Infected by conflict

6 November 2018

If policymakers are serious about tackling infectious diseases, they can’t afford to neglect the role of conflict as a key driver of vulnerability, Erin Sorrell and Claire Standley write.

Political instability and conflict have led to some of the worst humanitarian disasters this year. Globally, we are experiencing the highest levels of displacement in history, with an estimated 68.5 million people currently forced from their homes. There are twice as many internally displaced people (IDPs) as there are refugees in the world – an astounding 40 million and counting. Regional and local power struggles impact national governance, security and infrastructure, leading to mass displacement and inhumane living conditions

In addition, because of the destruction of physical infrastructure and loss of human resources and consumables, a lack of health services has allowed vaccine-preventable infectious diseases to re-emerge.

Conflict has long been associated with communicable diseases, which are typically contained through improved sanitation and hygiene, effective medication, and vaccination. But when violence and insecurity hinder humanitarian response mechanisms, challenges arise for both those in need and those providing services.

From 2014 to 2016, the world witnessed the Ebola virus wreaking havoc in Guinea, Sierra Leone and Liberia – three countries with already weakened health systems and populations that lacked trust in their governments due to political alienation or protracted civil war.

The Democratic Republic of Congo (DRC) is now facing similar challenges, where conflict and violence from militant groups has led to over two million IDPs, adding to the largest displaced population on the continent. At the same time, across the country, at least 13 million are in need of humanitarian assistance and protection.

DRC’s eastern province of North Kivu continues to be the hardest hit by conflict, suffering from almost 15 years of constant violence and currently hosting over one million IDPs. In July 2018, Ebola hit Mangina, a town in North Kivu. By the last week of October, the outbreak had resulted in at least 239 cases and 139 deaths. While Mangina saw a decline in cases in September, this surge in October indicates a second peak and spread to at least ten health zones in North Kivu and Ituri provinces, highlighting how the region’s history of conflict is impeding an effective response to this outbreak.

A successful response to Ebola must include the isolation of cases, effective contact tracing, and vaccinating high-risk populations, all of which involve various stakeholders and extensive coordination. During the present outbreak, the lack of access to at-risk communities, on top of targeted attacks against healthcare workers and humanitarian actors by militant groups in and around Kivu, make an already challenging outbreak response exponentially harder.

The Alliance of Democratic Forces (ADF), a Ugandan Islamic militant group with a history of violence against civilians, is just the latest actor instilling fear and prompting civilian displacement in a region which has been plagued by instability, conflict, and forced migration since the independence movements of the 1950s and 1960s.

The ADF has claimed responsibility for two recent attacks on civilians in Beni and Oicha in the Kivu province. The group’s actions have caused people to flee their homes and thwarted attempts to trace and respond to the Ebola outbreak. The World Health Organization was forced to suspend operations in Beni due to security concerns and while treatment centres remain open, vaccination campaigns have been put on hold.

The Ebola virus has an incubation period of two to 21 days. As a result, any lag in case identification and contact tracing can have a major impact on efforts to contain further transmission. But when the target population is constantly on the move, seeking safety within a conflict zone, monitoring patients and tracking contacts becomes difficult. On top of that, public resistance to vaccination campaigns is being fueled by local and provincial politicians, potentially causing some of the newly reported cases.

The danger of politicising disease outbreaks and response efforts is not unique to Ebola. A similar scenario combining political distrust and interference by local politicians led to boycotts of polio vaccination campaigns in Nigeria in 2007, allowing polio to spread beyond Nigeria’s borders.

The current situation in Kivu highlights the complexity of dealing with infectious disease outbreaks in areas affected by conflict. The international community has to develop novel solutions to navigate a delicate political situation, care for a fractured and reticent population, and ensure the safety and security of their own personnel while conducting epidemic response efforts.

These solutions must focus on empowering health and humanitarian organisations in building trust with community leaders where trust of government is lacking. Such communities have been plagued by insecurity and conflict for years; they must feel safe from attack in order to effectively participate in containment and control efforts. Without this exchange, the chance of containing this outbreak to the 10 health zones is extremely unlikely.

Weak health systems, transient and vulnerable populations, and a long-term lack of national governance are emblematic of the critical and on-going challenge of building sustainable global health security capacity. If policymakers fail to act on this issue, they will leave substantial areas of the globe at acute risk for the emergence and spread of deadly infectious diseases.

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