The government of Uganda announced Monday it has begun trial use for an experimental Ebola vaccine by Johnson & Johnson amid the second-worst Ebola outbreak on record. Uganda accepted the vaccine after the Democratic Republic of Congo (DRC)’s former health minister resigned over alleged pressure to introduce it into that country’s population.

The Ituri and North Kivu provinces of DRC are the epicenter of the current outbreak, which officially began a year ago. Both provinces border Uganda and the Ugandan government has documented three Ebola deaths on its soil, all members of the same family who crossed into DRC for the funeral of a relative stricken by the virus. North Kivu also borders Rwanda, where mass preparations to limit viral exposure have been underway for months.

Agence France-Presse (AFP) reported Tuesday that Ugandan authorities have begun administering the Johnson & Johnson vaccine to up to 800 health workers in the country, as well as others with high potential to be exposed to the virus, such as burial workers, near the DRC border. The trial will be the largest of an Ebola vaccine to date and is expected to last two years.

The world’s biggest pharmaceutical companies began developing vaccines for Ebola amid the outbreak that began in 2014 in Guinea, currently the largest and deadliest on record. That outbreak ended in 2016 after having killed thousands in Liberia and Sierra Leone as well as the country where the first patient contracted the virus. During that time, Merck began testing its vaccine, which comes in one dose and is believed to require ten days to take effect. As it was tested on the ground before the current outbreak, Congolese authorities allowed health workers to begin disseminating it within the DRC. Scientists have found that it works with 97 percent effectiveness, believed to be a major factor in keeping the spread of the virus at a minimum during an unprecedented outbreak targeting urban conflict zones.

In contrast to the Merck vaccine, the Johnson & Johnson vaccine must be administered in two doses two months apart. Some believe that the latter vaccine will offer longer-lasting resistance to the virus.

A third pharmaceutical corporation, GlaxoSmithKline, was working on two Ebola vaccines but announced this week it would cease its research and hand its work over to the Sabin Vaccine Institute in Washington, DC, for further research.

“While Ebola is a deadly and contagious disease, it is also still relatively rare, making the potential market for a vaccine sporadic and very likely unprofitable,” Reuters noted. “This poses a dilemma for drug companies: With no real prospect of a financial return, can they justify the investment in expensive development and trials?”

Two weeks ago, before Uganda accepted the Johnson & Johnson vaccine, a Bloomberg profile of the Ebola vaccine revealed that the company had made as many as 1.5 million Ebola vaccine doses, none of which DRC had accepted. The company has between five and ten years before the vaccines expire, but Merck, whose vaccine is actively in use, is not limiting its production of it and insisted “there is no crisis” in vaccine quantity at the moment. Merck claims it will give DRC 900,000 in the next six to 18 months, Bloomberg said. Another 245,000 are already in use.

Congolese officials are nonetheless facing extreme pressure from the World Health Organization (WHO) and Doctors Without Borders to use the Johnson & Johnson vaccine. The latter organization claimed that supplies of the Merck vaccine are running low, contradicting the corporation this month. WHO officials insist that all possible methods to contain the virus are necessary, particularly given the documentation of four cases in Goma, a border city of 1 million in North Kivu connecting the region to Rwanda.

Officials in DRC have rejected the Johnson & Johnson vaccine because they face extreme skepticism from locals in Ituri and North Kivu, particularly in the hard-hit remote areas, and fear that introducing a new vaccine – one that requires two doses – will confuse the population and lead to violence. Many in DRC, and Africa generally, do not believe that Ebola is a naturally occurring virus. Many believe that Western aid workers deliberately inject people with Ebola to keep African populations low. As a result, the many warring militias of North Kivu have attacked Ebola treatment centers and killed doctors and health workers, believing to be protecting the population.

Former DRC Health Minister Oly Ilunga accused international aid officials of ignoring the “trust problems” that could arise from abruptly introducing a new vaccine in affected areas. He resisted accepting the Johnson & Johnson vaccine until DRC President Felix Tshisekedi removed him from the government Ebola response, replacing his authority with a task force run by Jean-Jacques Muyembe Tamfum, director of the National Institute for Biomedical Research in Kinshasa. Ilunga resigned in disgust, noting that a health minister with no control of the Ebola response in DRC effectively had no power.

In his resignation letter, he referred to advocates of the Johnson & Johnson vaccine as having “an obvious lack of ethics.

“[It is] fanciful to think that the new vaccine proposed by actors who have shown an obvious lack of ethics by voluntarily hiding important information from medical authorities, could have a significant impact on the control of the current outbreak,” the former minister’s resignation letter read.

Prior to his resignation, Ilunga said those advocating for the second vaccine had “no respect for ethics” and were willing to “create new communications problems and trust problems with the community.”

Unfortunately for Johnson & Johnson, Muyembe has followed Ilunga’s path. Introducing a second vaccine “is not our priority,” Muyembe said in an interview Tuesday. He insisted that introducing a second vaccine was not a logistical problem, and stated that he had more research data on the Johnson & Johnson vaccine than the Merck variety, but a “communication” problem still existed with the affected communities. “If the population accepts, there is no problem,” he noted.

“As long as we do not have this community commitment, it is unlikely that we will be able to successfully extinguish this epidemic,” Muyembe noted.

Militias in North Kivu have attacked and burned down Ebola treatment centers; families have snuck into centers to steal away confirmed Ebola patients and “save” them from being killed by aid workers. The most high-profile victim of this violence was killed in April: WHO epidemiologist Dr. Richard Valery Mouzoko Kiboung.

In Butembo, North Kivu, where Mouzoko died, authorities are facing a potential health worker strike demanding freedom for three health workers arrested after Mouzoko’s death. Members of the National Council of the Order of Doctors announced on Tuesday that they will go on strike in the city, one of the hardest hit in the current Ebola outbreak, in 48 hours if the government does not release the doctors – Mundama Witende, Gilbert Kasereka, and Sangala Hyppolyte, according to the Congolese outlet Actualité.

“Law enforcement does not want to organize a trial, but continues to keep our colleagues under arrest,” health worker Kalima Nzanzu told Actualité. “Besides our colleague Gilbert who is under house arrest, the others spend their nights in bad conditions … imagine, [they are] senior executives, it’s humiliating.”

As of August 4, 2019 – the latest available numbers – the WHO has documented 2,763 cases in the current Ebola outbreak and 1,849 deaths, yielding about a 67 percent fatality rate.

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