The World Health Organization (WHO) declared the Ebola outbreak currently ongoing in the Democratic Republic of Congo (DRC) a “public health emergency of international concern” on Wednesday, urging more funding to stop the virus but warning against “travel restrictions” to prevent its spread.

The Congolese government declared an Ebola outbreak in August 2018, which has now affected 2,522 people and killed 1,698, according to the latest WHO estimates. Most of these cases were in North Kivu and Ituri provinces in the northeast, which border Uganda and Rwanda, respectively. Uganda has documented three cases of Ebola, all family members who traveled to DRC for the funeral of a relative who died of Ebola. Using containment practices and an experimental vaccine, Uganda has successfully limited exposure and infection in its territory despite a growing surge of refugees fleeing militia violence in Ituri.

Rwanda has not documented any cases of Ebola tied to the current outbreak, but the WHO declared an international emergency following the confirmation of a case of Ebola virus disease in Goma, the capital of North Kivu – a city of 1 million people that sits on the border with Rwanda and connects the province to the rest of the continental region. Officials in Goma insisted that they had prepared for months for the inevitable case to arrive there, but WHO Director-General Dr. Tedros Adhanom Ghebreyesus called the case a potential “game-changer” that should be interpreted as a global cause for concern.

On Wednesday, Ghebreyesus emphasized the gravity of the outbreak in declaring it a Public Health Emergency of International Concern (PHEIC).

“It is time for the world to take notice and redouble our efforts. We need to work together in solidarity with the DRC to end this outbreak and build a better health system,” he said, according to a press statement published by the WHO. “Extraordinary work has been done for almost a year under the most difficult circumstances. We all owe it to these responders — coming from not just WHO but also government, partners and communities — to shoulder more of the burden.”

The decision to declare the health emergency followed a meeting of the WHO’s emergency committee handling the Ebola outbreak, which determined that the outbreak is worsening and the geographical area at risk is growing. The notes published after the meeting listed particular risk factors that were making the situation in DRC more dangerous, saying:

Factors affecting the outbreak include population movement in highly densely populated areas; weak infection and prevention control practices in many health facilities; complex political environment; continued reluctance in the community; and the ongoing unstable security situation, which led to the recent murders of two community health workers.

The notes did list some positive developments in the field. The experimental vaccine developed following the Ebola outbreak originating in Guinea, western Africa, in 2014 appears to be working, and using it on health workers and those at highest risk of exposure “is proving efficient and successful.” Contact tracing – in which public health authorities track down all individuals known to have come into contact with an Ebola patient and quarantine and vaccinate them – has also contained the spread of the virus.

The WHO emergency committee expressed concern that the supply of Ebola vaccines was limited given its effectiveness so far. It also enthusiastically discouraged increased border controls at the crossings between the affected states of DRC and Uganda and Rwanda. The WHO identified the free flow of people through Goma, the Rwandan border city, as especially important, even while noting that 5,000 people cross into Rwanda there daily.

“Closing this border would strongly affect the population of Goma and have adverse implications for the response,” the emergency committee notes read.

In its declaration of an international health emergency, the WHO insisted that it would be “essential” for DRC “to avoid the punitive economic consequences of travel and trade restrictions on affected communities.”

The chairman of the committee on Ebola, Professor Robert Steffen, said it was “crucial” to not use the Ebola outbreak, and the new WHO designation, as an “excuse to impose trade or travel restrictions.”

The Congolese newspaper Actualité found some “surprise” and concern that the WHO would declare an international health emergency now, nearly a year since the outbreak began. Some expressed concern that the declaration would trigger an influx of international aid workers, who locals and regional militias severely distrust, many believing them to be deliberately infecting people with Ebola to commit genocide against Africans.

“There is no reason for the WHO decision, since the community [of Ebola victims] has begun to unite and commit and the number of cases of Ebola is diminishing,” the president of the North Kivu Civil Society organization, Edgar Mateso, told Actualité. While not opposing the designation, he hoped the WHO’s call for more global involvement would “not demoralize the community and bring back the old situation of mistrust.”

“There are mistakes that must be addressed first internally before seeking the support of the international community,” another civil society representative, Jules Vahikehya of Beni, North Kivu, told the newspaper. “For example, the problem of managing the frustration of local health organization staffers who are neglected while they are the ones who control the communities they manage on a daily basis.”

Vahikehya also cited “disparities between some of the practices of the response teams and the habits and customs of the local communities” as causing particular discord.

North Kivu and Ituri are essentially active war zones, home to dozens of militias fighting for control of the plentiful mineral resources in the area. While they are not officially at war, the militias routinely engage each other violently and instances of murder and rape against civilians are high, triggering a growing refugee flow out of Ituri into Uganda through Lake Albert, north of the center of the Ebola outbreak. The militias distrust Western humanitarian workers as much as many locals and have attacked Ebola treatment centers and killed health workers. Locals have helped suspected Ebola patients flee medical care, believing they are saving them from murder at the hands of the health workers.

Not all in the region expressed concern the emergency designation would hinder containment of the virus. Many, on the contrary, hoped renewed global attention would lead to authorities having more resources to fight Ebola’s spread.

“The WHO statement is a good thing because it is an admission of failure that can reframe the actions of the response teams, avoid the mistakes of the past, and improve the performance of these same teams,” Muhindo Mughanda, an international relations professor in Butembo, North Kivu, told Actualité.

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