The Ebola outbreak in the Democratic Republic of the Congo (DRC) continues, with health officials reporting 7 additional cases since Friday, August 31. The case count, as of September 4, stands at 127 total cases (96 confirmed; 31 probable) and 87 total deaths (56 among confirmed patients; case fatality= 68.5%).
One of Outbreak Observatory’s principal aims is to provide insight into the operational challenges faced by outbreak responders, and this week, we are able to bring you a firsthand account of the DRC Ebola response via an interview with Joseph Fair, PhD, outbreak response specialist and team lead for the International Medical Corps (IMC) response in North Kivu.
From your perspective, what are the biggest operational challenges facing the Ebola response in DRC?
Unfortunately, the same challenges exist in every outbreak and have yet to be addressed by any of the new global initiatives, including the Global Health Security Agenda. There is a lack of ability to physically communicate, and there is always a disconnect between headquarters operations, for all organizations, and the field. Nearly every technology that high-resource nations develop for use in outbreaks relies heavily on fast internet and the ability to communicate easily. Until we either provide the appropriate tools for the field or we start developing low-bandwidth technologies, this will continue to be the case.
In this particular outbreak, security has been and continues to be a major hindrance for outbreak responders. Recent attacks on UN and DRC national forces in Beni resulted in the evacuation of US government personnel to Goma [150 miles away]. Suspected cases have already been reported in the area of Oicha, an area known for heavily armed rebel forces, presenting even greater challenges to response teams. This means that teams cannot move freely to do case investigations out of concern for personnel safety. Responders have to be safe themselves in order to help the affected populations.
Things that many, including myself, would expect to be standardized by now—for example, posters communicating how Ebola is spread—are still not available and have been started anew in every outbreak of Ebola in which I have participated. These are very simple and basic measures, but to this day, they have not been completed or compiled, and they delay responses every single time. While we hold infinitely many meetings and conferences on lessons learned and how to do better the “next” time, these simple but critical measures always seem to fall through the cracks.
In your view, how does this outbreak compare to what you saw on the ground when you responded to Ebola in Sierra Leone?
As in West Africa, North Kivu borders the countries of Uganda and Rwanda, and while the outbreak is presently relatively small in magnitude, should cases flow through the very porous and open borders with these nations, we fear that we could experience an outbreak of the same or greater magnitude than was observed in West Africa. The same conditions—multiple state borders with common languages and frequent trade—exist in this region, providing access to Uganda, Rwanda, and Burundi.
Suspected cases, thus far all negative, have been repeatedly reported in Goma. Goma is a major urban center, and if the disease does present there, the scale of this epidemic would be expected to grow exponentially and then spread into border states. Goma is connected to every other major urban center in DRC as well as border state cities. Kampala (Uganda) and Kigali (Rwanda) are easily accessible via roads and trade networks that exist in the sub-region. Once the disease presents in a major city with frequent international travel, it is a near certainty that we would see cases in Europe and other regions of the world that are heavily connected to East Africa via trade, commerce, and tourism.
There is extremely limited access to needed resources, materials, equipment, and medical supplies in the epidemic zone, which further hampers the ability of the UN and non-governmental organizations to respond. In addition to the lack of materials, the region just entered its rainy season—exactly as happened in West Africa—and there is, in general, no heavy equipment available to build Ebola treatment centers. The ability to move quickly, including financially, is key to preventing this potentially catastrophic epidemic from spreading into the major urban centers of East Africa and on to the rest of the globe.
What resources would be most helpful at this moment?
Field-trained personnel and robust communication technologies. Regarding personnel, our schools of public health and medicine are turning out new generations of data epidemiologists and other disciplines that work primarily from computers to provide data analysis. Field epidemiologists are in extremely short supply, and without field personnel, there is simply no data to analyze. Pursuing a career as a field scientist makes regular employment more difficult, so a gap exists in the need versus availability. We simply need more field personnel than are currently being trained and deployed.
In DRC, are there any types of data or information that are not available that would be helpful to support response activities and planning?
Accurate and reliable maps are very difficult to come by, but they are absolutely required for us to be able to do our work effectively. We try to fill this need by working with local personnel who know the regions well, but maps are usually difficult to find in most areas that have experienced outbreaks of Ebola.
4X4 vehicles are also in short supply and are difficult to obtain in the areas where outbreaks occur. A few major suppliers like Toyota Gibraltar exist around the world, but whenever an outbreak occurs, there are runs on their supplies because we all essentially shop at the same places. The same is true for personal protective equipment (PPE) and other outbreak response essentials.
We need a whole-of-government response, with coordination between essential ministries. Disconnects exist between government ministries, and this is true for most countries that experience outbreaks of viral hemorrhagic fevers. While we rush to import critical donations of medicines, PPE, and other needed equipment, we have, at times, experienced extreme delays in getting those items to where they are needed due to normal operating procedures of import and customs authorities in developing world settings. Even though these supplies are humanitarian donations and time critical, we are often forced to pay excessive taxes and duties on them, and without doing so, they are not released for response efforts. I have encountered this same scenario in almost every outbreak in which I have participated.
What lessons can you share for those who have not faced a similar response, based on your experiences with Ebola or other infectious disease outbreaks?
If you want to do this type of work in any role, be prepared to be uncomfortable, to work marathon hours, to eat food you normally wouldn’t consider, and to be without things we have come to consider as essential to life: power, clean water, and climate-controlled living and working quarters. And expect delays in every aspect of life. Things that take minutes at “home” can take days to weeks in these settings. It is often difficult for individuals from developed countries to understand how and why things take so very long, but you have to consider the histories of the areas of the world in which we tend to work.
Physical and mental fitness is absolutely necessary to do this kind of work. Many of us do not pay much attention to our physical and mental fitness in our normal day-to-day lives, but when you are deployed to work in an outbreak, you need to be of sound of mind and body. If you are not, it can and does, at times, end in personal disaster.
Our mission for Outbreak Observatory is to conduct, support, and promote operational research during outbreaks. Analyses of the West Africa Ebola epidemic found that operational research was rarely conducted, as response activities understandably took priority. Considering that there appear to be more resources devoted to containing the outbreak in DRC, do you see signs that operational research is being conducted? If so, toward what sorts of topics?
The first priority is to find sick or potentially infected individuals and isolate them from physical contact with others in the community. All resources are fully devoted to this single mission, and operational research often suffers as a result. Operational research in certain areas of the response—including how to move money effectively, how to coordinate and consolidate efforts, and how best to communicate to the public—have just started to occur, 3-4 weeks into the outbreak. This is a normal timeline for most outbreaks of viral hemorrhagic fevers.
What is the most important lesson or experience from the West Africa epidemic that is being applied to the current response in DRC?
The world moves much faster now, as a reaction to what happened in West Africa. I sincerely hope this trend continues, because we can never afford to be complacent.
We would like to thank Dr. Joseph Fair for sharing his valuable time and experience with us. His perspectives will hopefully be valuable to others who may be preparing to face similar challenges in future outbreaks. For more information on IMC’s efforts in DRC and elsewhere, please visit their website: https://internationalmedicalcorps.org/
Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.