Owing to the tropical nature of disease such as Ebola, developing nations and groups suffering from economic hardships are disproportionately affected.
Additionally, countries with histories of Ebola outbreaks such as the DRC, Guinea and Sierra Leone have deep and varied cultural and political backgrounds. Colonial rule imposed upon many African nations and regions by Europeans (and with it, political and economic controls) drove a wedge between peoples, and when these colonial governments withdrew in the 20th century, often power vacuums developed.
After French rule in Guinea, many of the traditional cultures living in the forested regions in the far east and south east of the country had what they deemed to be ‘outsiders’ installed in their community hierarchies. These pseudo civil servants were seen as a direct extension of the government in Conakry, and many communities viewed them as an attempt to remove both physical assets and cultural heritage from the towns and villages which they were sent to govern. This deep divide continues today, and was seen as a critical factor in the violent backlashes against the Ebola response in Guinea during the 2014-16 outbreak.
Little more than a week before the declaration of the start of the current Ebola outbreak in the DRC, another Ebola outbreak ended in the Équateur province in north western DRC. This was a considerably smaller outbreak that remained contained in a demographically distinct region of the country, resulting in only 33 fatalities over two and a half months. This region of the DRC was not in a state of conflict, so contact tracing (the prerequisite to effective administration of the rVSV-ZEBOV-GP vaccine, see Ebola in the DRC – October Update, RAN news, October 22nd) was more easily performed and likely prevented further spread of the virus.
Unfortunately, the current outbreak is in the Kivu region in eastern DRC where conflicts between a collection of armed groups range over multiple issues from mining rights to land use. This has been exacerbated by the large numbers of groups involved, from different socio-ethnic backgrounds, with varying ideologies and end goals, including an attack within the city of Beni (North Kivu region) in April 2019 for which the Islamic State group claimed responsibility.
Conflict in the towns and cities where Ebola cases were identified has affected the relief effort in two main areas –preventing contact tracing and increasing community resistance to the response. As previously mentioned, contact tracing was paramount during the Équateur province outbreak as it allowed healthcare workers to vaccinate these individuals. At the funeral of the index case in that outbreak, eleven people became infected as a result of interaction with the deceased. All of these were subsequently traced, as were their contacts, and isolation and/or treatment was provided.
However, in the Kivu region, fighting and conflict has seen the contact tracing rate fall to as low as 20% in some instances, which has inevitably caused the virus to spread further and faster. This has been augmented by people displaced by the conflict living in temporary camps, in close quarters and often with poor sanitation, further facilitating virus spread. Secondly, the current outbreak has seen extensive community resistance to the response that has resulted in multiple attacks against healthcare workers and Ebola Treatment Centres.
Two serious attacks on MSF-run ETCs in Katwa and Butembo resulted in healthcare workers being injured (and in Butembo, two patients dying after equipment was destroyed). This violence against the Ebola response has been catalysed, among other reasons, by the warring factions in the area. Many of these groups have used disinformation (for example, promoting the concept that Ebola has been fabricated and introduced by the government and the international response teams) to facilitate community mistrust of authority and promote their own cause.
Early engagement of communities, even within active conflict zones, may provide an avenue to amicable interactions with aid workers, promoting accurate information and helping to ensure the safety of local and international healthcare workers. Winning the ‘information war’ is a crucial stage during any community-based disaster response and the concerted efforts to engage all parties – individuals and state – is of utmost importance.
