An Ebola Outbreak in a War Zone Is About as Bad as It Gets

In July, a 65-year-old woman running a high fever checked into a hospital in the province of North Kivu, along the Democratic Republic of Congo’s border with Uganda. She was later discharged and returned home to her remote town, only to die a few days later. By the time health officials checked in on the case, seven members of her immediate family had also died the violent, bloody deaths that can usually only mean one thing: Ebola.

Normally, this wouldn’t be reason to panic. The hemorrhagic fever, which takes its name from a river in the DRC, has struck the country nine times since 1976. This latest outbreak, declared in August, makes it ten. People there have experience. They know the drill: Track new cases, make maps of everyone those people have come in close contact with, don protective gear to limit the spread of highly infectious blood and fluids, set up field clinics and quarantine units to box in the virus and let it burn out before it can break free.

Plus, this time they’d also have brand-new, outbreak-combatting experimental treatments and a protective vaccine. Heroic health workers caring for the sick would get the shot. And anyone who’s had contact with Ebola, and all their contacts too. It would add a wall of human immunity to bolster the physical fortifications. Except. Except in this part of the Congo, controlled by clashing rebel militias, none of the usual rules apply.

Right now the DRC is experiencing a world-first: an Ebola outbreak in a war zone.

While disease hunters have learned a lot from previous tragedies, like the 2013 outbreak that killed more than 11,000 people in West Africa, this is the one scenario no one’s been able to prepare for. Speedy testing and new isolation techniques and genetic surveillance are no match for the chaos that comes with active conflict. “The foreigners that have come to support us are very scared,” one nurse in North Kivu told Canadian researchers in August. “Armed forces have to accompany them, which makes the process very heavy.”

Since then, conditions have only gotten worse. Last month, health workers suspended containment efforts following an attack in the epicenter of the outbreak that left more than 20 people dead. During those precious days, people fled the violence, disrupting efforts to vaccinate the exposed and trace the virus’s spread. Over the weekend rebels killed another 15 civilians, including two health workers, and kidnapped a dozen children.

As of Sunday the World Health Organization calculated 120 confirmed Ebola deaths so far, with 35 more deaths that were likely caused by the disease. Another 83 infected individuals remain alive.

“We have a serious problem with security in the area—that’s been the major rate limiter,” says UCLA epidemiologist Anne Rimoin, who’s been running an infectious disease research program in the DRC for the last 16 years. Her team is currently embedded in the region to monitor the effectiveness of the vaccine program. “It’s extraordinary what they’ve been able to accomplish in vaccinating so many people in such a small amount of time. But when you layer on the complexity of an Ebola outbreak to an active conflict area, even the smallest, most important steps to containing the disease become extremely difficult.”

Despite the setbacks, health workers have so far succeeded in vaccinating more than 20,000 people, according to the WHO's latest numbers. But the vaccine and the treatments can only be effective if they get to the people who need them. Every time someone who’s been exposed to Ebola disappears across a border or into a refugee camp, those drugs lose some of their outbreak-containing power. Changing the strategy to vaccinating whole cities or provinces risks drawing down the global stockpile, as the WHO deputy director-general of emergency preparedness and response told STAT.

Although the WHO has not yet declared the latest Ebola outbreak an international public health emergency, its latest report warned that the volatile security situation is making the risk of disease spread to neighboring countries very high. “These borders are very fluid, and when you have a lot of population movement across them, it will quickly become complicated in exactly the same way that it was in West Africa in 2013,” says Rimoin.

Health workers on the front lines might have the most advanced tools they’ve ever had to fight an Ebola outbreak, but without the ability to do the simple things, at any moment the situation could leap beyond their control.