in the area. "It is unacceptable for health workers to be threatened and assaulted in the course of their work," the officials said. "Likewise, it is unacceptable that families are prevented from burying their relative in a dignified and secure manner because of groups of unseemly people."
Because local health workers can't be pulled when security deteriorates, increased security is needed to keep the response going, the ministry said. It added that community members have demanded overall security improvements across the area and that a return to security is one of MSF's conditions for returning to Butembo and Katwa.
WHO officials, including Director-General Tedros Adhanom Ghebreyesus, PhD, arrived in Kinshasa today, where Kalenga received them and thanked them for their field work, especially their role in rehabilitating ETCs in Katwa and Butembo that were damaged in violent attacks.
Though the outbreak isn't under control, the ministry said progress so far is remarkable, given population movements and security challenges. "However, the risk of spread in other provinces and neighboring countries remains present as long as the epidemic remains active," it said.
WHO notes various hurdles
In its weekly snapshot of the outbreak, the WHO said today that virus transmission continues with moderate intensity and that Katwa and Butembo are still the main areas of concern, though small clusters continue to pop up across a wide part of the affected area.
For example, it said an emerging cluster in Mandima health zone is occurring in a previously unaffected village, consisting of five epidemiologically linked cases and a sixth involving a person who was probably exposed in Butembo. Also, a probable and confirmed case in Masereka have links to a Butembo transmission chain.
"These events highlight the importance for response teams to remain active across all areas, including those with lower case incidence, to rapidly detect new cases and prevent onward transmission," the WHO said.
Though the incidence of new cases is declining, a high proportion of community deaths are among confirmed cases, a low number of new cases are among known contacts, and delays persist in detecting illnesses and isolating patients in ETCs, the agency said.
Mar 7 MSF press release
Mar 7 DRC update
Mar 7 WHO update