THE COLLEGE HILL INDEPENDENT


Social Determinants

The DRC Ebola outbreak, explained

by Jacob Alabab-Moser & Izzi Olive

Illustration by Mariel Solomon

published September 20, 2019


“They were dying slowly—it was very clear. They were not enemies, they were not criminals, they were nothing earthly now—nothing but black shadows of disease and starvation, lying confusedly in the greenish gloom.”

Heart of Darkness, Joseph Conrad (1889)

    

Looking at headlines and photos today of Western health workers clad in hazmat suits vaccinating local children for Ebola conjures a trope of the Democratic Republic of Congo (DRC) as a place of disease, instability, and darkness—in contrast to that of the West as the torchbearer of civilization—readily recognizable in Joseph Conrad’s 1899 Heart of Darkness. This representation seems to transcend the 120 years of colonial rule and the series of independence movements that distance the modern DRC from the Belgian-ruled Congo Free State that Conrad portrayed in his novella.

Today, the DRC is facing the second-largest outbreak of Ebola Virus Disease on record; the DRC Ministry of Health’s latest report puts the total number of cases at 3,130, with 2,096 recorded deaths. The virus has also spread to parts of Rwanda, Uganda, and, as of last week, Tanzania. Six neighboring countries are also  at high risk.

As was the case at the time of Conrad’s writing, the West still presides over and bears witness to death in the Congo, yet contemporary Western nations’ relationship to and responsibility for public health crises in the sovereign DRC are far more ambiguous than they were at the dawn of Western imperialism. A status quo of Western patronage and creditorship has continued the extraction of the country’s resources and stalled sustainable development, problems which have resulted in extreme social instability. While many of the social ills in the DRC are traceable to internal corruption and conflict, in a postcolonial republic no part of the contemporary social situation can be understood without colonial context. In this article, Indy News tries to make sense of the ongoing Ebola epidemic and the global health response through the lens of postcolonial critique, raising questions about the West’s role in international health interventions, and by extension, in addressing the underlying social problems that plague former colonies.

 

A Word of Caution

We recognize that by writing about issues in Africa for a sympathetic Western audience we raise awareness but at the cost of reinforcing stereotypes of ‘Africa as victim.’ We write today about this current Ebola outbreak in the DRC because we found it necessary to provide nuanced coverage, but we also recognize that there is more to news coming out of Africa and the Global South than complex issues simplified and sensationalized by Western media outlets, and we encourage readers to seek out those narratives.

 

The Epidemic

In late July 2018, four fever cases surfaced in North Kivu, a northeastern province of the DRC which borders both Rwanda and Burundi. Within five days, the DRC Ministry of Health confirmed an outbreak of Ebola Virus Disease, commonly known as Ebola, and initiated an emergency response. In the earliest days of the outbreak, before a vaccine had even been authorized for use in preventing further transmission of the disease, efforts focused on containment: Ebola, which often manifests in flu-like symptoms but also interferes with the body’s blood clotting mechanism, is transmitted via direct contact with bodily fluids of an individual infected with the disease.

The United States’ initial involvement in the outbreak ended nearly as soon as it began. The US Centers for Disease Control (CDC) deployed experts on the disease to North Kivu just days after the outbreak was declared, only to withdraw them a few days later. Explaining this reversal in a testimony delivered to the House Foreign Affairs Subcommittee on Africa, Global Human Rights, and International Organizations, CDC Director Robert R. Redfield cited “security concerns.” The withdrawal applied to other US government personnel in the DRC, too: at the same time, the State Department reduced its staff in Kinshasa, the national capital. Redfield attributed this move to escalating violence between rival political factions in advance of the December 2018 DRC presidential election, testifying that “several areas of the country experienced a deterioration in the overall security situation.”

As Redfield’s quote suggests, the global health response was hindered by a climate of incredible violence that has characterized life in North and South Kivu provinces for decades. A report published in August by NYU’s Congo Research Group and the Human Rights Watch estimates that around 1,900 civilians have been massacred in North and South Kivu in past 3 years, while 3,300 have been abducted. While this violence in general has posed a serious obstacle to curbing the epidemic—it is far easier to treat disease in safe, stable environments—militia groups have also targeted health workers and treatment centers specifically, with a marked impact on disease containment.

Attacks on health care infrastructure and workers increased around the 2018 DRC presidential election after sitting President Joseph Kabila delayed voting for 1.2 million people in certain Ebola-affected regions known to be oppositional strongholds. The disease itself has thus become implicated in mistrust of the government, and treatment efforts have become collateral damage. Just when the DRC Ministry of Health had Ebola transmission “largely under control” in February 2019, a series of lethal attacks against treatment centers caused a marked uptick in transmission. And, as is evident in the CDC’s early withdrawal, violence impedes disease containment in a third way: by deterring the global health response.

The degree to which the outbreak has been successfully contained is somewhat remarkable given the volume of refugees that have fled the DRC since its onset. According to United Nations Refugee Agency spokesman Andrej Mahecic, Congolese refugees were fleeing to Uganda at a rate of 100-200 per day during the first months of the outbreak, yet it took nearly a year for a case to be reported outside of the DRC. In June 2019, Uganda confirmed the first incidence of Ebola. The World Health Organization declared a Public Health Emergency of International Concern less than a week thereafter.

 

What is Global Health?

So how did we get here? Why are decisions affecting the lives of millions in the DRC being made in bureaucracies thousands of miles away in DC or Geneva? We can roughly trace the beginnings of the international health regime to 1948, when the World Health Organization (WHO), an agency of the United Nations, was formed. The organization is aspirationally international in that its constitution claims “the health of all peoples is fundamental,” yet its interventions toward providing global health solutions have been undermined historically by the lack of cooperation from countries that host or donate to the WHO, and its own bureaucratic structure, which has been criticized for being overly centralized and slow-acting.

Moreover, we should consider that the majority of funding it receives comes from donors from the West, with the United States, the Bill & Melinda Gates Foundation, and the United Kingdom being the top three donors to the 2018 program budget. Even though this should not influence the WHO’s governance—its main decision-making body is the World Health Assembly with delegates from each of its 194 Member States—the majority of funding is earmarked by donors, or designated for a specific program. This means that as long as the Global North donates the most money, to a significant extent it dictates the priorities of the global health agenda.

This distinction might suggest the reasons behind certain policies by the WHO such as why, for example, it often places outsized emphasis on containing infectious diseases, since those pose the risk of traveling to the Global North and infecting people there. In 2018, the organization alloted almost triple the funding to the prevention of communicable diseases in Africa that it did to that of noncommunicable diseases in the continent (291 million vs. 105 million, 2018-19). This funding disparity stands in stark contrast to the fact that 71 percent of deaths worldwide result from noncommunicable diseases.

In a similar vein, Western donors prefer to fund emergency response measures, like constructing outbreak-specific facilities and offering poor countries ‘pandemic bonds’ to help them finance future responses, than to invest in a country’s overall healthcare infrastructure. Besides the fixation on communicable diseases, such long-term investments on healthcare are less economically attractive. In July, the Director-General of the WHO Tedros Adhanom Ghebreyesus tried to pitch them as economically savvy to a group of African entrepreneurs in Abuja, Nigeria: “Health creates jobs. It drives productivity. It stimulates inclusive growth. And it protects economies from the impacts of outbreaks and other emergencies.” These belated remarks, given after the Ebola outbreak had ballooned beyond the point of containment, demonstrate that the overall health for inhabitants of underdeveloped countries is treated as an after-thought, a remnant of colonial mentality.  And when brought up at last, health has to be pitched as an investment, a stimulator of capitalist growth.

While global health and humanitarianism in general are presented as apolitical and international-minded with ‘health as a right,’ this is impossible given the imbalance of power that privileges Global North countries’ ideologies surrounding public health; that is, prioritizing their citizens’ lives over those in the Global South, as well as their political aims and budgets.

To clarify, the WHO is not in itself the implementer of the response to the Ebola outbreak but rather acts as an advisory body to the DRC’s Ministry of Health, as well as the unified voice of the response and provider of technical support and monitoring, among other functions. It works with implementing partners like international organizations like the American Red Cross and Doctors Without Borders in addition to DRC-based NGOs, of which medical staff are deployed to the ‘frontline’ of the response.

 

Why the epidemic is unsurprising

The cycle of investment capital chiefly in the DRC’s lucrative mineral export industry echoes the extractive system of mercantilism from the colonial era. While many of the transnational mining companies active in the eastern DRC today hail from Europe like their nineteenth century forebears, those from Canada, Australia, and China have also joined their ranks. This is not to mention the role of neighboring countries like Rwanda and Uganda in looting mines in the eastern DRC through threats and coercion by armed rebel groups. Although many Western observers focus their critiques against China’s more recent entrance into mining in the DRC, it remains to be seen how or whether Chinese companies have deteriorated the status quo in terms of work conditions in the mines and macroeconomic indicators.

In Northern and Southern Kivu Provinces, the regional economy’s dependence on this system of mining has resulted in widespread poverty; the majority of unskilled laborers work for as little as $100 per month, according to the Nation. In this climate of economic exploitation by foreign transnationals and violence from armed groups, amid other factors, it is easy to see why communities are reluctant to let in health workers. Moreover, increased security forces like the Congolese army—sought by partners in the response following an uptick attacks on treatment facilities, warranting more thought on whom the global health regime decides to protect—has only caused local communities to vilify health workers more.

 

International involvement: Last time and now

You might be surprised to hear that a lot of progress has been made since the last Ebola outbreak in West Africa. New tools for rapid diagnosis, the new treatment ZMapp, and, most importantly, a new experimental vaccine have been deployed. In addition, WHO has streamlined its processes to rapidly deploy resources with the creation of an emergency fund.

Doctors Without Borders International President Joanne Liu, MD described to STAT the difficulty in containing this Ebola outbreak as “ironic,” since these significant developments have been rendered useless by the challenges specific to the DRC. Getting the outbreak ‘under control’ is now about more than providing vaccinations and treatments for a viral disease. Violence, insofar as it breeds uncertainty and fear, impedes public health measures of all kinds, creating an atmosphere in which disease can flourish. In the DRC, violence has posed a more specific threat to disease containment efforts, when treatment centers have been caught in the crosshairs or deliberately targeted, in some cases due to mistrust of the containment efforts. In these ways, the global health response now contends with the symptoms of the DRC’s deeper historical problems, many of which implicate Western imperialism.

It is worth noting that the United States, through the CDC and other health agencies, has been less involved in the response to current DRC outbreak than it was in the 2014-2016 West African one. While US officials have cited greater contributions by other governments in financing the response, other factors include concerns about the safety of personnel and the Trump administration's reduced foreign assistance in general, stemming from the president’s isolationist foreign policy. While less aid from the US translates to less dollars and technical resources for the response, it precludes the militarization of the US humanitarian response, which occurred during the West African outbreak and could have negative consequences in the DRC context.

  The relatively rural character of the current outbreak zone in the DRC’s interior also accounts for why the international community is paying less attention to this outbreak. Though granted a rural, less populated area puts less people at risk of infection and death, this outbreak’s distance from international borders and major cities has limited the response: the WHO decided against declaring the outbreak as a PHEIC three times for not posing “a public health risk to other States through the international spread of disease” before it finally did this July when it spread into Rwanda and Ebola. At the time of the PHEIC declaration, there were already 2,512 cases of Ebola since the outbreak began in August 2018 when in contrast, the more international 2014-2016 West Africa outbreak had 1,711 cases when it became a PHEIC. This delay in the DRC case suggests that despite the gravity of the situation, countries in the Global North did not care since there was no immediate threat of the disease spreading outside of the region and into their borders.

 

Conclusions

For now, the fate of the current DRC Ebola outbreak remains unclear. While the WHO has reported a gradual decrease of transmissions with the lowest weekly incidence on September 12 since March 2019, it cautions against interpreting that the virus’s transmission intensity has decreased. Even once the outbreak is under control, the communities affected will continue to face insecurity, conflict between militias, and a lack of support by the DRC government, which will only make them prone to epidemics and other ills moving forward. And as we have seen, neocolonialism looms as the cause behind much of the DRC’s strife.

The DRC Ebola outbreak is lethal and has demanded action from the international community, but there needs to be further explanation of the murky mechanics of aid allocations and the actual response on the ground for the citizens of both Western, aid-giving countries and of the DRC and other countries affected by the outbreak.

 

JACOB ALABAB-MOSER ‘20 and IZZI OLIVE ‘20.5 encourage you to read Rani Chumbak's 2016 Indy piece “Who Cares?: Medicine and Colonial Modernity” (https://www.theindy.org/810) for more information on the inherently colonial nature of global health.