Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Ebola Outbreaks in the Democratic Republic of September 10, 2020
Congo: Emergencies or Enduring Threat?
Tiaji Salaam-Blyther
On June 25, 2020, the World Health Organization (WHO) announced the end to an
Specialist in Global Health
Ebola outbreak that began nearly two years earlier in eastern Democratic Republic of

Congo (DRC). The outbreak—DRC’s 10th on record—was concentrated in a conflict
Alexis Arieff
zone, complicating containment efforts, and became the world’s second-largest Ebola
Specialist in African Affairs
outbreak ever. Attacks on health workers repeatedly impeded containment efforts, as did

political tensions, local community suspicion of government officials and international
actors, and local frustrations at perceived profiteering by responders. Eventual success in
containing the outbreak was attributable, in part, to the deployment of new vaccines first
pioneered during the West Africa outbreak, advances in experimental therapeutics, and changes in the
coordination of response efforts on the ground.
Relief over ending the 2018-2020 eastern DRC Ebola outbreak was muted, however, by the detection of a new
outbreak, DRC’s 11th to date, in the western part of the country in the same month—and by the global
Coronavirus Disease 2019 (COVID-19) pandemic, which has posed new health challenges in DRC and severely
affected the country’s economy. The DRC government and international partners also face other health
challenges, including intermittent outbreaks of measles, cholera, and malaria, and relatively high preventable
death rates (particularly in the areas of maternal and child health) resulting from inadequate access to clean water,
sanitation, and hygiene (WASH) and primary health care. Poor conditions at health facilities continue to frustrate
efforts to convince individuals with Ebola symptoms to seek diagnosis and treatment. According to the U.N.
Office for the Coordination of Humanitarian Affairs (UNOCHA), fewer than 30% of health facilities in the
country are equipped to provide basic medical care, including vaccines, antidiarrheal treatment, undernutrition, or
prenatal and postnatal care.
The prolonged battle to contain the Ebola outbreak in eastern DRC, coupled with what appear to be more frequent
outbreaks in the country, raise questions about the allocation of U.S. global health resources and bilateral aid for
DRC. New vaccines and therapeutics are potential game-changers in responding to new Ebola outbreaks, yet local
health system weaknesses, community mistrust, and barriers to humanitarian access have continued to present
obstacles. Among the issues that Congress might consider include the relative ranking of U.S. global health
priorities in the context of COVID-19, the implications of frequent Ebola outbreaks for the global health security
agenda, and lessons that may be gleaned from DRC about pandemic response in other complex conflict settings.
The United States was the largest country donor to the international Ebola response effort in eastern DRC, with
the U.S. Agency for International Development (USAID) and U.S. Centers for Disease Control and Prevention
(CDC) playing a lead role. If responding to and preventing Ebola outbreaks remain congressional priorities in the
future, Congress may consider how such efforts may be funded. Notably, USAID drew on unobligated
International Disaster Assistance (IDA) funds that Congress had provided in FY2015—in the context of the 2014-
2016 West Africa Ebola outbreak—as its core source of funding for Ebola response in eastern DRC. Since June,
USAID has allocated resources for countering the new outbreak in the west, but since March 2020, the agency
also has drawn on remaining unobligated FY2015 emergency Ebola appropriations to fund COVID-19 response
efforts in developing countries worldwide. The CDC, for its part, also drew on 2015 Emergency Ebola
supplemental appropriations, along with more recent appropriations for global disease detection and infectious
disease response that, likewise, may be focused elsewhere in the current context. Total USAID funding for
emergency response to the eastern DRC Ebola outbreak, at $342 million, also exceeded the U.S. annual bilateral
health assistance budget for DRC ($217 million allocated in FY2019). Much of the U.S. bilateral health aid
budget for DRC is focused on other disease-specific initiatives, namely HIV/AIDS, malaria, and tuberculosis,
although DRC also receives U.S. health system strengthening aid through global programs.
Congressional Research Service

link to page 4 link to page 5 link to page 7 link to page 9 link to page 10 link to page 11 link to page 11 link to page 13 link to page 13 link to page 4 link to page 12 link to page 8 link to page 14 Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Contents
Introduction ..................................................................................................................................... 1
Successes in Ebola Control ....................................................................................................... 2
Challenges in Ebola Control ..................................................................................................... 4
The International Response to the 2018-2020 Eastern DRC Outbreak ........................................... 6
U.S. Role and Funding: The 2018-2020 Outbreak in Eastern DRC ......................................... 7
Issues for Congress .......................................................................................................................... 8
Implications for U.S.-DRC Policy and Aid ............................................................................... 8
Lessons Learned for Pandemic Response in Conflict Settings? ............................................. 10
Global Health Security ............................................................................................................ 10

Figures
Figure 1. Documented Ebola Outbreaks in DRC to Date ................................................................ 1
Figure 2. U.S. Bilateral Health Aid for DRC, by Program Objective ............................................. 9

Tables
Table 1. Key Health Statistics: DRC, Africa, and the World ........................................................... 5

Contacts
Author Information ......................................................................................................................... 11

Congressional Research Service

link to page 4
Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Introduction
On June 25, 2020, a nearly two-year Ebola virus outbreak in eastern Democratic Republic of
Congo (DRC) was declared over, after claiming the lives of nearly 2,300 people.1 A new outbreak
emerged the same month in the west of the country, marking the 11th documented Ebola outbreak
in the country since the virus was first identified in DRC in 1976 (Figure 1).2 The eastern DRC
outbreak (the country’s 10th) unfolded in an area without recent experience with the disease, and
which was already experiencing complex armed conflicts and a protracted humanitarian crisis.3
The multilateral Ebola response effort confronted stark obstacles and frequent setbacks, including
attacks on health workers, political tensions, local disinformation campaigns, intense community
mistrust, and resource constraints, particularly in public health facilities.4 The outbreak, which
peaked in mid-2019, became DRC’s largest ever, and the world’s second-largest after the 2014-
2016 West Africa outbreak (which infected over 28,000 people and killed more than 11,000).
Figure 1. Documented Ebola Outbreaks in DRC to Date

Source: CRS graphic. Base map drawn from Esri (2016); case data from the WHO, as of August 2020.

1 Per World Health Organization (WHO) guidance, Ebola outbreaks are declared over when 42 days (twice the known
incubation period) pass, with no new cases, after the discharge of all known Ebola patients.
2 See U.S. Centers for Disease Control and Prevention (CDC), “Years of Ebola Virus Disease Outbreaks,” at
https://www.cdc.gov/vhf/ebola/history/chronology.html. Ebola is named after a river in DRC, and a Congolese
scientist, Dr. Jean-Jacques Muyembe, played a key role in the virus’s discovery in 1976. Dr. Muyembe currently heads
DRC’s National Institute for Biomedical Research and was appointed DRC’s national Ebola coordinator in mid-2019.
3 As of October 2018 (before the outbreak had substantially spread), 4.3 million people were in need of humanitarian
aid in the two provinces, according to U.N. Office for the Coordination of Humanitarian Affairs (UNOCHA) data.
4 See National Public Radio (NPR), “‘It was unmistakably a directed attack’: 4 Ebola workers killed in Congo,”
November 28, 2019.
Congressional Research Service

1

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

The deployment of new vaccines and therapeutics, improved coordination of response efforts on
the ground, and community-level engagement appear to have been key factors supporting
containment of the eastern DRC outbreak. Yet, flagging donor commitment and competing
needs—including the novel Coronavirus Disease 2019 (COVID-19) pandemic—have
complicated and arguably diverted national and global resources from controlling the new
outbreak in western Equateur province and ensuring adequate disease surveillance elsewhere the
country.5 In early August 2020, the WHO issued a donor appeal requesting $18.4 million to
control the new (11th) outbreak, which, at that point, was reportedly growing steadily with new
health zones affected in hard-to-reach, remote villages.6 As in the 10th outbreak, Ebola responders
have faced local resistance, particularly in reporting of cases, referring suspected cases to health
facilities, and following safe and dignified burial practices.
The prolonged battle to contain the Ebola outbreak in eastern DRC, coupled with what appear to
be more frequent outbreaks in the country, raise questions about the allocation of U.S. global
health resources and bilateral aid for DRC. Vaccines and therapeutics are potential game-
changers, yet health system weaknesses, community mistrust, and barriers to humanitarian access
remain obstacles. Among the issues that Congress might consider include the relative ranking of
U.S. global health priorities in the context of COVID-19, the implications of frequent Ebola
outbreaks for the global health security agenda, and lessons learned from DRC about pandemic
response in complex conflict settings. If responding to and preventing Ebola outbreaks remain
congressional priorities, Congress might also consider how such efforts may be funded.
Successes in Ebola Control
The extraordinary conditions in eastern DRC, particularly significant infrastructure constraints
and security threats, limited the implementation of conventional infection control and prevention
measures and required ever-evolving strategies for containment. Classic Ebola outbreak control
protocol entails
 infection prevention control (IPC) in health care facilities;
 management and isolation of patients, ideally in specialized Ebola Treatment
Centers (ETCs);
 fever surveillance with rapid diagnosis;
 tracing of Ebola cases and their contacts; and
 community awareness and adherence to IPC protocols, safe patient care, safe
body transport and burials, and household and environmental decontamination.
To overcome barriers caused by insecurity, inaccessibility, and poor IPC compliance in some
health settings, Ebola responders adopted modified approaches, including expanded application
of Ebola vaccines, deployment of innovative Ebola therapeutics, and local outreach to secure
access and protection of health workers.
Vaccines. During the 2014-2016 West Africa Ebola outbreak, health workers deployed a “ring
vaccination” strategy for the first time, using an experimental vaccine (unlicensed at the time)
under a “compassionate use” protocol. Ring vaccination entails vaccinating those who have come
in contact with a known Ebola case, as well as their contacts. The same strategy was employed

5 In March, the WHO appealed for donors to fill “an immediate US$20 million funding gap,” or risk running out of
money, and possibly missing new cases, before the outbreak was fully over. WHO, Remarks by Dr Ibrahima Socé Fall,
“End in sight, but flare-ups likely in the Ebola outbreak in the Democratic Republic of the Congo,” March 6, 2020.
6 UNOCHA, “Republique Demoratique Du Congo,” Note d’information, rapport #56, 18 août 2020.
Congressional Research Service

2

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

during the 2018-2020 outbreak in eastern DRC, although population mobility, suboptimal IPC
practices in local health clinics, gaps in rapid diagnosis and isolation of infected individuals, and
resistance by some communities limited its effectiveness.
In February 2019, the World Health Organization (WHO) Strategic Advisory Group of Experts
(SAGE) noted the “exceptional circumstances” of the eastern DRC outbreak (summarized above)
and recommended adding geographic-targeted vaccination, entailing vaccinating residents in the
area immediately surrounding an Ebola case, such as a village or neighborhood. In May 2019, the
WHO SAGE recommended additional adjustments to the vaccine strategy, including
 “pop-up” vaccination to make the process faster, more secure, and more
responsive to local feedback;
 streamlining implementation of the vaccination protocol;
 modifying follow-up for safety monitoring; and
 adjusting the dose of the vaccine to ensure vaccine availability (i.e., primary and
secondary contacts would receive one-half the previously used dose and tertiary
contacts would receive one-fifth of the previous dose).
By the end of the outbreak, over 300,000 people had been vaccinated in the main outbreak zone
(Ituri and North Kivu provinces) with the aforementioned experimental vaccine, rVSV-ZEBOV
(brand name Ervebo, produced by Merck). In December 2019, Ervebo became the first Ebola
vaccine to be approved by the U.S. Food and Drug Administration (FDA).7 In September 2019,
Congolese officials approved use of a second vaccine candidate, Ad26.ZEBOV/MVA-BN,
developed by Janssen Pharmaceuticals (a subsidiary of Johnson & Johnson) and Bavarian Nordic.
As of August 18, 2020, more than 22,000 people had been vaccinated against Ebola in the new
outbreak zone, Equateur province.8
Therapeutics. The FDA has not approved any antiviral drugs to treat Ebola, though experimental
treatments (known as REGN-EB3 and mAb114) were used to care for Ebola patients during the
2018-2020 outbreak.9 Caretakers had otherwise primarily focused on addressing Ebola-related
symptoms (e.g., through the provision of fluids intravenously, oxygen therapy, fever suppressants,
and pain relievers). In August 2019, a study by the U.S. National Institutes of Health (NIH), the
WHO, and the DRC National Institute of Biomedical Research reported that REGN-EB3 and
mAb114 had proven effective in improving survival outcomes for Ebola patients during an
investigational trial. While several other candidate therapies are also being evaluated, the WHO
announced in August 2019 that it would follow the recommendations of an independent Data and
Safety Monitoring Board to use only the two aforementioned therapies when treating Ebola
patients.10 Over 2,100 people were treated with these therapies during the eastern DRC
outbreak.11

7 WHO, “Ebola Virus Disease—Democratic Republic of the Congo, Weekly Epidemiological Record, Volume 27, Issue
95, pp. 301-324, July 3, 2020; U.S. FDA, Ebola Preparedness and Response Updates from FDA, at
https://www.fda.gov. FDA approval followed a determination by the European Medicines Agency to grant conditional
marketing authorization for the Ervebo vaccine.
8 UNOCHA, “Republique Demoratique Du Congo,” Note d’information, rapport #56, August 18, 2020.
9 CDC, Ebola Virus Disease, “Treatment,” at https://www.cdc.gov/vhf/ebola/treatment/index.html; and NIH,
Independent Monitoring Board Recommends Early Termination of Ebola Therapeutics Trial in DRC Because of
Favorable Results with Two of Four Candidates, August 12, 2019.
10 WHO, Update on Ebola Drug Trial: Two Strong Performers Identified, August 12, 2019.
11 WHO, “Ebola Virus Disease—Democratic Republic of the Congo, Weekly Epidemiological Record, Volume 27,
Issue 95, pp. 301-324, July 3, 2020.
Congressional Research Service

3

link to page 7 link to page 9 link to page 9 Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Local Engagement and Coordination of Response Efforts. Local resistance to Ebola response
activities was a persistent feature of the eastern DRC outbreak—at times amounting to armed
attacks and seemingly organized sabotage. While the extent of armed group involvement may
have been unique to the geographic location of the outbreak, community resistance remains an
obstacle in the new outbreak and likely in the future (see “Challenges in Ebola Control” below).
Because willing local participation in efforts to prevent, identify, and rapidly isolate Ebola cases
is crucial to containment, strong engagement with local communities has been a top priority
among organizations responding to Ebola outbreaks in DRC, and in Ebola response generally.12
Steps by the DRC government in 2019 to address internal coordination and accountability
problems may have helped improve coordination and local perceptions of responders. Notably,
after former opposition figure Felix Tshisekedi was inaugurated president in early 2019, he
centralized and elevated the coordination of response efforts to the office of the presidency,
appointed an expert virologist to lead these efforts, and pursued investigations into health sector
corruption under the previous DRC administration (see text box below). Donors, including the
U.S. Agency for International Development (USAID), invested in efforts to improve and
coordinate messaging around Ebola response efforts. In 2019, the U.N. peacekeeping operation in
DRC took on a greater role in ensuring financial, logistical, and policy coordination among those
involved in responding to the outbreak (see “The International Response to the 2018-2020
Eastern DRC Outbreak” below). Donors, including the United States, also expanded response
efforts to include support for broader health and food security initiatives in Ebola-affected areas,
both in response to local needs and as an effort to build local support for containment efforts.
Challenges in Ebola Control
Post-Outbreak Health Concerns. Scientists do not yet know whether Ebola infection confers
lifelong immunity in all cases, as had been assumed prior to the 2014-2016 West Africa outbreak.
Rare cases of relapse have been documented in West Africa and eastern DRC, while experts are
continuing to investigate whether other cases were reinfected or relapsed.13 The persistence of the
virus in the body has also raised questions about the risk for the reemergence of Ebola outbreaks
after their containment, including in West Africa, which has over 17,000 Ebola survivors, and in
eastern DRC, which has over 1,100 survivors.14 Noting that “survivor-linked transmission,
undetected chains of transmission, and new introduction of Ebola virus into the human population
from an animal reservoir” were possible, USAID reported in June 2020 that “response actors aim
to continue supporting critical activities to detect and respond to additional cases that may emerge
following the official end of the outbreak.”15
Health Infrastructure Constraints. DRC’s weak national health system posed a key challenge
to Ebola response efforts during the tenth outbreak, notwithstanding the country’s prior
experience and expertise in Ebola control. According to the U.N. Office for the Coordination of
Humanitarian Affairs (UNOCHA), as of early 2020 fewer than 30% of health facilities had the

12 See WHO, “Ebola in the Democratic Republic of the Congo: North Kivu, Ituri 2018 – 2020,” at
https://www.who.int/emergencies/diseases/ebola/drc-2019; and WHO et al, Risk Communication and Community
Engagement Preparedness and Readiness Framework: Ebola Response in the Democratic Republic of Congo in North
Kivu, September 2018.
13 WHO, Ebola Virus Disease-Democratic Republic of the Congo: External Situation Report 72, December 17, 2019.
14 C. Raina MacIntyre and Abrar Chughtai, “Recurrence and Reinfection-A new Paradigm for the Management of
Ebola Virus Disease,” International Journal of Infectious Diseases, volume 43, (2016), pp. 58-61.
15 USAID, “Democratic Republic of the Congo – Ebola Outbreaks,” FY2020 Fact Sheet #7, June 29, 2020.
Congressional Research Service

4

link to page 8 link to page 8 link to page 8 link to page 8 link to page 8 link to page 8 link to page 8 Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

operational capacity to provide basic medical care, significantly limiting the ability to provide
preventive care, including the provision of vaccines, maternal and child health care, and control
of measles, cholera, and malaria.16 Deaths and illness from these causes in DRC have, for years,
exceeded regional and global averages (Table 1). Faced with limited health resources, authorities
redirected local health resources to Ebola control in some hotspots, including those for regular
vaccination campaigns, deepening mistrust by some of government authorities. Between 2019
and mid-2020, DRC experienced the world’s worst measles epidemic at the time, which killed
over 7,000 children. Health system capacity has likely been further weakened by Ebola deaths
among health workers: the WHO reported in December 2019 that Ebola had killed at least 34
health workers in eastern DRC since the outbreak in that region began.17
Table 1. Key Health Statistics: DRC, Africa, and the World
Maternal
New
Mortality
Child
Stunting
New HIV
Malaria
New TB
Ratioa
Mortality
Among
Infectionsb Infectionsb Infectionsb
Physician
(per
Rateb (per
Children
(per 1,000
(per 1,000
(per
Densityc
100,00 live 1,000 live
Under 5
uninfected
pop. at
100,000
(per 10,000

births)
births)
(%)
pop.)
risk)
pop.)
pop.)
DRC
473
88
42.7
0.21
319.8
321
0.7
Africa
525
76
32.5
1.07
229.3
231
3.0
World
211
39
21.3
0.24
57.4
132
15.6
Source: WHO, World Health Statistics 2020: Monitoring Health for the SDGs [Sustainable Development Goals], 2020.
a. Data col ected in 2017.
b. Data col ected in 2018.
c. Data col ected in 2016.
Security and Governance Challenges. At the height of the eastern DRC outbreak in mid-2019,
U.S. officials and other health experts identified local tensions and political grievances, along
with security threats, as key challenges.18 Attacks by local militias and criminal groups, political
protests, health worker strikes, and security force abuses repeatedly disrupted and impeded
response efforts. In 2019, then-USAID Administrator Mark Green urged a multifaceted
“development approach” toward the outbreak, referring to DRC as a “failed democracy” that had
undermined “the Congolese people’s trust in institutions.”19 From the start of the outbreak in
August 2018 through March 2020, the WHO documented 420 attacks on health facilities in the
main outbreak zone, resulting in 11 deaths and 86 injuries.20 In many cases, assailants were never
conclusively identified.
Local mistrust of government officials and perceived outsiders (including Congolese responders
from other parts of the country) contributed to community resistance. The first year of the

16 UNOCHA, Democratic Republic of the Congo, Health Cluster Report, March 2020.
17 WHO, Disease Outbreak News Report on the DRC, December 12, 2019.
18 See, for example, House Foreign Affairs Subcommittee on Africa, Global Health, Global Human Rights and
International Organizations (“HFAC Africa Subcommittee”), hearing, “Eradicating Ebola: Lessons Learned and
Medical Achievements,” June 4, 2019; and WHO, “High-Level Event on Ebola Virus Disease in DRC,” July 15, 2019.
19 Mark Green, testimony before the Senate Appropriations Subcommittee on State, Foreign Operations, and Related
Programs, hearing, “Review of the FY2020 Budget Request for USAID,” April 30, 2019; and “How to End the Ebola
Crisis [Op-Ed],” CNN, August 22, 2019.
20 WHO, Remarks by Dr Ibrahima Socé Fall, March 6, 2020, op. cit.
Congressional Research Service

5

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

outbreak also coincided with a fraught political transition process, during which the outgoing
national government’s decision to delay and, in some cases, cancel elections in the outbreak zone
(an opposition stronghold) heightened tensions and spurred conspiracy theories.21 Perceptions that
outsiders were profiting financially from the response effort, or that international interventions
were driven more by Westerners’ fear of contagion than by concern for locals’ wellbeing, also
appear to have fueled local mistrust, as well as kidnappings of Ebola responders.22

Corruption Concerns in the Ebola Response
From the start of the eastern DRC outbreak, the DRC government’s health responses were coordinated by the
Ministry of Health (MoH), as in past Ebola outbreaks in the country. In July 2019, newly elected President Etienne
Tshisekedi transferred coordination responsibilities to an expert committee headed by the director of DRC’s
national biomedical research institute, Dr. Jean-Jacques Muyembe. Dr. Muyembe is a renowned expert on Ebola
who helped investigate the first known outbreak of the disease in DRC in 1976. Health Minister Dr. Oly Ilunga
resigned fol owing Dr. Muyembe’s appointment, complaining of a dilution of his authority, confusion about the
lines of coordination, an insufficient focus on the health system, and opposition to introducing a second vaccine as
part of the response. A DRC government investigative commission subsequently issued scathing criticism of Dr.
Ilunga, indicating, among other things, that the minister and his team had displayed an “aggressive and ostentatious
attitude” when visiting the outbreak area and had squandered Ebola response funds on fancy cars and hotel
rooms.23 In March 2020, a DRC court sentenced Ilunga to prison for allegedly embezzling Ebola response funds.24
This was not the only case of apparent misappropriation of funds and other abuses by various actors involved in
responding to the eastern DRC outbreak. As of mid-2020, investigative journalists, U.N. agencies, and NGOs had
identified a range of problematic behavior that likely contributed to local mistrust of responders, including alleged
sexual exploitation, petty corruption, and inflated fees and kickbacks paid to DRC state security forces (who have
repeatedly been implicated in gross human rights violations).25 Overall, perceived profiteering and corruption
among DRC officials and others came to be known as the “Ebola business.”
The International Response to the 2018-2020 Eastern
DRC Outbreak
The Congolese government has led the response to successive Ebola outbreaks in DRC, with
support from the World Health Organization, nongovernmental organizations, donors, and other
partners. National and international nongovernmental organizations partnered with the Congolese
government to provide direct support for activities such as IPC training, communication
campaigns, and disease surveillance, while U.N. agencies (including the WHO), other multilateral
entities (including the World Bank), and foreign governments provided funding, technical
expertise, coordination, and/or logistical assistance. Most of the direct patient care was provided
by Congolese nationals. As a WHO official noted at the height of the outbreak in June 2019, “If
you go into the treatment facilities now it is Congolese doctors and nurses in the front line. There
may be NGO or WHO badges on the tents but the doctors and nurses are Congolese; surveillance
officers are Congolese; 80% of the vaccinators in this response are Congolese.”26

21 See CRS Report R43166, Democratic Republic of Congo: Background and U.S. Relations.
22 New York Times, “Ebola Outbreak Reaches Major City in Congo, Renewing Calls for Emergency Order,” July 15,
2019.
23 New York Times, “In Congo, a New Plan to Fight Ebola Follows a Government Power Struggle,” July 26, 2019.
24 Reuters, “Former DR Congo Health Minister Convicted of Embezzling Ebola Funds,” March 23, 2020.
25 The New Humanitarian, “How ‘Ebola business’ threatens aid operations in Congo,” June 18, 2020.
26 WHO, “Ebola Outbreak in the Democratic Republic of the Congo,” Press Briefing, June 6, 2019.
Congressional Research Service

6

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

The African Union (AU) Africa Centers for Disease Control and Prevention (Africa CDC) also
deployed members of its voluntary response corps to DRC and neighboring countries to provide
technical assistance. The U.N. Stabilization Mission in Congo (MONUSCO) provided logistical
and security support to Ebola response efforts while also seeking to fulfill its otherwise wide-
ranging civilian-protection and stabilization mandate.
Starting when the WHO declared the eastern DRC outbreak to be a Public Health Emergency of
International Concern (PHEIC) in July 2019 (about 11 months after the first cases were
identified), the WHO sought emergency donor funds, as well as international support for
addressing local political and security challenges. Over a series of appeals to donors from August
2018 through mid-2020, the WHO sought a total of $570 million to support public health
response and regional preparedness efforts, of which donors ultimately provided about $276
million.27 The WHO appeals aimed to support clinical care, disease surveillance, contact tracing,
vaccinations, laboratory capacity, infection prevention and control, clean water and sanitation,
safe and dignified burials, psychosocial care, operational preparedness, and coordination.28
In May 2019, in response to concerns (including among U.S. officials) that a lack of operational
coordination and transparency were stymying efforts to improve humanitarian access and address
security threats, the U.N. Secretary-General established a new position of U.N. Ebola Response
Coordinator. David Gressly, a U.S. citizen serving as the Deputy Special Representative of the
U.N. Secretary-General within MONUSCO, was appointed to the post. He sought to strengthen
financial tracking, humanitarian coordination, political engagement, and “preparedness and
readiness planning,” while the WHO continued to lead on health operations and technical support
activities.29 Gressly returned to his regular position within MONUSCO in March 2020, at which
time the U.N. response coordinator position was deemed no longer necessary.
U.S. Role and Funding: The 2018-2020 Outbreak in Eastern DRC
The United States was the largest country donor to the international Ebola response effort during
the outbreak in eastern DRC. USAID and CDC were the primary federal entities involved. The
Trump Administration largely restricted U.S. government personnel from traveling to and within
the main outbreak zone for most of its duration due to security concerns, with some exceptions
for high-level visits. (U.S. personnel were stationed in Kinshasa, in the eastern DRC city of
Goma, and in neighboring countries, while U.S. implementing partners used U.S. resources to
conduct activities within the outbreak zone.) The Trump Administration deployed a USAID-led
Disaster Assistance Response Team (DART) to the region starting in September 2018 to
coordinate the U.S. response in support of the DRC government, the WHO, and other partners,
and established a Washington, D.C.-based Response Management Team to support the DART.
CDC staff supported and participated in these effort, while NIH supported trials of Ebola vaccines
and therapeutics in partnership with the WHO and DRC’s National Institute of Biomedical
Research.
Over the duration of the eastern DRC Ebola outbreak (August 2018-June 2020), USAID provided
over $342 million in support of response and preparedness activities in DRC and neighboring
countries. The bulk of these funds were drawn from unobligated FY2015 International Disaster
Assistance (IDA) that Congress had appropriated on an emergency basis for Ebola response
during the West Africa outbreak under P.L. 113-235. USAID also drew on foreign assistance

27 See WHO strategic response plans, at https://www.who.int/emergencies/diseases/ebola/drc-2019/funding.
28 See WHO and DRC Ministry of Health, Strategic Response Plan for the Ebola Virus Disease Outbreak in the
Provinces of North Kivu and Itur, Democratic Republic of the Congo, July – December 2019.
29 Ibid. See also Ziemer testimony before the HFAC Africa Subcommittee, “Eradicating Ebola,” June 4, 2019, op. cit.
Congressional Research Service

7

link to page 11 Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

funds provided under the Global Health Programs (GHP) and Food for Peace (FFP) accounts.
CDC, for its part, allocated approximately $36.7 million in support of Ebola control efforts in
eastern DRC, drawing on the 2015 Emergency Ebola supplemental appropriations, 2018 and
2019 appropriations for global disease detection, and the Infectious Disease Rapid Response
Reserve Fund.30 CDC provided technical assistance through its personnel in the field and at
headquarters in the United States.
According to the U.S. Embassy in DRC, total U.S. federal funding allocated in response to the
eastern DRC Ebola outbreak reached $600 million, including CDC and NIH activities as well as
other U.S. Department of Health and Human Services contributions.31 More broadly, the United
States is the top country donor of emergency humanitarian assistance to DRC and the top
financial contributor to MONUSCO (see “Issues for Congress” below).
Issues for Congress
In FY2015, at the height of the West Africa Ebola outbreak, Congress appropriated $5.1 billion
for Ebola response and preparedness on an emergency basis, including $1.436 billion in multiyear
International Disaster Assistance (IDA) funds (Title IX of Division J, P.L. 113-235). USAID
primarily used the unobligated balance of these IDA funds to respond to the 2018-2020 eastern
DRC Ebola outbreak. As of August 2020, it was unclear whether any of these funds were being
used to support Ebola control efforts in Equateur (western DRC) after a new outbreak was
detected there in June 2020. USAID’s heavy reliance on FY2015 emergency appropriations for
Ebola response may raise questions about how the agency would provide additional support for
Ebola control if the Equateur outbreak is not rapidly contained or if another outbreak occurs in
the near term, in DRC or elsewhere.
Looking ahead, and weighing the threat of Ebola against other global pandemic threats such as
COVID-19, Congress may consider what funding mechanisms, if any, the United States might
use to support Ebola prevention and preparedness in the future. Members may also examine the
U.S. role, vis-à-vis other actors (including other countries, multilateral entities, and private
sources), in financing Ebola prevention and preparedness activities, and may debate strategies for
securing additional contributions from other sources.
Additional issues Congress might consider are discussed below.
Implications for U.S.-DRC Policy and Aid
The prospect of potentially larger and/or more frequent Ebola outbreaks, alongside competing
global pandemic response needs, may raise questions about where Ebola response fits into
broader U.S. health and stabilization priorities and approaches toward DRC, and Africa more
broadly. This includes the extent to which Ebola-related foreign assistance should continue to be
funded via global emergency response mechanisms, as opposed to being integrated into annual
bilateral aid budget planning. The U.S. Embassy in DRC reported in June 2020 that, the United
States would be able “to build up the DRC’s longer-term preparedness capacity amidst the varied
health-security threats the DRC faces,” as a U.S. Global Health Security Agenda (GHSA)

30 CDC response to CRS query, July 2020.
31 U.S. Ambassador Mike Hammer, “Together We Stopped Ebola in the East; Together We Can Advance a Better
Future for the DRC,” U.S. Embassy Kinshasa, June 25, 2020.
Congressional Research Service

8

link to page 12
Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

intensive support country.32 U.S. GHSA aid programming is generally funded through globally
allocated resources, as opposed to bilateral foreign assistance planned at the country level.
DRC is a significant recipient of U.S. bilateral aid in sub-Saharan Africa, with $284 million
allocated in FY2019 appropriations. Of that total, $217 million (76%) was for health assistance
(see Figure 2), roughly the same proportion as for U.S. bilateral aid to sub-Saharan Africa
generally.33 The United States is also by far the top country donor of emergency humanitarian
assistance for DRC, with programs focusing on conflict-affected populations and those suffering
from acute food insecurity. Excluding funds primarily targeted at Ebola response, U.S. emergency
humanitarian aid obligations for DRC in FY2019 totaled $344 million.34
Figure 2. U.S. Bilateral Health Aid for DRC, by Program Objective
State Department + USAID, Allocations of FY2019 Appropriations

Source: Created by CRS using data provided to CRS by USAID, February 2020.
Notes: Does not include funding administered on a global basis (including Global Health Security Agenda and
pandemic preparedness funds) or U.S. contributions to multilateral initiatives. DA=Development Assistance;
ESF=Economic Support Fund; GHP=Global Health Programs.
Given that the lengthy and costly international response to DRC’s 10th outbreak was prolonged, in
part, by armed conflicts and political instability, Members of Congress may weigh the scale and
prioritization of aid and diplomatic resources devoted to addressing these challenges. DRC is a
significant recipient of U.S. aid for peace and security and for democracy and governance
activities: the State Department and USAID allocated $12 million in FY2019 bilateral aid
appropriations to support the professionalization and capacity of DRC’s military, police, and
internal security forces, and $17 million in support of democracy, governance, and human rights-
related programs in the country.35 The United States is also the top provider of funds for
MONUSCO (as with all U.N. peacekeeping operations), allocating $313 million in FY2019.36
Whether enduring problems illustrate that existing donor aid is insufficient, or, alternately, that
existing aid programs are ineffective, may be debated. The Trump Administration has repeatedly
proposed to decrease U.S. bilateral aid for DRC—although not as much as for many other African
countries, and its bilateral health aid budget proposals have varied. In foreign aid appropriations
measures between FY2018 and FY2020, Congress generally did not enact the Administration’s

32 U.S. Ambassador Mike Hammer, “Together We Stopped Ebola in the East; Together We Can Advance a Better
Future for the DRC,” U.S. Embassy Kinshasa, June 25, 2020.
33 CRS Report R46368, U.S. Assistance to Sub-Saharan Africa: An Overview, coordinated by Tomas F. Husted.
34 USAID, “Democratic Republic of the Congo – Complex Emergency,” FY2019 Fact Sheet #2, September 30, 2019.
35 CRS calculation based on data provided by USAID (February 2020) and published in the State Department Budget
Justification for FY2021.
36 State Department Congressional Budget Justification for FY2021; see also CRS In Focus IF10597, United Nations
Issues: U.S. Funding of U.N. Peacekeeping, by Luisa Blanchfield.
Congressional Research Service

9

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

global foreign aid budget proposals, including with regard to DRC. For example, Congress
provided at least $80 million in Development Assistance (DA) budget authority for DRC in
FY2020 appropriations, nearly twice the Administration’s budget proposal for bilateral economic
aid to the country.37
Despite its regular criticisms of U.N. peacekeeping worldwide, the Administration also voted in
the U.N. Security Council to extend MONUSCO’s mandate for at least one more year on
December 19, 2019, via a Resolution that recognized the mission’s “positive role” in coordinating
international Ebola response efforts.38 At the same time, the Administration secured a decrease in
MONUSCO’s authorized troop level in the same Resolution, along with language calling on the
mission to plan to draw down further in the coming years, with an eye toward full exit.
Lessons Learned for Pandemic Response in Conflict Settings?
With its many setbacks, the 2018-2020 Ebola response effort may contain lessons for pandemic
preparedness and response efforts in other conflict-affected settings where central government
authority is weak or contested. Many of the challenges that confronted Ebola responders in
eastern DRC are not unique to the area, and are reminiscent of challenges facing efforts to contain
COVID-19 in many parts of the world, including in some parts that are ostensibly peaceful.39
These include persistent misinformation and conspiracy theories about the disease, corruption in
the allocation of public health resources, a lack of coordination among responders, community
resistance to public health measures, and local mistrust of public authorities.
Greater prioritization of local community engagement—including efforts to address perceived
exclusion of local residents in hiring decisions—and improved transparency and coordination of
international aid activities arguably led to a turning point toward Ebola containment in late 2019.
(Whether local hiring initiatives specifically contributed, knowingly or not, to kickback schemes
and other alleged corruption in the response effort is unclear.40) USAID’s decision to broaden its
emergency Ebola response funding to include resources, for example, for broader health
initiatives and food aid for affected communities within the outbreak zone, as well as stepped-up
resources for communication and messaging, may also have helped alleviate local rejection of the
Ebola response effort.
Global Health Security
The Ebola outbreak in eastern DRC prompted the resumption of discussions about strengthening
health systems worldwide, particularly with regard to pandemic preparedness. During that
outbreak, several Members introduced legislation aimed at bolstering U.S. engagement in the
multilateral GHSA—through which the United States has prioritized pandemic preparedness and
response in DRC—and for strengthening health systems worldwide. In 2014, during the Obama
Administration, the United States and the WHO co-launched the GHSA to improve countries’
ability to prevent, detect, and respond to infectious disease threats.41 The United States, the largest

37 Explanatory statement accompanying Division G of H.R. 1865 (P.L. 116-94). For FY2020, as in prior years, the
Administration proposed to replace the DA foreign assistance account and several others with a consolidated Economic
Support and Development Fund (ESDF) account.
38 U.N. Security Council Resolution 2502 (2019).
39 See also CRS Insight IN11285, Fostering Behavior Change During Disease Outbreaks: Insights from Ebola
Response in Africa, by Alexis Arieff, Tomas F. Husted, and Nicolas Cook.
40 The New Humanitarian, “How ‘Ebola business’ threatens aid operations in Congo,” op. cit.
41 For more information on the GHSA, see CRS In Focus IF10022, The Global Health Security Agenda (2014-2019)
Congressional Research Service

10

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

donor to this multilateral effort, pledged to support it with $1 billion from FY2015 through
FY2019. In 2019, the White House released the United States Government Global Health
Security Strategy, which outlined the U.S. role in extending the GHSA and improving global
health security worldwide.42 Although the Trump Administration, through the strategy and public
statements, has signaled support for extending the GHSA through 2024, officials have not
provided comprehensive information on what that support would entail. Congress might consider
funding provided for global health security and pandemic preparedness through regular
appropriations. Over time, appropriations for preventing and responding to pandemics have
totaled far less than the billions spent on responding to pandemics and infectious disease
outbreaks.
Given U.S. endorsement of the GHSA across two Administrations and the emphasis the United
States has placed on DRC through the initiative, Members of Congress may consider what role, if
any, the United States should play in supporting the GHSA, including whether to codify U.S.
engagement in the GHSA. President Obama issued an executive order in November 2016 that
established an interagency Pandemic Preparedness and Response Directorate to bolster pandemic
preparedness capacity at home and abroad.43 The executive order named the National Security
Council as the chair, specified $1 billion for advancing the GHSA, and outlined the role of
participating agencies and departments. The Trump Administration has provided verbal support
for the GHSA but has dismantled some of the structure established through the executive order.44
A number of bills have been introduced in the 116th Congress to codify a coordinated approach to
pandemic preparedness and support for the GHSA. The Global Health Security Act of 2020 (H.R.
2166 and S. 3302), for example, would call for establishing a Special Advisor for Global Health
Security within the Executive Office of the President to coordinate U.S. federal government
global health security activities, convene and chair a Global Health Security Interagency Review
Council, and submit a biannual report to Congress on related activities, among other things.

Author Information

Tiaji Salaam-Blyther
Alexis Arieff
Specialist in Global Health
Specialist in African Affairs

and International Health Regulations (2005), by Tiaji Salaam-Blyther.
42 White House, United States Government Global Health Security Strategy, 2019.
43 White House, “Advancing the Global Health Security Agenda to Achieve a World Safe and Secure from Infectious
Diseases Threats,” November 4, 2016.
44 Ronald Klain, Testimony before the Asia, Pacific and Non-Proliferation Subcommittee of the House Committee on
Foreign Affairs, “Lessons from the West African Ebola Response: How to Save Lives and Protect Our Nation During
the Novel Coronavirus Epidemic of 2020,” February 5, 2020.
Congressional Research Service

11

Ebola Outbreaks in the Democratic Republic of Congo: Emergencies or Enduring Threat?

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

Congressional Research Service
R45933 · VERSION 5 · UPDATED
12