No sooner had one outbreak of Ebola in the Democratic Republic of Congo (DRC) been declared over than another broke out. The latest outbreak is particularly threatening as it is in North Kivu province, an area beset with violence between rival militia groups. On top of struggling with violent conflict that has lasted, in some areas, for more than 20 years, the DRC is one of the world’s poorest countries and lacks a well-developed infrastructure.
Infectious disease outbreaks are more dangerous in countries like the DRC because fragile or severely off-track countries have little health care infrastructure to support the necessary steps to contain the outbreak. Although the DRC has had many Ebola outbreaks and more experience containing the disease than any other country, the conflict environment exacerbates the threat.
{mosads}Outbreaks like this are not just a threat to the health security of the DRC; they are a threat to global health security. North Kivu is near the borders of Rwanda and Uganda, reminding us of the challenges with the 2014 outbreak that began at the borders of Guinea, Liberia, and Sierra Leone.
From that outbreak, we learned a great deal about how to respond in a fragile state setting. Traditional leaders and faith leaders played an important role in communicating necessary information and behavior change requirements to isolated groups who did not necessarily trust the government or health care workers.
Because of the lack of administrative structures, working with villages to directly train them on surveillance and develop village-to-village relays to share information was an effective method to minimize exposure. Developing respectful ways to manage and bury the dead was essential, as the U.S. government estimated that up to 70 percent of infections were caused by handling infected human remains, and the disease was transmitted through burial rituals that included touching, washing, and kissing of the deceased. Efforts to enforce cremation in Liberia were not successful, nor was outlawing the sheltering of Ebola patients in Sierra Leone.
However, responding is seldom as effective as preventing. We know that fragile states are the most likely places for outbreaks to emerge and that zoonotic diseases — those that pass from animals to humans — are responsible for the most dangerous outbreaks. We also know that an effective health system can help prevent, detect, and respond to outbreaks so they don’t become epidemics. That is why the World Health Organization (WHO) and the U.S. Agency for International Development (USAID) have made health system strengthening the cornerstone of epidemic preparedness and response.
Disease outbreaks start and end at the community level and often in those communities at the last mile, so focusing efforts there, especially in a fragile environment, is critical. This means investing in both training and surveillance. In Liberia, for example, relatively small investments by USAID into community-led total sanitation efforts protected hundreds of communities surrounded by Ebola hotspots.
At the global health nonprofit where I work, Management Sciences for Health, we help local authorities develop preparedness plans so that leaders know how to react, communicate risks, and lead residents in adopting preventive behaviors. In Madagascar, with support from USAID, we trained more than 1,000 community health volunteers, village and other local leaders, and health center staff to detect and report suspected infectious disease cases using a mobile application.
That paid off in November 2017 during an outbreak of bubonic and pneumonic plague. Community health volunteers alerted district authorities when plague first hit, and authorities summoned help from WHO.
Preventative investments can mean the difference between life and death for people in those countries and the difference between an outbreak being contained or becoming an epidemic. As we face repeated outbreaks of infectious diseases, including new pathogens, it is essential that U.S. policy-makers continue funding the operations that make containment possible. These include ensuring continued funding of Centers for Disease Control and Prevention (CDC) and USAID operations overseas.
These investments help us conduct disease surveillance in the low-income countries where the next deadly virus is likely to originate. CDC operations also include training frontline health workers and strengthening or building efficient reporting systems so disease outbreaks can be caught early and at the source.
Likewise, the U.S. should continue to support global health efforts, including those that focus on animal health and zoonotic disease threats. We know that when Ebola reached Nigeria in 2014, the country stopped it in its tracks thanks, in part, to previous investments by USAID to eradicate polio.
Drawing on this capacity, once a diagnosis of Ebola was made, health workers completed contact tracing, ongoing monitoring, and isolation of potentially infected contacts. This limited the spread of Ebola to only 19 people instead of potentially tens of thousands throughout the densely populated and heavily travelled city of Lagos, a transit hub of Africa. If those investments had not been made, the disaster would have been unthinkable.
Global health security is only as strong as its weakest link. We learned so much from the 2014 Ebola epidemic, and it is vital that the U.S. continues to invest in preventing a repeat of such an event — or worse.
Ashley Arabasadi is a health security policy adviser at Management Sciences for Health, a nonprofit global health organization.