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GENEVA — An Ebola epidemic that experts are calling “exceptionally dangerous” is unfolding in the Democratic Republic of Congo.

So far, there have been more than 420 cases and 240 deaths, which makes it the largest outbreak of Ebola since the 2014-2016 West Africa outbreak that killed 11,000. It’s also the second-largest Ebola outbreak on record.

Humans have tangled with the Ebola virus for centuries with deadly results. But until five months ago, Ebola had never emerged in an active war zone.

On August 1, the World Health Organization declared an Ebola outbreak in the Democratic Republic of the Congo. The virus had started spreading in cities in North Kivu, an unstable province in the Central African country, where fighting among multiple rebel and militia groups has repeatedly interrupted the painstaking work of health workers who came to respond to the outbreak.

Even though Ebola responders have never had so many tools at their disposal to fight the virus — experimental vaccines and treatments that have shown promise — the incidence of the disease has more than doubled since September. Even worse, many of the newly diagnosed cases cannot be linked to other known cases. That means there are still people spreading the disease whom health officials have not yet identified.

Due to the ongoing conflict in the region, the US government has decided it’s too dangerous to allow its top Ebola experts to work at the outbreak’s epicenter. The US has maintained this stance despite outcry from public health officials who say the US isn’t doing enough to help.

To unpack how the outbreak got so bad, and what the WHO needs right now, I sat down with Peter Salama, the head of the new Health Emergencies Program at the WHO. His team was created in 2016 as a direct response to the WHO’s fumbling of the West Africa Ebola outbreak. This year alone, he’s helped the organization respond to 50 health emergencies in 47 countries.

But the Ebola outbreak in DRC is something different, Salama said. Sitting in his office in Geneva, in front of a map of DRC — which he keeps in front of him “to remind me I need to keep focused on this on a minute basis” — he walked me through the extraordinary complexity of trying to quash an Ebola outbreak in a war zone and why the WHO could use the world’s best Ebola minds right now. Our conversation has been edited for length and clarity.

The Ebola response could use US experts

Julia Belluz

The US pulled its Centers of Disease Control and Prevention workers out of Beni, the outbreak epicenter. They decided it was too dangerous for America’s best Ebola experts to be there — and it sounds like they are not coming back anytime soon. Could the US be doing more? Does the WHO need those experts now?

Peter Salama

As we go more and more into the outbreak, it taxes all of our capacities, so we have to give staff an opportunity to take a short break at some point and refresh. We have to look at rotating staff — because people are working 20 hours a day here in Geneva and [in DRC]. We don’t want people so exhausted they burn out. So we need people. We have people coming in and for some countries, not just the US, they do have security concerns.

Julia Belluz

But I understand Canada, the UK, even nonprofits with US personnel, are sending people, and you have hundreds of WHO officials deployed. Is the US government an outlier?

Peter Salama

The US government is the main country that has had constraints. But others have asked a lot of questions, need reassurance, and are limited in their responders.

Julia Belluz

What kind of people do you need at this point?

Peter Salama

Some of the key areas where it’s not easy to find people are the most senior viral hemorrhagic epidemiologists, the people who are specialized in viral hemorrhagic fevers. [We need] medical logisticians but not just general logisticians — it’s people who know how to set up the cold chain at negative 60 to 80 degrees Celsius [to keep the vaccine cold] and ensure its integrity right through to Beni. So it’s not just the average humanitarian worker we need.

Julia Belluz

What about money? The health emergency fund at WHO has never gotten the $100 million from donors, including the US, it requested. How do you operate in this constant state of underfunding?

Peter Salama

We asked for $100 million initial capital when we started three years ago. We never got to $100 million. But because it’s constantly used and constantly replenished, it’s not the end of the world. In the last two years, we’ve used around $60 million to respond to 70 events. This year, we’ve received almost $40 million with additional pledges. So it’s been well supported.

I’d like to get to some more formal system in place whereby, for example, the G20 country says we guarantee this fund, because it is so important for global security, will never fall below $50 million. That’s where I’d like to get to.

What makes this outbreak different from all the rest

Julia Belluz

DRC had seen nine Ebola outbreaks since the virus was discovered in 1976. What makes this 10th outbreak different?

Peter Salama

It’s an outbreak I describe as a perfect storm — a combination of this deadly disease in one of the most difficult, protracted crises we have around the world.

In North Kivu, there’s a long civil conflict, the proximity to numerous international borders — Uganda, Rwanda, and South Sudan — and a population that’s constantly on the move with 1 million displaced people out of the [6] million residents. It’s also a population that’s highly traumatized, especially in and around Beni [the outbreak epicenter]. People have been subject to an enormous number of severe attacks consistently since 2014 but dating back to even the Rwandan genocide [in 1994].

That population is so traumatized that everything for them is viewed through the lens of distrust of authority, physical insecurity, and the inability of the world to protect them. These viruses manage to exploit social vulnerabilities and fault lines. That’s what we’re seeing in this Ebola outbreak starkly.

Julia Belluz

One reason that’s been cited for the ongoing Ebola spread is the mistrust brought on by this violence and instability in North Kivu — that it contributes to the spread of Ebola when people won’t go to treatment centers or work with responders. What is the WHO doing to overcome that?

Peter Salama

The most important thing we can do is understand what community perceptions and behaviors are related to the outbreak. We have sociologists and anthropologists — both local and international — working closely with WHO. So we ask them questions we want to know.

For example, when we first went into North Kivu, we wanted to understand more about the political economy. It’s a mineral-rich part of DRC: 60 percent of the world’s cobalt, the critical ingredient for electric car batteries. The mineral wealth has a lot to do with why it’s so unstable. The anthropologists gave us an initial briefing, to help frame the response from WHO.

Since then, we’ve asked them more mundane but critical questions — about key burial practices, the ongoing perception of the Ebola response. Some of the feedback we got was fascinating. Everyone assumed, this being the 10th outbreak of Ebola in DRC, that there would be a high knowledge and awareness about Ebola. But the level of awareness was abysmal, including among health care workers.

Julia Belluz

There was an interesting Lancet study a little while back showing that people in DRC trust the Ebola vaccine but would not send their family to treatment centers. Is that still the case?

“We have 300 staff, and every night I lose sleep thinking about the fact they are in the line of fire”

Peter Salama

The awareness and knowledge [about Ebola treatment is changing]. There’s a much more sophisticated understanding of how this Ebola response fits in with populations’ concerns around protection and security. The constant refrain has been, “Look, we think the Ebola response is really important and support it as a community, but we want you to give at least equal if not more attention to our physical protection and security. We don’t want to survive Ebola to die from physical violence.” The women’s groups, the youth groups — they are very articulate about that. They are sending a message to the international community.

Julia Belluz

That seems like a much bigger challenge than your unit or the WHO can address.

Peter Salama

We have 300 staff, and every night I lose sleep thinking about the fact they are in the line of fire. Two weekends ago, a there was a huge incident in Beni. There were bullet holes through several of our staff’s walls. They were sending us pictures. We temporarily moved staff who were feeling the effects of being in the line of fire. An ordnance landed on their guesthouse. It didn’t explode, but if it did, they probably would have all died.

Julia Belluz

This violence and insecurity — would you still say that’s the major impediment to getting this outbreak under control?

Peter Salama

The key challenge here has always been this conflation of really violent security incidences and constant attacks. Beni, the epicenter, has had more than 20 serious attacks since the outbreak was declared on August 1, so it’s constant. On the other hand, we know that it is a vicious cycle with the community mistrust. So they go together.

Julia Belluz

But people are accepting the vaccine?

Peter Salama

When you look at the ring vaccination, you find a confirmed case and the contacts around the case and vaccinate them. We have done maybe 240 rings around confirmed cases. With over 90 percent of those rings, we are achieving between 95 and 100 percent of coverage. So there’s overwhelming acceptance.

But what comes up more so is people questioning why the vaccine is not being used on a much wider scale — so they are not understanding this ring vaccination strategy.

It’s not an easy question to answer. We have to explain that it’s a specific strategy that worked for the eradication of a disease [smallpox], and it’s worked in previous Ebola responses. Also, we don’t have a licensed product and we have a limited quantity, so we have to use a vaccination strategy that conserves the vaccine.

We don’t vaccinate the majority of our staff. They aren’t at imminent risk if they don’t participate in burial work or clinical care. So I haven’t been vaccinated because I don’t do direct clinical care.

The promise of new Ebola drugs and vaccines

Julia Belluz

WHO is now giving out the vaccine preventively in Uganda — but given all that you’ve described, it’s surprising it hasn’t already spread across borders.

Peter Salama

There’s been a lot of firsts in this outbreak response, things that have never been done before. One of them is the use of this experimental Ebola vaccine at this scale. We have more than 37, 000 people vaccinated.

We know vaccination is having an important impact. In [outbreaks], we talk about something called the reproductive number [or the number of people one sick person can infect]. Even for Beni, the reproductive number is 1. When Ebola is really hot, it can get up to 2 to 4.

Testing the limits of our Ebola knowledge

Julia Belluz

A lot of observers are talking about this Ebola outbreak as the major test for your health emergencies unit. Has it caused you to rethink how you’re working or structured?

Peter Salama

This is probably the biggest test of any public health institution or knowledge in terms of an Ebola outbreak. This is the most difficult context we’ve seen, and we have people who have been involved in Ebola since the ’80s. So it’s a test for everyone, including WHO.

We are very confident we have the right people and systems. The issue really is the context — an outbreak that’s this volatile requires us to revise strategies regularly. We are keeping open and making sure we listen to experts from various advisory groups.

We are using that [advice] to continue to challenge any assumptions and revise our strategies. There won’t be one point in time when we say, “Let’s change everything and start again.”

We know these strategies — traditional public health measures and breakthroughs like vaccines and therapeutics — will help us stop the outbreak. But the minimum requirement from this point on, according to the epidemic curve, is that it will take six months minimum [to stop the outbreak].

The tension elections in DRC bring

Julia Belluz

This month, there are elections coming up in DRC. This is a moment of real tension given the fraught political environment. Is there a concern that the elections could hamper the response, and what is WHO doing about it?

Peter Salama

The elections are scheduled for December 23, and we are very vigilant in trying to ensure that Ebola is not used as a political issue in the context of the elections.

It’s difficult — we have to engage all the community leaders, whether it’s the governor of Kivu, the mayor of Beni, opposition parties — to ensure everybody understands this is off the table. We don’t want to use Ebola for that purpose. So far, they’ve been receptive to that. But it’s a constant awareness-raising and education process. It’s important to have the community behind us on this.

Julia Belluz

I remember learning early on as a health reporter that Ebola was a virus no one thought would go epidemic because it was so hard to transmit — people got so sick and died so fast. But that was knowledge from rural outbreaks, and since it’s been showing up in urban areas, we’ve seen Ebola’s true, deadly potential. What’s the big takeaway here from an outbreak response point of view?

Peter Salama

In the last two years since I have been here, 80 percent of our major outbreaks have been in conflict-affected areas. This is the issue of the future.

The issue of urban outbreaks of high-threat pathogens is really an issue of our generation. I don’t think we’ve fully grappled with that. Now with yellow fever, plague, with Ebola, we are starting to see these patterns. All bets are off [in terms of] thinking we know about the transmission of diseases because of what happened in rural outbreaks in the past. It’s completely different now.

Clarification, December 2: We updated the headline to more accurately reflect the current status of the outbreak.