1000 Deaths and Rising: The Complexity of DR Congo’s Ebola Outbreak

The Ebola epidemic in the Democratic Republic of Congo (DRC) has officially taken the lives of over 1000 individuals, according to the country’s Ministry of Health. These statistics, which were released at the end of last week, have been accumulating since the outbreak’s onslaught in August 2018. This occurrence is considered the second deadliest in the history of this Filoviridae Virus in the world and the deadliest in the DRC. This specific incidence afflicting humanity is often referred to as the Kivu outbreak due to the initial emergence in this northeastern DRC province; however, the identified virulent strain is the Zaire Ebola Virus which happens to carry the highest rate of mortality of all strains.

The following is an up-to-date timeline of the current Ebola outbreak’s transition to an epidemic:

  • August 1st, 2018: The DRC’s Ministry of Health declares an Ebola outbreak in Mangina, North Kivu
  • August 7th, 2018: Laboratory findings confirm this outbreak is caused by Zaire Ebola
  • October 17th, 2018: World Health Organization (WHO) convenes a meeting about the Kivu outbreak. WHO declares this situation does not constitute the classification of a “Public Health Emergency of International Concern”
  • October 20th, 2018: An armed attack occurs in Beni, Kivu at a health care facility leaving 12 people dead
  • November 9th, 2018: The number of cases in DRC reaches 319 which marks the largest outbreak in the country’s history
  • November 29th, 2018: The Kivu epidemic becomes the second largest recorded outbreak of the Ebola virus in the history of the disease on this planet.
  • December 27th, 2018: There is an announcement of postponement of elections in Benin & Butembo which are two largest cities in Kivu.
  • February 24th, 2019: An MSF health care facility is partially burned down and MSF suspends activities in North Kivu by unknown militants
  • February 27th, 2019: A second MSF health care facility is attacked also by unknown militants and the NGO is forced to evacuate staff and suspend all operations in the province of Kivu
  • March 20th, 2019: The outbreak reaches the 1,000 confirmed cases mark of the Ebola Virus
  • April 12th, 2019: WHO holds an additional meeting but finds the Kivu outbreak still doesn’t qualify as a “Public Health Emergency of International Concern”
  • May 3rd, 2019: The number of deaths secondary to the Ebola virus reaches 1000

Although each explicit manifestation of this deadly communicable disease carries with it seemingly insurmountable barriers in the form of human resources, supply logistics, social tendencies, and global support, the Kivu is particularly devastating due to political uncertainty, lack of trust in the health care system, and civil unrest.

Despite the increase in novel innovations for treating Ebola and even a promising vaccine that can prevent the virus virology, the Kivu outbreak continues to surge ahead and torture the human species in large part to a break down of trust in the medical system. The surge has lead to identifying 126 confirmed cases over a seven day stretch at the end of April 2019 in addition to the aforementioned data confirming this outbreak to be the second largest in the history of Ebola. Despite this, the mistrust has amassed in a disbelief that the outbreak even exists. A study conducted by the Lancet in March 2019 revealed that 32% of the respondents believed that the outbreak did not exist in the DRC, it only served as a way serve the elite’s financial interests. Another 36% stated that the Ebola outbreak was fabricated to further destabilize the surrounding areas. With these sentiments, the responders marked that fewer than two-thirds would actually want to receive the vaccine for Ebola. These perceptions of fellow humans provides an additional barrier to overcome for health care professionals in addition to treating a high mortality rate disease in resource limited settings.

While the mistrust in the healthcare system provides a tremendous intrinsic challenge for the DRC, the civil conflict that has targeted Ebola treatment centers delivers a physical and emotional component of the devastatingly uniqueness of this outbreak. With over 100 armed groups thought to be estimated within Kivu province, this has led to widespread violence causing this area to be difficult to maintain access. Due to the high rate of armed groups and the political unrest, there has been 119 incidents of Ebola treatment centers and/or health workers that have been attacked since the start of this outbreak. A few shocking examples include the murder of Dr. Richard Mouzoko who was a Cameroonian WHO physician and the two torched MSF facilities in the northern part of Kivu that were mentioned in the timeline.

The Kivu Ebola outbreak has been unanimously christened one of the most complex humanitarian crises that faces this fragile planet today – the global health community is attempting to treat a disease with a 50% mortality rate, with inadequate but effective evidence-based treatment options in a resource-limited setting, all while in a treacherous war zone. Although these are insurmountable odds, health care professionals across Africa and other parts of the world are addressing the needs of their patients and communities to defeat this ailment. These physicians, nurses, pharmacists, and so many others are generating trust in the health care system at a grass-roots level in the DRC to combat the negative perceptions and the actual outbreak. This example, that the global health community can learn from, highlights the role each person dedicated to global health needs to undertake before an outbreak batters a part of this fragile planet. The vitality of trust can start to be built through having individual/group conversations truly listen to health beliefs, coming in with an open mind to acknowledge local health treatments to complement evidence-based treatment, providing patient centered care that encompasses their culture and values, supporting capacity-building initiatives that allow humanity to act accordingly, investing both time and resources in local public health care infrastructure, and expressing empathy ubiquitously socially and professionally.

Being part of the global health community, it is imperative that this outbreak is adequately supported by humanity. As fellow humans striving towards a healthier society, health care professionals and public health experts must accompany those tormented by the social factors associated with Ebola and the actual virus through global awareness of the situation, an un-stigmatized compassion for those who contract the disease, and a pragmatic solidarity to address this humanitarian crisis.  

Tick, tick, tick: Reflections from this year’s annual meeting

Tick, tick, tick.

The ticking of Dr. Victor Sidel’s metronome resonated throughout the large ballroom where a reception in his honor was held during the first days of the 2018 APHA Annual Meeting in San Diego. Dr. Sidel, a formative figure in the field of public health and a past president of APHA, died earlier this year after spending his career as a physician vigorously defending the rights of the world’s most vulnerable populations. The beats of the metronome, which he used to punctuate his presentations and speeches since the 1980s, were meant to represent the social disparities inherent in global public health. One tick meant that somewhere in the world, a child was dying due to preventable illness. One tick also represented tens of thousands of dollars spent in weapons sales. Among Dr. Sidel’s published works included seminal books such as War and Public Health and Social Injustice and Public Health, both edited by his longtime collaborator Dr. Barry Levy, who spoke at the APHA reception to honor his colleague. At a prior eulogy for Dr. Sidel, Dr. Levy summed up the body of work that had driven them for decades: “Vic taught us that health, peace and social justice were not isolated concepts, but tightly woven together. I can still hear him saying there cannot be health without peace and social justice, and there cannot be peace and social justice without health.” In many ways, the 2018 APHA conference showed just how deeply these intersections between health, peace, and social justice have been woven into the fabric of the organization, starting with honoring Dr. Sidel, continuing with the breadth and diversity of panels and posters, and concluding with a number of resolutions that were adopted.

Many panels examining various aspects of health and social justice were available throughout the conference. The International Health Section sponsored panels on topics like global health and human rights, equity in global women’s health and maternal, neonatal, and child health, health and war in countries like Yemen, Mexico, Syria, and Gaza, and refugee health. The Peace Caucus sponsored several complementary panels on topics of war and public health, militarization of the border, and violence on indigenous women, along with a presentation from the joint Lancet- American University of Beirut Commission on Syria. The Human Rights Caucus also presented panels on sexual and reproductive rights, as well as issues of health governance and advocacy. A search through the 2018 conference program found topics like environmental justice, worker’s rights, racial disparities, the rights of the incarcerated, and many other issues of social and health justice presented throughout hundreds of panels, roundtables, and posters.

More than many other health-related organizations and associations, APHA has long served as an advocacy platform for the pressing social issues of the time, recognizing the depth of issues that influence public health. While many APHA resolutions address topics traditionally associated with clinical outcomes, like smoking, diet, and reproductive health, combing through the decades of policy statements on the APHA Database shows positions on timely and controversial issues like opposing military action in Afghanistan and Central Asia in 2002, ensuring access to health services for undocumented immigrants in 1994, and raising concerns about the health impacts of fracking in 2012. This year was no different, with a total of 12 new policy statements adopted, many directly focusing on contemporary issues of social justice such as opposing family-child separations at the US border and addressing police violence as a public health issue.

The latter topic was first brought to APHA in 2016, where a collective of authors, motivated by grassroots organizing against state violence, recognized the significance of a national public health entity taking a strong position on the issue. While the resolution passed the APHA Governing Council vote overwhelmingly in San Diego (87% to 13%), just last year it was voted down by a 30-point margin (35% to 65%). A year of collaborative work on drafting and promoting the statement resulted in this year’s triumphant victory, which was crafted to specifically point to the public health implications of the “underlying conditions of the institutions, systems, and society we live in that determine our health outcomes,” according to the End Police Violence Collective. For them, APHA recognition of this resolution “is one more tool that organizers against law enforcement violence can use to pressure their elected officials.” This success, they state, is also portending a needed shift in public health from focusing primarily on behavioral interventions to considering structural ones as well. APHA’s role as a representative of the field of public health makes its willingness to frame public health inequities as social justice issues significant. Despite the two-year trajectory of this resolution within APHA, the Collective maintains that “this work has been ongoing for generations, in communities organizing to draw attention to, intervene on, and rebuild after experiences of law enforcement violence. This statement is a product of those generations of work. It is an important step. But there is more work to be done.”

A reminder of work to be done may be seen in another resolution that came before the governing council but was not met with the same cheers and jubilation. Members from the International Health Section, including Dr. Kevin Sykes, the Chair of the Advocacy and Policy Committee for the IH Section, and well-known scholars of war and public health Leonard Rubenstein and Dr. Amy Hagopian, put forward “A Call to end to attacks on health workers and health facilities in war and armed conflict settings.” Incidentally, the latter two authors have both been recipients of the APHA Victor Sidel and Barry Levy Award for Peace, in 2011 and 2018, respectively. The statement was introduced as a latebreaker due to the accelerated pace of attacks on health workers in 2017, as detailed by a report published by Safeguarding Health in Conflict, a coalition of which APHA is a member, and received several endorsements from multiple APHA components, including from the Peace Caucus, the Occupational Health and Safety Section, and the Forum on Human Rights. However, opposition to some of the specific details of the statement, especially those regarding Israel, led to a contentious process that culminated in little floor debate on the merits of the resolution and, ultimately, the governing council voted no (25% to 75%). Dr. Hagopian echoed the sentiments of the End Police Violence Collective when discussing the importance of APHA taking a stance on issues of social justice, despite what she sees as the sometimes conservative stance of the governing council when it comes to controversial issues. “People working to make the world a better place need all the support they can get- both this sort of written, academic association support as well as political support out in the world. When they can cite the APHA, as the largest and longest stand public health organization in the country, as being on board, that carries weight.” As a result, Dr. Hagopian plans to revise the statement and resubmit it for next year’s APHA conference in Philadelphia. Upon receiving the Award for Peace at the IH Section Awards Ceremony this year, she said “It’s important to be on the right side of history, early and often. So we’ll be back another day.”

Tick, tick, tick.  

Public Health and Migration

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.  

 

Attacks on Healthcare are Beyond the Limits of War

In the spring of 2016, the 15 members of the United Nations Security Council adopted Resolution 2286, which had been cosponsored by more than 80 Member States. The issue behind the Resolution, which brought such overwhelming support from a sometimes fractious body, was the increase in attacks on medical staff and facilities in conflict zones. The Resolution was broad, covering attacks or threats against patients, personnel, transportation mechanisms, and medical facilities. It emphasized that such attacks are not only detrimental to those immediately affected, but for the long-term consequences on already fragile health outcomes and systems. Of course, these protections are not new, codified by the Geneva Conventions in 1949 and the Additional Protocols from 1977 and 2005. However, an unprecedented number of attacks on health, many of which were occurring in the same few countries, led to this new push to pressure antagonists to cease their attacks and provide medical and humanitarian personnel with their due protections under humanitarian and human rights law. “Even wars have rules,” said then-UN Secretary-General Ban Ki-moon.

Despite the strong words from the UN and organizations like Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC), little action was prompted by the newfound interest in health-related attacks. As a result, attacks have only increased since the year before the resolution was passed; while there were 256 attacks in 2015, there were 302 recorded attacks in 2016, 322 in 2017, and 149 attacks in the first quarter of 2018 alone. Not surprisingly, attacks in Syria propel the bulk of these numbers, with the Central African Republic, Pakistan, Libya, and Nigeria rounding out the top five countries featuring attacks in 2017. Of course, with the imperfect methods of collecting data in these fragile countries, as well as fears of witnesses or survivors to speak out about perpetrators, it is likely that more threats and attacks exist than can be captured by these data. In fact, as attacks continue and even proliferate, medical workers who risk their lives documenting attacks and their outcomes have questioned whether their work is worthwhile.

In these fragile countries, where access to health care is vital in maintaining a civilian population’s ability to stay, fifty-six health programs were closed due to increased insecurity to the facilities and staff in 2017. Ambulances are destroyed or hijacked. Health workers are arrested or kidnapped. Some countries have attacks that are more specific to the nature of their conflict- for example, the occupied Palestinian Territories, where movement restrictions are common, reported the highest numbers for obstruction to the provision of healthcare. In countries affected by polio, such as Nigeria, vaccination efforts are common targets of attacks. Countries where terrorist groups such as the Islamic State reside see reports of fighters disguised as medical personnel to attack or occupy hospitals. While the mechanism of attack differs, the outcomes are the same: terrorized civilians, diminished health infrastructure, demoralized health workers, prolonged conflict, and a frustrated but ultimately immobilized international community.

Despite these grim reports, there are still actions that can be taken by stakeholders of all levels that can hope to at least minimize these attacks. A two-pronged approach is required: one focusing on investigation and the other on penalties. First, a robust investigation and data collection mechanism must be developed and, most importantly, implemented where needed. MSF president Joanne Liu urged the UN Security Council to conduct robust, independent, and impartial investigations of such attacks, noting that previous calls for such initiatives have been disregarded. In almost all cases where investigations are conducted, they are led and settled by the perpetrator themselves. Independent, well-funded, and rigorous investigations, coupled with new methods of surveying and interviewing witnesses and survivors, should be supported by the UN and civil society in such nations. Additionally, it is apparent that such attacks persist due to the lack of consequences on offenders. Perpetrators on or allied with members of the UN Security Council would be tasked with condemning or punishing themselves and each other, unlikely in the current environment of norms in the international order. While a strengthening of the commitment of states to international humanitarian law is long overdue, in the meantime, action is not necessarily limited to the walls of the UN. Some humanitarian organizations, such as Oxfam, are taking a more direct approach, petitioning states to stop selling arms to countries that have used these weapons to attack civilian infrastructure like hospitals.

Addressing the World Humanitarian Summit in 2015, ICRC President Peter Maurer said “Wars without limits are wars without end. Limiting wars is an intrinsic test of our civilization, and probably of all civilized worlds.” Public health advocates must insist that the international community draws a line on protecting those serving the world’s most vulnerable in the most challenging environments imaginable. While war may be inevitable, the erasure of the human rights of those involved is entirely preventable through collective advocacy and action. Much of the needed action lies at the institutional level, but individuals concerned with these issues can follow social media campaigns like #NotATarget, started by the UN and the theme of World Humanitarian Day 2017, or support NGOs tasked with delivering healthcare in conflict environments, either on the local level or with international organizations such as the ICRC and MSF. Lastly, organizations like Safeguarding Health in Conflict, Insecurity Insight, and Physicians for Human Rights produce data and reports about these issues that can be used to direct advocacy or propel research efforts.

Internship Opportunity with the Environmental Change and Security Program at the Wilson Center

The Wilson Center’s Environmental Change and Security Program is looking for the Fall 2017 class of interns, who will be based at the Wilson Center in Washington, DC. The application closes this Sunday, July 16th.

Since 1994, the Environmental Change and Security Program (ECSP) has actively pursued the connections between the environment, health, population, development, conflict, and security. ECSP brings together scholars, policymakers, media, and practitioners through events, research, publications, multimedia content, and an award-winning blog, New Security Beat.

The Environmental Change and Security Program is seeking interns to:

– Write for their award-winning blog, New Security Beat
– Network with leading experts in the environment, development, and security
– Work closely with the friendly, dynamic “Green Team” at the Wilson Center

Assignments may include:

– Researching and writing stories for New Security Beat and ECSP’s website
– Assisting with events and conferences
– Researching environment, security, development, global health, and demography topics
– Assisting the preparation of publications and/or outreach materials
– Performing administrative assignments in support of ECSP activities

Requirements

Potential interns should be students, prospective students (within the next year), and/or recent graduates (within the last year) with an interest in, coursework related to, and/or experience working on environmental and human security.

In addition, applicants should:

– Possess strong research, writing, and/or administrative skills
– Be detail-oriented
– Be able to work both independently and as part of a group

ECSP currently offers unpaid internships. They are looking for candidates who are willing to devote at least 21 hours per week, up to a maximum of 35 hours per week. Interns work seven hour days.

For the full description, list of qualifications, and instructions on how to apply, please see the Wilson Center website:
https://www.wilsoncenter.org/opportunity/internships-the-environmental-change-and-security-program