The lethality of the Ebola outbreak in the Democratic Republic of Congo (DRC) is not just in its genome. Neither is it entirely explained by the country’s internal instability and defunded, broken health infrastructure. Have we allowed the virus to outsmart us by overlooking past lessons?

The signs around the DRC’s 17th Ebola outbreak indicate that it has reached the dimensions of a Shakespearean tragedy. If the Global Preparedness Monitoring Board, set up after the great West African epidemic of 2014-16, sends the Bard on a review mission, his back –to –office report may well conclude, as in Julius Caesar: “The fault, dear [Tedros], is not in our stars/ But in ourselves, that we are underlings.”

The limits to blaming

In a nutshell, that is what vexes this columnist: How much of Ebola getting out of control is because of DRC’s “stars” or self –induced troubles from its chaotic scramble for gold and guns with associated population movements, violence and broken health infrastructure?

And how much is it the failure of factors such as our global health structures, or the country’s dependence on donations, with decisions and directions from Geneva and Addis Ababa?

I interrogated publicly available data and found that a systematic analysis of the relative contributions of different factors is impossible. 

A study of the 2018–19 North Kivu epidemic indicated significant conflict–related disruptions of public health interventions. These are suggestive but largely modelling –based qualitative judgments. 

Meanwhile, other researchers found no significant short –term correlation between pathogen reproduction numbers and conflict counts, and only a modest correlation across the whole outbreak.

Every rookie epidemiologist knows that correlation does not prove causation. Meanwhile, the closest estimate of the fraction of an outbreak attributable to conflict is 12% for DRC cholera outbreaks. This is not comparable to Ebola but a smaller proportion than most commentators guess.

Frustrated by my ambiguous delving into a region the difficulties of which I know well from previous terrible times, I turned to the latest large language models set to their “highest level of effort”. Whatever the fear of AI wiping out humanity, it still could not give me a hallucination–free answer.  

There is inconclusive evidence to blame conflict and instability for the majority of the Ebola response underperformance in DRC. 

There is a stronger case for aid–defunded health systems bearing some responsibility, but combining these constraints is still not enough to explain a massive collective failure. Besides, other experiences show that we have done better in other places facing similar or worse challenges.

Flashing signals

Understanding why DRC’s Ebola outbreak continues to outpace control requires reverting to fundamentals, starting with the earliest signals.

These emanated when four health workers died over four days in April in Mongbwalu, a gold–rush town in Ituri. A short serial interval cluster is the classic sentinel signal for a viral haemorrhagic fever. This is not to be confused with malaria, typhoid and yellow fever  – all endemic in Ituri – but which predominantly kill patients and not their healthcare attendants. A cluster of staff deaths discriminates in a way that a cluster of community deaths does not, even if other common conditions are early mimics of Ebola.

Did complacent confidence in DRC’s extensive Ebola experience mean missing the oldest signal in filovirus epidemiology – the tell at outbreaks in Yambuku (1976), Kikwit (1995), and Gulu (2000)? 

When the alert reached Geneva on 5 May 2026, it did not immediately disturb anyone’s sleep. Why not? Reading signals is as much art as science, involving intuition honed by experience and not just following protocols. Did weaknesses in the emergency function in WHO Geneva and its regional and country offices in Brazzaville and Kinshasa, and the Pandemic and Epidemic Intelligence Hub in Berlin, forget this?

Or was this a case of crossed wires over too many switchboards? There is indication for this, with one analysis suggesting that the problem was not in signal availability  – including from ProMED, HealthMap and WHO’s own EIOS feeds – but in integrating concurrent multi–source signals into a unified decision product at the required speed.

 This enjoins humble circumspection before blaming donor aid cuts that halved global health assistance since 2021 and took a quarter off sub-Saharan Africa’s share in one year. 

Largest late detection

Although there is evidence that background disease surveillance was politically easier to abandon, the eastern DRC system limped along, to the credit of its underpaid and violence–threatened staff. They did produce the earliest signals missed on distant radars.

 It was not till 15 May that DRC declared the outbreak, and Africa Centres for Disease Control and Prevention followed three days later. With 246 suspected cases and 80 deaths, that was five times the size of the West African epidemic at its March 2014 announcement. 

Meanwhile, phylodynamic reconstruction suggests sustained transmission beginning around 22 February – and perhaps earlier still. This makes the current outbreak the largest late detection in the history of Ebola. It appears that the lesson on tardiness learnt from West Africa was unlearned.

With this outbreak passing 1,000 confirmed cases within 40 days of response activation, compared to the 2018 DRC outbreak taking 235 days to reach this milestone, fatal momentum was inevitable. 

Part of the confirmation delay was indeed due to reagents in Bunia’s laboratory being geared for the Ebola Zaire species. This was the Bundibugyo species produced false initial reassurance while infections multiplied undetected. Bundibugyo was first identified in 2007, but 19 years and three outbreaks later, there are no bedside tests, vaccines, or therapeutics because it historically killed the fewest people. 

And so it attracted the least funding, the unlearnt lesson being that closing preparedness gaps requires proactive investment in medical countermeasures because markets will not do that. This is further evident in current trials of oral prophylaxis restricted to those over the age of 12, pending a paediatric formulation, although children under five have twice the mortality of adults. 

Nevertheless, one lesson fully learnt was in Dr Tedros’s speedy declaration of a Public Health Emergency of International Concern (PHEIC) on 17 May, without awaiting his full advisory committee to opine. What is the subsequent impact?

Dashboard indications

Data through 10 September show 7,022 confirmed cases, 3,398 deaths, 823 in isolation, and 1,647 recoveries across seven provinces. The crude case fatality ratio (CFR) of 48.4%, up from 39% in July and 29% in June, does not signify a virus growing crueller. Sequencing of 626 genomes found increasing diversity but no fitness–altering mutations (as yet) from a lineage already distinct when it emerged.

The CFR is a proxy for system functioning and indicates how responses must be tailored to correct gaps. For example, North Kivu’s reported fatality ratio of around 66% contrasts with Ituri’s 45%, reflecting, in part, that Ituri finds the living and North Kivu mostly finds the dead.

A fixation with counting the dead does not help the living. Illuminating here are the US CDC’s five critical public health response indicators: case detection alerts, contact tracing, laboratory testing, isolation of infected persons, and safe and dignified burials. Their set targets are modelled toward progressive outbreak elimination. 

The latest operational scorecard is unsparing. Against a target of 20 contacts to be identified per case, the response managed 10.6. Against a target that 90%of new cases come from known contacts, the last available figure was 15-20%. Testing reached 72% of validated alerts against a 90% target. 

Fewer than half of affected health zones have a safe burial team. Contact follow-up has, however, crept to 85 % and is approaching the 95% needed.

In short, there are glimmers of progress with the outbreak’s uncontrolled expansion phase moderating towards end August to, perhaps, start plateauing. But it is still expanding geographically nearly seven months from its probable initial origins.

Seeking hope in effort

None of this is a failure of effort. WHO has shipped over 330 tonnes of supplies, deployed more than 300 experts, and expanded laboratory capacity from one national reference facility to a network of 24. 

Nearly 1,400 treatment beds stand across 59 centres. I can vouch, as a former WHO director for emergency response, that this is among the fastest of WHO scale–ups, and certainly better than the embarrassing WHO show during the early days of the West African epidemic. Tedros’s own trips to the region were welcome morale boosters.

However hard the response runs now, it cannot make up for early shortcomings that saw a headquarters – demoralised by its own downsizing from aid cuts – sending disordered messages across rigid hierarchies and processes (a longstanding WHO problem), and despatching inexperienced initial staff to the field. 

An egregious illustration of this is that although a public health emergency of international concern (PHEIC) declaration requires operational delineation to be done, this does not appear to have happened between the Geneva–based emergencies programme and the African regional office in Brazzaville. However, commendably, the Kinshasa country office, which is perhaps its most emergency–burdened, was quickly bolstered. 

Meanwhile, the Bundibugyo virus made good use of unresolved answers to the oldest question in crisis health management. This is about whether emergency responses to existential threats of the nature of Ebola are best served by top-down command, and control arrangements or ground-level distribute–and–share partnerships. 

The self-evident metric for assessing the effectiveness of organisational approaches is achieving disease control quickly to minimise avoidable mortality and morbidity.

The conundrum of models

This was not an issue in WHO’s earliest years because of prevailing low levels of global development. But it increasingly torments the organization now. It is odd that an effective solution has eluded all Directors–General, largely because the evidence-proud but constitutionally constrained WHO has never evaluated different organisational models. 

This is for political reasons, which Africa brings to the fore because of the continent’s strident sovereignty movement demanding African solutions for African problems. 

That legitimate aspiration is somewhat hollowed by insufficient investment in necessary continental capacities. In any case, these take time to mature, and the popular delusion that great crises are opportunities to change and grow is patently dangerous when massive numbers of lives are at stake.

Nevertheless, who can dispute the excellent ideal of “One WHO” with its notion of one results framework, one budget, one harmonised workforce, and common administrative processes? 

The reality is more human, with reviews showing that where this works, it is because of cordial, cooperative personalities that override underlying mistrust and misaligned incentives and cultures. In other words, going beyond the bureaucratic matrix division of duties and responsibilities such as the post 2016 Emergency Response Framework.

The key learning is that no organisation can sustain itself solely on the basis of personalities because these come and go. That applies particularly to the emergencies function where collective accountability under the “One WHO” approach could mean that there is none. That is the worry in the current case.

Meanwhile, my rough-and-ready review produces some organisational insights. Principally from three inquiries: WHO’s own 2015 Ebola Interim Assessment Panel, the UN’s 2016 High–level Panel, and the 2015 Harvard–LSHTM Independent Panel. 

They located West African response failures in the space between different WHO levels rather than exclusively in any one of them. A synthesis review concluded that post-2014 reforms did not achieve the necessary evolution in WHO and global health structure and governance that the West Africa debacle called for.

I think that is too harsh, as many capacity improvements have come about since then. But, as we shall see in the forthcoming Part II of this review, those may be drowning under the weight of complexities that the reforms have also introduced.

Regardless of these debates, current Ebola response directors would do well to consult previous learnings. WHO is no exception to the general lack of institutional memory among international bodies or free from the attitude to which every high–flier succumbs: to drive on regardless of the view in the rear-view mirror. And so, cycles of errors and oversights can repeat.

Legacies and inheritances

This should concern those seeking to be the next Director General. In less than a year, one of them inherits an outbreak that will, at best, have slowed down. Even that containment cannot be taken for granted as the virus appears to be getting closer to densely populated Kinshasa. 

Although Uganda – with relatively good health systems  – has succeeded in stemming domestic spread from imported cases and Rwanda remains firmly vigilant, fragile Central African Republic and South Sudan are most vulnerable as DRC cases creep closer to their borders. The next DG could, therefore, be faced not only with an urbanised DRC outbreak but a regional epidemic.

Reason enough for the current DG, four months into the ongoing response, to commission an independent real–time evaluation to suggest immediate improvements and enhancements.

Objective real-time scrutiny is an established good practice in major humanitarian operations. WHO already has its Intra –Action Review methodology, part of the IHR Monitoring and Evaluation Framework, developed and used during Covid.

This column has focused on WHO but the unfolding Ebola story is bigger than one agency. And so, a follow–on column will examine the wider regional and international response, including Africa CDC, the UN, operational partners and emerging issues of financing and co–ordination. 

Meanwhile, our global health leaders gather in New York on 25 September for the second High-Level Meeting on pandemic preparedness, under the banner of equity and solidarity. Shakespeare offers them advice via The Tragedy of King Lear: 

Poor naked wretches, wheresoe’er you are,
That bide the pelting of this pitiless storm…
O, I have ta’en
Too little care of this! Take physic, pomp;
Expose thyself to feel what wretches feel,
That thou mayst shake the superflux to them,
And show the heavens more just.

Mukesh Kapila is professor emeritus of global health and humanitarian affairs at the University of Manchester, and a board member of Health Policy Watch. Vital Signs in Global Health is a regular column, and the opinions expressed are solely those of the author. 

 

 

 

Image Credits: Anicet Kimonyo, X/Tedros Adhanom Ghebreyesus, X/Tedros Adhanom Ghebreyesus, DRC Department of Health.