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February 6, 2019
Ebola Outbreak: Democratic Republic of Congo
For years, Congress has provided funds to prevent, detect,
As of February 4, 2019, WHO reported 785 confirmed and
and respond to infectious disease threats, including those
probable Ebola cases in Ituri and North Kivu, including 484
with pandemic potential like Ebola. In regular
deaths. Observers are concerned that the outbreak could
appropriations, since FY2014 Congress has annually
spread to Goma, the capital of North Kivu, a city of over 1
provided $72.5 million to the U.S. Agency for International
million people that is also an operational hub for the United
Development (USAID) for such efforts. From FY2015 to
Nations (U.N.) peacekeeping mission and international
FY2017, Congress appropriated annually $55.1 million to
relief efforts in DRC, as well as to neighboring countries.
the U.S. Centers for Disease Control and Prevention
While Uganda (which borders the most affected areas in
(CDC); in FY2018, it provided $108.2 million, including an
DRC) has prior experience in Ebola control, Rwanda and
authority to spend $50 million over three years for global
Burundi do not. South Sudan’s current minimal state
health security efforts. (See CRS Report R43115, U.S.
capacity and protracted armed conflict suggest a
Global Health Appropriations: FY2001-FY2019.) In
coordinated disease control response would be highly
FY2015, Congress also provided over $5 billion in
challenging.
emergency funds for domestic and global efforts to contain
the 2014-2015 West Africa Ebola outbreak (P.L. 113-235).
International and U.S. Responses
Some of those unspent funds were used to contain a 2018
Confirmed Ebola cases are being treated with experimental
outbreak in western Democratic Republic of Congo (DRC)
Ebola therapeutics in Ebola Treatment Centers (ETCs). As
and are being used to fight the ongoing outbreak (see CRS
of January 28, 2019, six ETCs and two isolation treatment
Report R44507, Status of the Ebola Outbreak in West
units were operational, with occupancy rates ranging from
Africa: Overview and Issues for Congress).
60% to 110%, with additional ETCs being constructed.
Between August 2018 and early February 2019, the DRC’s
On August 1, 2018, the World Health Organization (WHO)
Ministry of Health (MoH) and partners vaccinated roughly
reported a new Ebola outbreak in eastern DRC, about one
73,000 Ebola cases and their contacts. In bordering
week after declaring that a separate outbreak had ended in
countries, over 2,600 health workers (HWs) have been
western DRC. The ongoing Ebola outbreak—the 10th to be
vaccinated in Uganda, more than 1,400 HWs in Rwanda are
documented in DRC—is the largest in the country’s history
designated to be vaccinated (once the protocol is approved),
and has continued to spread (Figure 1). It is occurring in
and approximately 300 HWs have been vaccinated in South
North Kivu and Ituri provinces, where a protracted conflict
Sudan. The WHO has conducted readiness assessments in
has caused a long-running humanitarian crisis: as of mid-
neighboring countries, and the U.N. Central Emergency
2018, 4.3 million people were in need of humanitarian aid.
Response Fund has contributed $10 million toward regional
In addition to classic public health response tools
Ebola control and preparedness efforts.
(surveillance, contact tracing, isolation, and safe burials),
When the outbreak began, USAID and CDC deployed staff
health workers (HWs) are using an investigational vaccine
to DRC and the region. In October 2018, USAID
to counter the spread of disease. Unpredictable armed
announced it had deployed a Disaster Assistance Response
conflict and intermittent community resistance to these
Team (DART) to coordinate the U.S. government response
efforts are hindering all aspects of outbreak control.
in support of the MoH, WHO, and other international
Figure 1. Ebola Virus Outbreaks in DRC: 1976-2019
partners. The United States, more broadly, is the top
bilateral humanitarian donor to DRC and the top financial
contributor to the U.N. peacekeeping operation there, which
has provided “life-saving logistics support to the Ebola
response” in North Kivu and Ituri, according to U.S.
officials. U.S. support for outbreak control also includes the
following:
USAID: As of February 5, 2019, USAID has provided
more than $33 million in FY2018-FY2019 to
nongovernmental organizations (NGOs), U.N. agencies,
and other partners for Ebola response in DRC and Ebola
preparedness in neighboring countries. USAID funds are
supporting disease surveillance, infection protection and
control, risk communication and community engagement,
safe and dignified burials, water and sanitation aid, and
prepositioning of medical supplies.
Source: CRS graphic, based on WHO data.
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Ebola Outbreak: Democratic Republic of Congo
CDC: CDC personnel provide direct support to the MoH,
health workers and patients at risk. As of February 3, 2019,
WHO, and the DART and are supporting disease
65 health workers had contracted Ebola in the current
surveillance, contact tracing, data management, infection
outbreak, 22 of whom died. From December 1, 2018,
protection and control, risk communication and community
through January 28, 2019, 18% of confirmed Ebola cases
engagement, laboratory strengthening, emergency
reported having visited a health center before developing
management, and surveillance at points of entry. CDC staff
symptoms, suggesting they may have been exposed to the
are also supporting Ebola preparedness efforts in Rwanda,
virus at the facility. The MoH, WHO, and other partners
South Sudan, and Uganda.
have identified health facilities where Ebola transmission
may have occurred and are addressing lapses around triage,
U.S. Department of Defense (DOD): DOD supplies
case detection, and infection prevention and control.
laboratory training to Ugandan researchers and partners
with them to conduct clinical trials of Ebola vaccines.
Early symptoms of Ebola and malaria are similar, and a
spike in malaria cases in and around Beni City has
Challenges
compounded pressure on its health facilities and ETCs. A
Insecurity. Ebola cases are concentrated in Beni and
January 2019 WHO report indicated that up to 50% of
Butembo districts in North Kivu, a site of armed conflict
people screened in ETCs had malaria. In November 2018,
since the 1990s. Dozens of armed groups are active in the
the DRC National Malaria Control Program, supported by
area, including the Allied Democratic Forces (ADF), a
WHO, the United Nations Children’s Fund (UNICEF), the
nebulous armed group implicated in attacks on U.N.
Global Fund, and the U.S. President’s Malaria Initiative,
peacekeepers, local military forces, and civilians. Elements
launched a prevention and treatment campaign to curb
of the state security forces also reportedly maintain ties
malaria deaths and reduce pressure on the health system.
with armed groups and have been implicated in serious
abuses. Road travel is often dangerous, with frequent
Outlook
reports of militia attacks, armed robbery, and kidnappings.
The ongoing Ebola outbreak is in its seventh month, and
control efforts have shown mixed results. While the number
Fear and misinformation have also prompted community
of new cases have declined in some areas, infection rates
resistance to Ebola control efforts. Health workers and
have risen in others. Insecurity in North Kivu has disrupted
facilities have been attacked, and community resistance to
response activities, raising questions about how to carry out
conducting safe burials has hindered containment efforts.
Political unrest related to DRC’s
disease control in unsafe settings. Protracted conflict in
national elections in
Pakistan and Afghanistan, for example, has stymied global
December 2018 has also posed challenges. The DRC
polio eradication efforts, while political instability in
government postponed voting in Beni and Butembo, citing
Venezuela has contributed to the resurgence of malaria in
risks of contagion (although the MoH had earlier suggested
the country, imperiling the rest of the region.
such risks would be mitigated), spurring protesters to
ransack and burn down part of an ETC in Beni.
Political instability aside, the inability to control disease
outbreaks is largely a symptom of weak domestic health
The U.S. government has placed constraints on the
systems. To address this challenge and improve countries’
movement of U.S. personnel due to security threats in the
ability to prevent, detect, and respond to infectious disease
east and political unrest throughout the country. In
threats, the United States and WHO co-launched the Global
September, USAID and CDC withdrew their personnel
Health Security Agenda (GHSA) in 2014. The United
from the outbreak zone pursuant to security concerns. The
States, the largest donor to this multilateral effort, pledged
CDC Director stated to the press that the CDC’s preference
to support it with $1 billion from FY2015 through FY2019.
would have been to maintain staff in the field. U.S.
Much of the emergency appropriations that have been used
personnel continue to provide technical assistance from the
in support of GHSA and to control the ongoing Ebola
capital, Kinshasa, and from neighboring Rwanda and
outbreak is expected to be expended by the end of FY2019.
Uganda, while implementing partners (WHO and NGOs)
The Trump Administration has signaled support for
are continuing Ebola control efforts with U.S. resources.
continuing the GHSA. Clearer signals of how the
Health System Constraints. Low health worker density,
Administration proposes extending U.S. engagement may
low health spending, and prolonged conflict have weakened
be found in the forthcoming FY2020 budget request.
DRC’s health system and hindered Ebola control efforts. A
In the 115th Congress, H.R. 7290, Global Health Security
ratio of at least 2.3 health workers per 1,000 people is often
Act of 2018, would have codified an Obama-era executive
used as a proxy for measuring minimum health delivery
order setting out agency roles in supporting the GHSA. In
capacity in a given country. According to the latest
the 116th Congress, H.R. 826 would seek to facilitate
available data from WHO, DRC had roughly 1.1 health
research and treatment of neglected tropical diseases,
workers per 1,000 people as of 2009. WHO reported that as
including Ebola. Members may continue to debate what
of 2015 (latest available), health spending accounted for 5%
role, if any, the United States should play in supporting
of government spending, which would amount to roughly
global health system strengthening efforts to bolster global
$3.30 per capita, one of the lowest rates in the world.
health security and whether to adjust funding levels to meet
The WHO suggests that Ebola transmission may be
ongoing and looming infectious disease threats.
occurring in ill-equipped, untrained, and/or understaffed
health facilities. Inconsistent adherence to infection
Tiaji Salaam-Blyther, Specialist in Global Health
prevention and control, periodic disruptions in the personal
Alexis Arieff, Specialist in African Affairs
protection equipment supply chain, and limited access to
IF11100
water for handwashing in some health facilities is putting
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Ebola Outbreak: Democratic Republic of Congo
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