Stakeholders need to engage effectively with community leaders to regain public trust, says this BMJ Opinion piece

This week, a year after an outbreak of Ebola was first declared in the Democratic Republic of the Congo (DRC), the second case of Ebola was confirmed in Goma, the capital of the North Kivu province. The spread of Ebola virus to this large city, which is home to two million people and an international airport, has represented a crucial milestone in the response to this current epidemic. When the first case of Ebola was confirmed in Goma on 14 July, it was described as an “alarm signal” by Mike Ryan, WHO assistant director general for emergency preparedness and response, and a “potential game changer” by Tedros Ghebreyesus, WHO director general.  

The DRC Ebola outbreak continues to spread relentlessly since its first detection in August 2018. It has claimed more than 1800 lives, infected more than 2600 people, and spread across the border into neighboring Uganda. Ebola control efforts by the WHO and Africa CDC have been complicated by ongoing armed conflicts in the area and ineffective community engagement, which has failed to overcome public distrust.

Compared with previous Ebola outbreaks, we now have better prevention and treatment options. More than
180 000 people have received the experimental Merck (VSV-EBOV) vaccine, which, according to preliminary results from the WHO, confers a high level of protection. Frontline healthcare workers, the contacts of patients infected with Ebola, and the contacts of contacts (in the so called “ring of vaccination”) have received the vaccine. More than 1000 patients have received one of four experimental drugs initially given under the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI) protocol, which have been administered within a randomised clinical trial or under compassionate use since the beginning of the outbreak. Yet despite improvements in the clinical management and infection control interventions we have for Ebola, and availability of a vaccine and specific drugs, the DRC outbreak has become the world’s second largest Ebola epidemic after the 2014-16 west African outbreak.  

Since the beginning of the DRC outbreak, the International Health Regulations Emergency Committee for Ebola virus disease in the DRC had deliberated three times, before finally advising the WHO director general to declare this outbreak as a Public Health Emergency of International Concern (PHEIC) on 17 July 2019. Since 2009, a PHEIC has been declared four times: for (swine flu (2009), polio (2014), west African Ebola (2014), and Zika (2016)).

Declaring a PHEIC makes it easier to share information for risk assessment and for the emergency committee to formulate temporary recommendations for member states. Importantly, this declaration also increases international diplomatic, public health, security, and logistical efforts, as well as generating additional financial resources from UN member states.

In our view, the criteria for declaring a PHEIC had already been met when the earlier meetings took place. In the time between the last two meetings, nothing much had changed in terms of the technical criteria to trigger an emergency, but perhaps the committee had grown frustrated with political indifference to the crisis. The WHO’s hesitation to declare the ongoing outbreak a PHEIC is reminiscent of the widespread criticism its leadership received during the 2014-16 west African Ebola outbreak. As in the 2014-16 outbreak, it appears that the reluctance in declaring the current outbreak a PHEIC was due to the perceived negative economic impact it could have on travel and trade. However, it’s worth noting that declaring a PHEIC was initially envisaged as a way to manage and control infectious diseases outbreaks and epidemics without isolating the affected countries with travel and trade restrictions. 

The outbreak continues to spread and is no longer contained exclusively within two provinces of DRC. A larger mobilisation of resources as a result of declaring a PHEIC could help facilitate more funds being channelled into the response and help raise awareness. However, local communities’ distrust of national authorities, aid groups, and UN peacekeepers is a continuing challenge. 

Decades of armed conflict, neglect, and economic exploitation have created this distrust and recent events have only aggravated it. Take, for example, the decision of the DRC’s former government to exclude the areas of Beni and Butembo from the presidential elections, ostensibly to prevent Ebola spreading. The nature of the relief efforts, after so many years of people experiencing complete neglect, have also raised suspicions that Ebola is a money making issue, and the “militarised” response of treating patients as biothreats rather than humans has made local communities wary. Between January and May 2019, there were 174 attacks against Ebola responders, which caused 51 injuries and five deaths. Two more murders happened on the day when the first Goma case was identified.  

The declaration of the Ebola outbreak in DRC as a PHEIC by the WHO should not deter the international media from continuing to highlight and make visible the devastation this epidemic continues to inflict on local communities. We would not want the mistakes of the west African Ebola epidemic repeated, which saw the epidemic only receive prominent media coverage once patients from western countries were affected. Communication is an essential component of responding to an outbreak and Africa’s media should take the lead in this, pushing national authorities and communities to assist more effectively in the response. 

In Africa, it seems that responsive public health systems are difficult to sustain unless long term political commitment and planning, combined with adequate financial resources, are taken on board by countries with the help of global public health bodies. Right now, the situation in the DRC needs WHO, Africa CDC, WHO AFRO, USAID, DFID, the European Commission, and other donor agencies, together with national and regional decision makers, to engage effectively with community leaders to ensure that the trust of the population is gained.

Giuseppe Ippolito, MD, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.  

Chiara Montaldo, MD, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.  

Francesco Vairo, MD, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.  

Michel Pletschette, MD, Department of Tropical and Infectious Diseases, Medical Center of the University of Munich, Germany.

Antonino Di Caro, MD, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.  

Francine Ntoumi, Prof, Foundation Congolaise pour la Recherche Medicale, Brazzaville, Republic of the Congo; Marien Ngouabi University, Faculté des sciences et techniques, Brazzaville, Republic of the Congo; University of Tübingen, Institute for Tropical Medicine, Germany. 

Gino Strada, MD, EMERGENCY (NGO), Milan, Italy.

Mark M Rweyemamu, Prof, Foundation for One Health, Sokoine University of Agriculture (SUA), Tanzania. 

Alimuddin Zumla, Prof, Division of Infection and Immunity, University College London, and UCL Hospitals NIHR Biomedical Research Centre, London, UK. 

John PA Ioannidis, Prof, Departments of Medicine, Health Research and Policy, Biomedical Data Science and Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA.

Author declarations: All authors have no conflict of interest to declare.

The National Institute for Infectious Diseases, Lazzaro Spallanzani acknowledge support from the Italian Ministry of Health.

Giuseppe Ippolito, Antonino Di Caro, Francesco Vairo, Chiara Montaldo, Francine Ntoumi, and Alimuddin Zumla are members of the Pan African Network for Rapid Research, Response, and Preparedness for Infectious Diseases Epidemics consortium (PANDORA-ID-NET) and acknowledge support from the European and Developing Countries Clinical Trials Partnership (EDCTP2) programme (grant RIA2016E-1609). 

Giuseppe Ippolito, Antonino Di Caro, Francesco Vairo, Michel Pletschette, and Alimuddin Zumla are members of the International Public Health Crisis Group (IPHCG)