Sixteen days ago, a puzzling cluster of severe illness and death in eastern DRC was finally attributed to the Bundibugyo ebolavirus. The same Ebola variant that killed Dr. Jonah 19 years ago, one of our closest friends and colleagues, and left us in the center of an unfolding outbreak. This time we were nowhere near, but we did get an immediate call from our team who had high risk exposures, and we’ve spent most of the last two weeks embroiled in the science, logistics, politics and faith of response. Our Serge surgeon, Dr. Peter Stafford, became infected and dangerously ill, but is now in recovery, and for that we are grateful beyond measure to an unseen army of people and grace.
I’ll close below with some personal thoughts, but since this sorrow is unfolding in Congo and a group of Congolese doctors and scientists published their initial report in the Lancet this weekend, let me use their observations. Five reasons this epidemic poses a particular challenge, and seven steps that must be taken immediately.
FIVE CONCERNS about this 17th Ebola outbreak in DRC (italics are direct quotes from the article)
- First, the outbreak is caused by Bundibugyo virus, for which there are no approved virus-specific therapeutics or vaccines, which deprives response teams of crucial tools for breaking the chain of transmission and reducing disease fatality.
Like our smaller epidemic in 2007-8, the diagnosis was delayed because the initial tests for Ebola were carried out on more common strains, and turned up negative results. This variant has no specific treatments and no vaccine to quickly interrupt susceptibility and transmission. Even diagnostic test kits are scarce. The “index case” so far identified was a health care worker who fell ill April 24th, died April 27th. Bundibugyo ebolavirus was confirmed May 15th. We started behind, and the spread is outpacing capacity.
2. Second, the outbreak is occurring both in urban and rural areas.
In 2007, Bundibugyo district had a SINGLE unpaved road access, and relatively little population density or movement. This time the Ituri epicenter contains Bunia, a small city of nearly a million people. Many live in crowded camps for the internally displaced (like a refugee but no international border crossed). Urban density, and the difficulty of reaching a widespread network of rural villages, make this setting more challenging. Samples have taken days to send for testing and receive results, by which time spread has continued or the patient has died.
3. Third, the epicentre of the outbreak is located in a province that shares borders with three other provinces and two countries, which increases the risk of national and regional spread.
Ituri shares a long border with Uganda, and some Ebola-infected patents have already sought care there. It’s a geological and cultural rift valley, where language groups are artificially divided by unseen borders they frequently cross.
4. Fourth, the outbreak is occurring in areas affected by insecurity, population displacement, and mining-related population movement, all of which can increase the risk of transmission.
The sorrows of eastern DRC preceded the outbreak of Ebola. Decades of suspicion and fear have boiled up in armed attacks, informal militias, shifting alliances, a thousand roadless wilderness miles from the central government’s order. Gold, cobalt, and other valuable minerals have fueled a scramble to exploit and control this territory. Arms and money cross the border, resources spill out, and children and the poor risk their lives to scrabble together a dangerous living as miners so that we have convenient cell pones. Congo’s poverty and insecurity are partly our global market’s making. It’s one of the most challenging places for Serge to maintain a team. 17 of 36 health zones in Ituri are at last partly inaccessible due to insecurity. And not many outsiders choose to live there.
5. Fifth, Ituri was one of the provinces affected by the 2018–20 Ebola outbreak and has a history of high community resistance, especially against safe and dignified burials, due to deeply entrenched cultural and spiritual funeral traditions.
When your view of the world is dominated by the danger of displeasing ancestral spirits, who can (and do) cause grievous and fatal harm to you and your children . . . the risk of an improper burial looms more tangibly real than the risk of a virus you’ve never heard of. And when your entire region has been exploited by outsiders lying to take advantage, the trust in the sudden descent of foreigners is low.
SO WHAT DO WE DO NOW?
- Retrospective case investigation must be stepped up. We don’t know how many cases we have already missed, and in what direction they have spread. The DRC dash shows 559 suspected and confirmed cases and 253 suspected and confirmed deaths today . . .but the news says the cases are likely much higher. Uganda has 9 cases and 1 death so far.
- Investigate every new case to find the time of infection and identify all contacts. Contact tracing, monitoring, treatment and isolation are the key to stopping the spread of the virus.
- Engage community leaders in the response. Outsiders who lack the language and cultural bridges will never be able to enjoin behavior changes that lower risk. Our team doctors, and a couple of other faith-based-NGO doctors, have been zoomed into meetings even while in quarantine. The trust of living for a decade in a place is invaluable when life and death are on the line.
- Engage the armed groups that control affected areas. The public health response has to work with the real humans in the real place, not a theoretical structure hundreds or thousands of miles away.
- Fifth, urgently establishing Ebola treatment centres equipped with appropriate infection prevention and control measures, including adequate personal protective equipment for front-line health-care workers, is essential not only for preserving a crucial workforce, but also for preventing amplification of transmission within health-care settings. Samaritan’s Purse has flown in 25 experts and tons of materials, as has World Health Organization. AND YET, here we are on day 16 with faltering steps and slow. By this point in 2007 we were miles further.
- Step up infection control in ALL health centers in the area. This Ebola presents non-specifically. Bleeding is late, and not universal. MOST cases look exactly like malaria, or typhoid, or a dozen other more common illnesses. Any patient could be the next case, and every health care worker needs adequate resources to safely care for and diagnose.
- Neighboring countries also need to be ready. Uganda’s Ministry of Health task force issued procedures for border districts, which is why we had to cancel our hand-over celebration for the new Bishop Barnabas Theological College this week. Our entire region needs to practice good public health.
Please pray for Congo. Pray that the virus would mutate to become less transmissible and less severe. Pray that people would work together, that paradoxically the desperation of this epidemic would overcome the divisions and fear that splinter the area. Pray that God would supernaturally protect the caregivers, and heal the sick, that grace would fill the gaps left by a slow inadequate global response. Pray for innovations and hard work to accelerate the healing, for Congolese ingenuity and grit to amaze the world. Pray for the brave people of faith, from caregiving mothers to missionary pilots to village health workers to research epidemiologists, to be filled with love that overcomes death.
And join us in thanking God for sparing Dr. Peter. He was severely ill, unable to walk without assistance and troubled by mental anguish and high fever by the time the evacuation flight could finally be arranged. His life was spared by the grace of God, the prayers of hundreds if not thousands, and the competent persistent work of many people in several countries. He’s nearly finished the treatment period and entering convalescence, as his family and another doctor (Dr. Patrick LaRochelle) have a final week of quarantine to be sure they escape infection, but so far so good.
The last post I wrote before Ebola grabbed our world again was about Dr. Jonah’s family. Ebola is a headline grabber for a few weeks or months, but the devastating effects last years and decades. We at Serge are long-term invested in the places God sends us, and nearly 20 years post-Ebola in Bundibugyo we are still using the funds raised there to educate new doctors and nurses and lab techs and nutritionists . . . and to sponsor Dr. Jonah’s children through their entire education. Our team will be back at work in Congo, for this year and for many to come. WE have set up a “Congo Recovery Fund” to help (click here) with the immediate response. Others will do much more in the emergency relief, but we will continue much longer in building capacity so this does not happen again and again.
The primary experience for us in these two weeks and two days has been to marvel at the timing, the connections, the rescues, the mercy we have been shown, and to mourn the real loss and heartache and fear that has gripped a place and people we love. Our team does not like to talk about themselves, but we all are willing to talk and write in ways that allow us to be a lens for the world to see Congo.
*for further updates, follow the Serge press releases here.
