The world has ridden fast to rescue DRC from Ebola. But four months on, nobody can say for sure how many agencies are responding, how many people they employ, how much money has arrived, or what it bought. There are, however, coordinators galore. But the virus is still outwitting them.

Time and again, we learn that how a crisis is defined is how it evolves and resolves. So what is DRC’s 17th Ebola outbreak: a health crisis, humanitarian tragedy, or development failure? 

This matters because health labelling implies a technocratic approach to squash an un-eradicable virus until it re-emerges, while a humanitarian framing dooms the afflicted to dependency, and development tagging signifies solutions kicked into the long term.

These are, of course, generalisations. But the reality is that multiple dimensions are always present in complex socio-politico-economic-security contexts like in DRC. These defy simple prescriptions and, often, all we can do is to muddle through uncertainty and confusion. 

How well we are muddling through is the focus of the second part of my analysis of the Ebola response in DRC. 

The first part considered how slow recognition of the outbreak’s start allowed the virus to outpace control. 

A major national and international mobilisation has followed. What difference is that making?

An arguable response

As I write, the response is arguing within itself. Over the space of a few days, the DRC’s health minister announced encouraging signs since cases peaked in the week of 3-9 August, the UN coordinator warned that the peak call was premature, Africa CDC scientists said that the situation is heterogeneous with peaks and declines in different zones, and the WHO chief landed in between with cautious optimism while noting that the outbreak continues to grow. 

All are reading the same daily situation reports, and all are right within their own remits. A  government must show its strategy is working, a coordinator must keep agencies galvanised, a regional agency must be sensitive to constituency concerns, and a global agency must cheer-lead the world.

But when the drivers cannot agree on the speed and direction of their train, there is a problem beyond epidemiology. And that befuddles the public at a time when careful information is as lifesaving now as a potential vaccine may be in the future. 

However, do not be too hard. With dynamic virus spread, data interpretation debates are expected before a professional consensus emerges. However, the time and patience that takes are always short during emergencies.

Meanwhile, if it is challenging to get four lead agencies – DRC government, UN, WHO, Africa CDC – to cohere, consider the truth-determining complexity around scores of partners with fingers in the response pie. Each has constituencies to keep on side, not least for funding. 

Hence, the determination of whether the outbreak is waxing or waning is not simply about examining numbers. It can be an existential issue for some aid-fuelled agencies. For them, a longer crisis is better for balance sheets. 

Besides, how is the end of the 17th Ebola outbreak to be defined? WHO has the easy job of declaring it over when no new cases have been detected for 42 days (twice the maximum incubation period). But that is not the end of the crisis for those mourning their losses while trying to recover fractured lives and livelihoods. Even without aspiring to “build back better” through improved healthcare and surveillance for the next outbreak. 

These are some reasons why this columnist has long argued for independent mechanisms for evaluating the progression and outcomes of humanitarian and health crises. This is of utmost importance to reverse the loss of trust in aid systems.

Painful root canal data extraction

In that spirit, how do we assess Ebola response in DRC? It starts with verifying scale-up claims. Why is it so difficult to get a clear answer on who is doing what and where? The WHO-led health cluster in DRC has 119 partners: 45 international NGOs, 60 national NGOs, 5 UN agencies, 5 national authorities, 2 donors and 2 observers. But this was in June. Besides, it covered the country and is not specific to Ebola.

Meanwhile, also in June, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) listed 218 operational actors in six eastern DRC provinces, but an up-to-date breakdown is difficult. 

Many agencies discharge crucial tasks such as building and operating treatment centres (WHO, Médecins Sans Frontières, International Medical Corps, Congolese-led ALIMA), safe and dignified burials (DRC Red Cross with the International Federation of Red Cross and Red Crescent Societies), family care, child protection, water and sanitation (UNICEF), food and logistics including the UN Humanitarian Service (World Food Programme), screening along travel routes and border crossings (International Organisation for Migration). 

Several are also engaged in risk communications and community engagement, and not to be overlooked are Congolese institutions – the health ministry and its technical bodies and provincial divisions – as well as many local civil society organisations. 

If a comprehensive census of agencies is elusive, counting the numbers of people engaged in Ebola work – a proxy for response effort – is even more so. 

Some numbers can be gleaned from agency publicity. Thus, WHO has 300 experts deployed in September, Africa CDC had 84 in June, while MSF, the largest non-state agency has 1400 staff, presumably mostly nationals.

Pull out your own calculator

Putting together patchy data, I estimate that 10,000 to 15,000 people are working on Ebola, ranging from epidemiologists to doctors, nurses to laboratory technicians, and pilots to grave diggers. Not forgetting administrators, accountants, logisticians, and security personnel.

But how many are needed to cover all essential action fronts across a vast Ebola-affected zone approaching the size of France and Greece combined? There is no consolidated target, even as advocates plead for more resources. 

And while there is some modelling of outbreak size, there is no translation into the response scale-up required to achieve control. Although we have public health criteria and indicators for determining when we get there. 

Concerned outsiders must mine data from selective agency reports, publicity releases, and media interviews, and do their own calculations. We learn from WHO that 1,600 more treatment beds are needed, which, at three carers each, require 4,800 more skilled workers. Africa CDC says that it needs 450 more field staff. Meanwhile, 25 more decentralised testing facilities with trained staff are needed, doubling the current endowment.

Half the affected zones still don’t have safe burial teams. Increasing coverage with eight volunteers per Red Cross team equates to needing 1,000 more volunteers. Achieving the target of 20 contacts traced and followed up daily for 21 days requires at least 3,000 more tracers. With screening at 153 points only partly staffed, and using staffing ratios from previous outbreaks, IOM could benefit from 800 more screeners.

In addition to direct clinical responses, community risk must be tackled across the 14 million frontline population. UNICEF estimates there are three million vulnerable children and adolescents, while WFP says that 2.65 million face food insecurity.

My projections suggest an additional need for some 10,000 responders of different types i.e. a doubling of current capacity. Practically, this must be overwhelmingly sourced from among the Congolese – suitably trained and financed.

We live in a world of dashboards. Would it not be helpful if some authority maintained one to show these numbers and how they tick upwards?

Multiple plans, appeals, and a missing ledger

That brings us to financial confusion. A joint WHO – Africa CDC continental plan asks for $518 million for June to November. This covers 11 countries, not just DRC. On 4 September, the DRC government launched a revised six-month plan costing $1.3 billion.

On the humanitarian side, OCHA’s revised plan for DRC calls for $2.1 billion, of which some $300 million is Ebola-related. The Red Cross Red Crescent appeals independently, and IFRC increased its ask to CHF 65 million in August. The largest independent responder – MSF – has a private funding approach.

It requires forensic accounting skills to disentangle these plans to verify gaps and overlaps. How do these resourcing envelopes map to priority activities under, to quote Dr Tedros, “one plan, one budget, one team”? 

Africa CDC and WHO are seeking to unify financial tracking. But will that include the humanitarian track under OCHA? That such a system does not exist several months into a serious emergency does little for urgent resource mobilisation from sceptical donors who are obliged to make their own funding decisions that may not coincide with priorities.

Meanwhile, how much funding has come in? Nobody provides an accurate tally. My own rough calculation suggests that about $1.5 billion out of the ask of $3 billion has been secured. 

Terms such as “mobilised, secured, committed, allocated, pledged and disbursed” are being used interchangeably while they mean different things. That means we don’t really know what cash has actually been turned into practical goods and services delivered at the frontlines. 

Traditionally, budget execution rates tend to be low. Therefore, the current Ebola financing system is worse than broken. It has gone backwards from the previous DRC outbreak by becoming less transparent even as appeal sizes have grown. Donor aid cuts cannot be blamed for this.

This is a mess that some call a lucrative Ebola business, with the host country’s health minister reduced to asking in public where the money is and what is being done with it. Meanwhile, on the ground, problems are being caused by agencies paying different remuneration rates, while health workers have been striking because of not being paid fairly in a timely manner. 

Conversely, fraud and scams with fictitious payrolls are requiring the belated introduction of biometric registration, distracting effort from the primary response. 

Two systems, two constitutions

The financing muddle is reflective of a structural problem. Eastern DRC is served by two international machines with separate legal foundations that pull in opposite directions.

Global health co-operation rests on respecting national sovereignty under the International Health Regulations (IHR). States report outbreaks, and responses are state-led. That is why Dr Tedros says WHO works under the government’s leadership, and why Africa CDC frames its role as African solutions for African problems.

The global humanitarian system rests on UN General Assembly resolution 46/182 of 1991 – a political settlement based on four principles, one of which is independence. Thus, humanitarians have the dispensation to negotiate with whoever controls the ground, including armed groups the state is fighting.

Eastern DRC is a patchwork of territories controlled by different groups and varying virus epidemiologies. It is difficult to honour differing international health and humanitarian approaches within the same broad space.

The tension is reflected in top-level pronouncements. In briefing member states, the UN Emergency Relief Coordinator committed to a combined response led by the UN Humanitarian Coordinator. In the same session, the WHO Director-General said they were working under the government’s leadership. Each is correct within their own constitutions. But the two statements are not fully compatible despite affable expressions of partnership.

This is not legalistic nitpicking but has life-and-death implications. 

For example, safe and dignified burials are an infection control act, which is why the DRC health minister complained that some partners (humanitarian system) undertaking burials were not funding (health system) the gravediggers or providing body bags. 

Feeding isolating households is WFP’s humanitarian mandate, yet you cannot quarantine (health mandate) a breadwinner without it. 

Access negotiation with armed groups is an ICRC and OCHA competence. Essential services – measles, malaria, maternal care – fall between both systems, and neither appeal owns them. It is possible that when final audits are done, as many or more people may have died from non-Ebola causes as from Ebola itself.

An epidemic of coordinators

Meanwhile, as the Bundibugyo ebolavirus doubled every two to three weeks, so did the coordinators.

In May there was a DRC health minister and a national institute. By June, there was an Emergency Operations Centre in Kinshasa, and seven provincial health teams with their coordinators. 

In June, the UN Resident and Humanitarian Coordinator, WHO Representative and an incident manager were activated, as well as WHO’s regional directorate in Brazzaville, and of course, the WHO Emergencies Team in Geneva and the Pandemic Hub in Berlin.

By July, a UN/WHO Senior Ebola Coordinator had been installed at Bunia and a WHO/Africa CDC Continental Incident Management Support Team in Kampala. Also, the Geneva-based UN Inter-Agency Standing Committee was activated with a system-wide scale-up, which is a mechanism for coordinating the coordination.

August was less frantic on the coordination front, as it is the traditional northern hemisphere  holiday season. The virus, of course, took no vacation.

By September, the Africa CDC Emergency Consultative Group was reviewing the work of others, and the African Union Summit convened in Bujumbura.

In approximate summation, we have around 16 strategic coordination initiatives, each with their own coordinators. Plus coordinators of eight operational clusters and some 11 pillars. The plethora could not avoid being highly productive, with at least three plans and five appeals that now require further coordination to deconflict, update, and track.

Amazingly, there remains scope for yet more coordinators. With insufficient burial teams, perhaps we need a Chief Burials Coordinator, and to accelerate contact tracing, a Chief Contact Tracing Coordinator. Looking ahead, we will need a Chief Vaccination Coordinator when the scramble starts to access a successful but inevitably scarce vaccine.

To be fair, all the coordination functions have followed recommendations made after past Ebola and other emergency crises. But the virus attends no coordination meetings.

Muddling through

So, back to my original question. What is DRC’s 17th Ebola outbreak? On four months of evidence, it is all things. The virus is being confronted by a health system that treats it technically, a humanitarian system that treats it as a caseload, and a development discourse that promises to address underlying causes once both go home. Each answers honestly within its own frame. But none of them own the space between the frames, and that is where the virus proliferates.

Meanwhile, muddling through this crisis is not a disgrace. But there is a difference between muddling honestly and unaccountably. Honest muddling publishes its numbers, admits what it does not know or can’t do, and submits to outside scrutiny. What we have instead is a response that cannot say how many agencies are working, how many people they employ, how many more they need, and what it has received or spent.

This is not a problem of field workers labouring under risky circumstances with several losing their lives. It is the responsibility of chiefs, communicators, and coordinators in Geneva, Addis, and Kinshasa to sort out.

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: DRC Health Ministry, DRC Health Ministry, Africa CDC.