Last year I wrote a few posts ([1](https://steemit.com/steemstem/@nonzerosum/the-control-of-ebola-virus-disease-in-2018), [2](https://steemit.com/steemstem/@nonzerosum/ebola-outbreak-in-the-democratic-republic-of-congo-update), [3](https://steemit.com/africa/@nonzerosum/congratulations-dr-congo-today-you-reached-42-days-since-the-last-case-of-ebola)) about an outbreak of Ebola Virus Disease that was occurring in the Democratic Republic of the Congo. With the formal definition of the end of an outbreak being two incubation periods (21 days for Ebola) without a reported case (within an under-surveillance population) this outbreak in the North West of the country was brought to a close sometime in late July <sup>[1](https://www.who.int/csr/don/25-july-2018-ebola-drc/en/).

A few weeks on from the official end of the outbreak, however, another was sadly declared<sup>[2](https://www.who.int/news-room/detail/01-08-2018-cluster-of-presumptive-ebola-cases-in-north-kivu-in-the-democratic-republic-of-the-congo)</sup>, possibly due to a transmitted case that slipped through cracks in surveillance (seeing as it’s the same Zaire strain of the virus). This time Ebola was to flare up in the highly populated North East of the country. 

I didn’t write about it at the time for fear of becoming repetitive in my content, but I’ve kept an eye on news surrounding it and after six months of continuous transmission this new outbreak is now the second largest in history, and is currently poised to bubble over into a far more worrying crisis with some striking similarities to that of the 2014/15 outbreak.

In this post I want to illustrate the tricky intersection that exists between public health and governmental cooperation and highlight just how difficult this game of “disease wacky-a-mole” in The Congo is at the moment. 

## The Congo’s current Ebola outbreak  
The first confirmed case of Ebola in this latest outbreak appears to have occurred the week of the 9th July last year.

_Side note: Yes, this confused me too! It being before the previous outbreak was declared over. From what I’ve read, the early cases in the current outbreak would have come to light later when [contact tracing](https://steemit.com/steemstem/@nonzerosum/the-control-of-ebola-virus-disease-in-2018) traced cases back._    

Since then, as of the latest data, there have been 537 confirmed cases, 48 probable cases and 356 confirmed deaths <sup>[3](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)</sup> (a 66% case fatality rate! This is very high, even for Ebola). These cases are currently situated in the North Kivu and Ituri provinces of the Democratic Republic of the Congo. 

<center>https://cdn.steemitimages.com/DQmdbqiXz2yAZRyZSdrYXwRxdYQP1aA1FdDDCxtTzkKkaRH/image.png</center>
<center><sup>Image credit [WHO External Situation Report 27th December](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)</sup></center>

International response to this outbreak was speedy as many Ebola response personnel were still located in the country <sup>[2](https://www.who.int/news-room/detail/01-08-2018-cluster-of-presumptive-ebola-cases-in-north-kivu-in-the-democratic-republic-of-the-congo)</sup> and there was optimism in September that this would be a similarly short-lived outbreak <sup>[4](https://www.who.int/csr/don/14-september-2018-ebola-drc/en/)</sup>. The characteristic peak of an outbreak had passed and the number of confirmed cases were trailing down to the single digits, as can be seen in the early September stats in the figure below.

<center>https://cdn.steemitimages.com/DQmVAAchGQ9LCqkqbcQFf7dRxeUcSVyXxhU9dJzUUCzzb56/image.png</center>

<center><sup>Image credit [WHO External Situation Report 27th December](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)</sup></center>

This optimism, however, was short lived as the disease continued to increase its rate of spread and the outbreak continued. With a fifth of the total case load having been reported in the past 21 days it is possible that this outbreak is far from over <sup>[3](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)</sup>.

_I will state at this time that while the WHO class the risk of the outbreak spreading nationally as high, on an international scale risk of an outbreak is still very low. So I write this article as a reminder that Ebola continues to be an public health issue in The Congo, even if those of us in high income countries do not see the headlines on a day-to-day basis._

## Some context for the current outbreak
Since the country’s civil war during the late 90’s/early 2000’s The Congo has been mired with violence. Armed conflict between government forces and militant rebel groups has persisted until today <sup>[5](https://www.worldvision.org/disaster-relief-news-stories/drc-conflict-facts)</sup>. As such there are now somewhere in the order of 4 million internally displaced people across the country as a whole <sup>[6](http://www.internal-displacement.org/countries/democratic-republic-of-the-congo)</sup>. 

The provinces of North Kivu and Ituri, where the current outbreak is situated, are two of the most populated provinces in The Congo with some cities in the region, such as Butembo (pictured below) having over half a million residents. There is also continuous movement of refugees to neighbouring countries of Uganda, Burndi and Tazania from these countries.

<center>https://cdn.steemitimages.com/DQmbJzEmeaNF1XGMGtdHW6cBQzStmbmPnab2mYJYhkYYM8r/image.png</center>

<center><sup>Image of Butembo. Credit: [Wikimedia](https://commons.wikimedia.org/wiki/File:Butembo,_2016.jpg)</sup></center> 

The health care system that does exist in these provinces is constantly stretched thin due to a high burden of deceases including cholera, measles, monkeypox and yellow fever. The Congo also have the second highest number of cases and deaths from malaria in the world to contend with <sup>[7](https://www.severemalaria.org/countries/democratic-republic-of-congo)</sup>.

Add all of these factors together, throw in the usual distrust of the government and international aid workers during a crisis, and you have ripe conditions for a disease such as Ebola to spread 

## Recent developments that are cause for concern
One of the overriding reasons to suspect that Ebola will continue to spread at a greater rate now has its roots in the current presidential elections. A general election was initially scheduled to occur during November 2016, this vote was (contentiously) postponed until a couple of weeks ago on December 23rd 2018. 

Voting went ahead as planned however a decision was made to postpone the election in the cities of Beni and Butembo, with the current outbreak of Ebola cited as the reason for this delay. With a total of over a million voters in these cities combined, a lack of an explanation of how their votes would be incorporated after the election had taken place, and a high percentage of the population likely to vote against the incumbent president, outrage from the local population was inevitable.     

This announcement lead to violent protest in these areas, with much of the violence targeted toward Ebola response personnel <sup>[8](https://www.bbc.co.uk/news/world-africa-46692506)</sup>. This violence has lead to Ebola response NGOs, such as International Rescue Committee, temporarily suspending their aid efforts in the country <sup>[9](https://www.rescue.org/press-release/election-related-violence-democratic-republic-congo-forces-irc-temporarily-suspend)</sup>    

This violence has lead to in influx of refugees crossing the border into Uganda, causing disputes related to their Ebola screening process <sup>[10](https://apnews.com/35484caa0c1c4ca589da4a9b4255448a)</sup> and to try and gain some control over the situation, as of last Wednesday, it appears that the government may have cut the countries access to the internet <sup>[10](https://apnews.com/35484caa0c1c4ca589da4a9b4255448a)</sup>. This in total is causing massive disruption to treatment, contract tracing and data dissemination, the bread and butter of an effect Ebola response.   

## The way forward
After catching up on the outbreak this week, the high case fatality of 66% and also the low number of probable cases (the blue on the graph above) are starting to make sense to me now. Trying to apply medical care in an area of conflict and political upheaval is a constant challenge. Especially when it relies on very high levels of trust from the population. 

Since August the outbreak has lead to 54 health workers being infected with Ebola and 18 of those cases leading to death <sup>[3](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)</sup>. Add on top of this the violence directed towards health care workers and this demonstrates the extrema risks associated with treating Ebola in such a setting. As I’ve said before on this blog, those that work in public health and choose to run into the fire to help those in need have my absolute infinite respect.

I expect the “news worthiness” of the outbreak will increase if cases soon start appearing in Uganda. Cooperation between nation states can add to the complicity in outbreak control, but the solutions are all still readily available, things just need to calm down a little. We have learnt to react quickly to Ebola now but there are still many concrete steps that the world need to take to make sure we don’t have to rely on response efforts each time a outbreak flares up.

Some of these are:
1.	Build capacity in the global health care system (read [this](https://www.politico.com/story/2018/12/29/ebola-doctor-united-states-1076875 ) if you’d like an example of what high capacity in high-income countries looks like)
2.	Reduce the burden of neglected tropical diseases on the existing health care systems
3.	Continue development of vaccine and other treatment options
4.	Fix politics 

The last point may not at first seem like a public health intervention but the longer I’m in field the more I feel that this is the issue that needs to be addressed if we want the health of the world to continue to improve.  

_Footnote: If anyone here on Steem lives in The Congo (I know we have quite an active African user base on this platform so there’s a chance) please do get in touch and let me know if and where I’ve gone wrong on this post. Also, I’d be very interested to hear about your personal experience in the country these days, is Ebola a concern in you life at the moment or am I missing the point and there are far more pressing concerns in your life these days?_  

<center>https://cdn.steemitimages.com/DQmchEh9SBGnagf7dW8uMpoAej2s1KME4knBjpMxre7cwDk/image.png</center>

## About me 
My name is Richard, I blog under the name of [@nonzerosum](https://steemit.com/@nonzerosum). I’m a PhD student at the London School of Hygiene and Tropical Medicine. I write mostly on [Public Health](https://steemit.com/steemstem/@nonzerosum/redefining-health-for-the-21st-century), [Effective Altruism](https://steemit.com/effectivealtruism/@nonzerosum/is-the-play-pump-the-answer-to-the-world-s-clean-water-problems) and [The Psychology of Vaccine Hesitancy](https://steemit.com/steemstem/@nonzerosum/the-state-of-vaccine-confidence-in-2018). If you’d like to read more on these topics in the future follow me here on Steemit or on Twitter [@RichClarkePsy](https://twitter.com/RichClarkePsy).

I'm also a proud member of the @steemstem community and you should be too! Find more information about their fine work [here](https://steemit.com/steemstem/@steemstem/steemstem-summer-2018-project-update)
![SteemSTEM gif.gif](https://cdn.steemitimages.com/DQmNNVoB2Wn5mRkY8mCR5ZpDU1fFys7yvFtPG72fYkx3d7L/SteemSTEM%20gif.gif)

<center>https://cdn.steemitimages.com/DQmchEh9SBGnagf7dW8uMpoAej2s1KME4knBjpMxre7cwDk/image.png</center>
## References:
[1] The World Health Organisation: [Ebola virus disease – Democratic Republic of the Congo – Disease outbreak news 25th July 2018](https://www.who.int/csr/don/25-july-2018-ebola-drc/en/) 
[2] The World Health Organisation: [News - Cluster of presumptive Ebola cases in North Kivu in the Democratic Republic of the Congo](https://www.who.int/news-room/detail/01-08-2018-cluster-of-presumptive-ebola-cases-in-north-kivu-in-the-democratic-republic-of-the-congo)
[3] The World Health Organisation: [Ebola virus disease – Democratic Republic of the Congo – Situation report 27th December](http://apps.who.int/iris/bitstream/handle/10665/277405/SITREP-EVD-DRC-20181227-eng.pdf?ua=1)
[4] The World Health Organisation: [Ebola virus disease – Democratic Republic of the Congo – Disease outbreak news 14th September 2018](https://www.who.int/csr/don/14-september-2018-ebola-drc/en/)
[5] World Vision: [DRC conflict](https://www.worldvision.org/disaster-relief-news-stories/drc-conflict-facts)
[6] Internal displacement monitoring centre: [Democratic Republic of the Congo](http://www.internal-displacement.org/countries/democratic-republic-of-the-congo)
[7] Sever Malaria Observatory: [Democratic Republic of the Congo](https://www.severemalaria.org/countries/democratic-republic-of-congo)
[8] The BBC: [DR Congo election: Protesters attack Ebola centre in Beni](https://www.bbc.co.uk/news/world-africa-46692506)
[9] International rescue Committee press release: [Election-related violence in Democratic Republic of Congo forces IRC to temporarily suspend life-saving Ebola response programming](https://www.rescue.org/press-release/election-related-violence-democratic-republic-congo-forces-irc-temporarily-suspend)
[10] Associated Press: [Congolese flee to Uganda after vote raising Ebola fears](https://apnews.com/35484caa0c1c4ca589da4a9b4255448a)