Tedros Adhanom Ghebreyesus concentrates on a map of a long-forsaken war zone in the north-eastern provinces of the Democratic Republic of the Congo (DRC). Ebola is gaining ground here and Tedros, the director-general of the World Health Organisation (WHO), needs to stop it.
He huddles in a dim corner of a mess hall with his officers on the frontlines. Their fingers dance across the map as they point to areas occupied by militia and explain how their teams struggle to circulate through these parts with vaccines and thermometers – key tools for limiting Ebola’s transmission.
As darkness falls, more WHO staff file into the hall at the United Nations compound in Butembo, a volatile city in North Kivu Province. The din of their conversations rises as a buffet of stewed meat, fried fish and plantains gets cold and some boxed wine grows warm. Eventually, Tedros, as he prefers to be called, ends the meeting with his top aides and announces that it is time to eat.
He settles into a chair at a table of young Ebola responders — mainly Congolese public-health specialists and physicians — and falls silent.
It was June and Tedros was facing pressure from all directions. The outbreak had already grown to be the second largest in history. And despite having a new Ebola vaccine and drugs to treat the disease, the death rate was soaring at 67 per cent because the therapies weren’t reaching everyone in need. Armed groups weren’t the WHO’s only challenge.
Many residents just didn’t accept that Ebola responders were there to help. A deep-seated scepticism of outsiders comes from more than a century of conflict, exploitation and political corruption in the region. And wars over the past 25 years have destroyed any semblance of a reliable, regulated health system.
“The outbreak of Ebola is a symptom,” Tedros explains. “The root cause is political instability.”
This explanation doesn’t satisfy health-policy analysts who observe the escalating outbreak — which has killed more than 2,000 people — and question the WHO’s ability to contain it. Their criticism comes just as the organisation is asking governments and philanthropists to give millions more dollars for the response. The WHO has more Ebola responders on the ground than any other international organisation because ongoing violence keeps many others at bay. The responders have faced death threats and stones, bullets and grenades.
Tedros had come to Butembo to hear about obstacles and to speak to leaders around the city about calming tensions so that his teams could work without harm. As he eats with the responders, he grows defensive on their behalf.
“They are working day and night,” he says. “Other groups come and stay for a few hours; they run when they hear one bullet fired.” He rests a hand on the shoulder of an epidemiologist sitting beside him. Her colleague, Richard Mouzoko, was shot dead at a hospital in Butembo two months earlier. “She’s taking the same risk Richard took,” Tedros says. “We are doing this to save lives.”
In the morning, Tedros heads into the luminous forests on the outskirts of Butembo in a convoy of black armoured jeeps. In the town of Katwa, the vehicles pull over at an Ebola treatment centre that came under fire a few months earlier. Snipers from the DRC army now guard its entrance. Tedros strides rapidly through the wards and poses for a flurry of photographs with his team wearing WHO tactical vests. “I am very proud,” he tells the workers. “Even when I’m not around, I am thinking of you.”
In a flash, he is back in the motorcade, rushing to a runway where a helicopter awaits. Ibrahima Socé Fall, the official leading the WHO’s Ebola response on the ground, sees Tedros off. I stay behind with Fall, to see what it means to battle one of the deadliest pathogens known to humankind in a city tortured by war.
We slide into an armoured vehicle and head north to the city of Beni on an unpaved highway that slices through tall grass and lush, tropical trees. This strip of land is controlled by grassroots militia groups known as the Mai-Mai, so the vehicle moves at a steady clip behind a pickup truck carrying soldiers in the back. When the sky opens with heavy rain, they pull faded winter parkas over their heads.
On the drive, Fall talks about the toll of violence. A surge of killings, arson and gang rapes has traumatised communities. Around 1,900 civilians have been massacred in North and South Kivu in the past three years and another 3,300 people have been abducted, according to the Congo research group, a non-profit investigative project at New York University.
Parents mourn for children who have been stolen and forced to serve as soldiers. “The people here are very stressed,” Fall says. He notes that clashes a week earlier, in the Ebola-stricken province of Ituri, killed 160 people and sent 300,000 fleeing for their lives. It hardly made the news. “The people here don’t believe that anyone cares for them, even their own government, so it is very hard to convince them that we are here to help,” he says.
The roots of mistrust run deep. The east has been embroiled in wars that began in 1996, after the genocide in Rwanda spilled into the DRC. At least eight other African countries were soon involved in what became known as Africa’s World War.
By 2007, an estimated five million people had died from violence, disease and malnutrition as systems crumbled. Although the wars have technically ended, around 130 armed groups now occupy the east.
It was into this tinder-box that Ebola spilled over from an animal reservoir, most likely bats or apes, into humans. On August 1, 2018, a patient’s blood sample collected near Beni tested positive for Ebola. Oly Ilunga Kalenga, the DRC minister of health at the time, declared that the virus had arrived in north-eastern DRC for the first time.
“From day one,” says Ilunga, “I warned everyone that this would be a very bad outbreak because of conflict.”
Within a week, the Ministry of Health, the WHO and aid groups began establishing Ebola treatment centres. Health workers carted high-tech coolers filled with frozen Ebola vaccines into the rainforest, and epidemiologists from the WHO’s emergency-operations division arrived to investigate the spread of the disease. They were trying to learn how each individual got infected and to search for anyone those individuals touched while sick.
Health workers monitor these contacts for signs of Ebola, such as vomiting and fever, for 21 days — the incubation period of the virus. If they suspect an infection, they test and isolate people before it spreads. This cornerstone of the Ebola response, called contact tracing, is the key to stopping the virus’s transmission.
In a country with a strong, centralised network of doctors and public health workers, contact tracing is manageable. But after decades of political instability, eastern DRC has no such system, and conflict makes it impossible to create one quickly. Between September and November last year, an armed group infamous for hacking civilians to death with machetes, the Allied Democratic Forces (ADF), slayed an estimated 55 civilians in and around Beni, and kidnapped dozens. Amid one attack, a rocket-propelled grenade hit the Okapi Hotel, where Ebola responders from the WHO were staying. It failed to explode, sparing their lives.
After each attack, frontline responders pulled back for their safety and the disease spread unfettered, with a surge of people dying from Ebola in the weeks following violence. Marta Lado, an infectious-disease physician at an Ebola centre in Beni, explains: “We start thinking we’ve got it under control, and then an attack happens and for three or four days, we can’t go into the community because it’s not safe, and the contacts disappear.”
By December, the outbreak had already become the world’s second-worst. Then things went from bad to worse. The president at the time, Joseph Kabila, barred more than one million people in Beni and Butembo — strongholds of opposition parties — from voting in the upcoming election. He blamed it on Ebola and the security situation, but many DRC citizens saw this as a thinly veiled attempt to retain power after an 18-year stranglehold on the presidency.
Volatile demonstrations erupted across the country. An Ebola centre was looted during one protest in Beni, but the real damage to the Ebola response was the politicisation of the outbreak. The voting ban seemed to confirm rumours that this terrifying disease was a tool designed to disenfranchise the opposition and make money.
After all, many Ebola responders came from the capital, Kinshasa, and from other countries. They stayed in comparatively upscale accommodations and hadn’t cared about suffering in the region before. Some residents believed that these foreigners were importing Ebola to kill them, similar to the ADF, which arose seemingly out of nowhere and with international ties. As a doctor from Beni explained to me, “People think this is just another thing brought from outside to kill.”
Mistrust grew in January after the election, which was widely considered a sham. Kabila handed the presidency to a candidate who would later allow him to share power. On the night of February24, assailants burnt down parts of an Ebola treatment centre in Katwa. Three days later, they set another centre and its vehicles ablaze in Butembo.
Immobile patients watched in fear from their hospital beds. Four people with Ebola fled into the forest. This attack coincided with the centre’s busiest hour, as daytime staff handed over to the evening shift. “They were such violent attacks. And they were planned,” says Trish Newport, an Ebola programme manager at the aid group Médecins Sans Frontières (MSF, also known as Doctors Without Borders). Fearing for their safety, MSF evacuated staff from Butembo and Katwa, and the WHO and the DRC Ministry of Health together filled the vacuum.
Tedros has put the WHO in the spotlight in the DRC. Throughout this year, the WHO has had around 700 of its staff in the cities and towns where Ebola is spreading. In contrast, the US Centers for Disease Control and Prevention (CDC) has had only about a dozen epidemiologists in the country, and they are not in the hot zone. Other aid groups that were at the forefront of the world’s largest Ebola crisis — in West Africa from 2014 to 2016 — such as MSF and the Red Cross, are helping, but in lesser numbers than the WHO.
In July and August, armed groups killed and abducted more DRC civilians. In response, residents of Beni held a protest directed at UN troops and the authorities who had failed to protect them. The responders stayed indoors that day. As of September 7, Ebola had infected roughly 3,080 people, killed 2,060 and spread 700 kilometres to the war-weary province of South Kivu, bordering Burundi and Rwanda.
A prospect that terrifies specialists on pandemics is that the outbreak in eastern DRC represents a type of complex emergency that no health agency will ever be able to extinguish rapidly. Ebola and other deadly pathogens will keep spilling over from animals into humans, and the ever-increasing mobility of people will help infections spread. It is no coincidence that the world’s two largest Ebola outbreaks have exploded in densely populated regions of countries with ineffective health systems, extreme poverty and a history of exploitative colonization and conflict.
Chikwe Ihekweazu, the director of Nigeria’s Centre for Disease Control, reflects on Ebola responders who have been stationed at the epicentre of the outbreak for months. “I know how hard my colleagues in the field are working — 18-hour days, losing track of the weekend,” he says. “In some ways, they are paying for all of us ignoring the situation in this part of the continent for many years.”
This outbreak will eventually end, but it could cost tens of thousands of lives and billions of dollars. When Tedros took the helm at the WHO, the top of his agenda was not emergency response, but universal healthcare — delivering basics such as antibiotics, vaccines and a network of labs to identify infections. Curbing Ebola should be straightforward with political stability and a robust health system, Tedros says. But in their absence, a cycle of tragic, multimillion-dollar health disasters will continue to flourish in the DRC, Yemen and other fractured regions of the globe. “As long as places are this vulnerable, this will keep happening,” he says. “We will fix Ebola — and it will come back tomorrow.”
- A Nature magazine report / By Amy Maxme