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A Tale of Two Outbreaks: Why Congo Conquered Ebola

How did Congo get away with a short Ebola outbreak while West Africa faces months of an epidemic? Experience matters, one expert says.

Two outbreaks, two entirely different outcomes. The World Health Organization has declared an outbreak of Ebola over in the Democratic Republic of Congo after just 66 cases and 49 deaths. It lasted three months.

Yet the epidemic in Liberia, Sierra Leone and Guinea’s been going for nine months, with more than 15,000 cases, 5,000 deaths and no end in sight.

What’s the difference? Experts say experience matters — it was the seventh outbreak in the former Zaire. But equally important is the fact that the village where it started was extremely remote, and the country has a rudimentary system of healthcare workers who know to look out for Ebola.

The latest outbreak started when a pregnant woman was preparing game her husband had brought home for the family in Ikanamongo, a village in northwestern Democratic Republic of Congo (DRC).

“Congolese people have been hearing about Ebola for years and years and years."

After she died of an unknown illness, healthcare workers performed a cesarean section to remove her fetus. “It’s local custom — you can’t be buried with a fetus inside,” said Ben Monroe, a Centers for Disease Control and Prevention epidemiologist who’s worked in both the DRC and Liberia.

“All the health care workers involved fell ill.” Within a week of the unfortunate woman’s death on Aug. 11, there were 23 other cases and 13 of them had died.

“That raised a lot of alarm in the system. Someone in … the health authority there recognized what was going on,” said Monroe.

“Congolese people have been hearing about Ebola for years and years and years,” Monroe added. “They put a fair amount of effort into preparing for situations like this.”

Not too far away, the Ebola River flows. Dr. Peter Piot, who discovered the Ebola virus in 1976, named it after this river.

It also didn’t hurt that the CDC had been studying monkeypox in the same forests since 2010. “We go every year, and train health care workers on infection control and disease surveillance,” Monroe said. “There’s been a lot of public education in this particular region in addition to training health care workers.”

Local health experts knew to quickly identify potential cases and isolate them. It doesn’t help the patients much — the death rate is still very high — but it keeps the virus from spreading. Isolation is also not difficult. The area’s very heavily forested and most people live along the rivers. There’s not much travel or trade.

Compare that to the area where Guinea, Liberia and Sierra Leone come together in West Africa. The current boundaries cross over ancient kingdoms, and people travel freely across the borders in trucks, by canoe, on motorcycles and on foot. There’s a lot of informal trade and commerce.

Years of civil war have left little infrastructure and even less trust in government, especially in Liberia.

Ebola had never been seen there. When someone shows up with fever at a clinic, health workers usually assume it’s malaria, and if there are more severe symptoms they might suspect another viral hemorrhagic fever, Lassa fever, or yellow fever. Ebola didn't enter anyone’s minds for months as the virus was carried across borders and finally into crowded cities like Monrovia.

Malaria isn’t contagious from person to person. It’s spread by mosquitoes. So is yellow fever. Lassa is spread by rodents but can spread person to person, though it’s not as deadly as Ebola. And when people die of these diseases, their bodies are not hotspots of infection, the way an Ebola victim’s body is. So West Africans were completely unafraid of handling dead bodies.

They were totally unprepared for Ebola.

United Nations, World Bank and World Health Organization officials met in Washington D.C. Friday and warned that the West African epidemic is far from over. Volunteers from around the word have been educating local residents about Ebola, about the need to quickly isolate people with potential symptoms so they don’t infect anyone else and about ways to safely bury someone who’s died of Ebola.

“It can happen anywhere. So long as we have these weak public health systems and the world is not investing in them, this kind of thing can occur.”

Ironically, many of the DRC’s Ebola experts were not even on hand for the recent outbreak there. “They were in Guinea,” Monroe said. “The DRC actually exports their Ebola expertise to other countries.”

So long as the epidemic continues, the whole world risks seeing at least some Ebola cases.

There have been 10 in the U.S., four diagnosed in the U.S. and the rest transported for treatment, with two deaths.

Mali is fighting off an outbreak that started when a religious leader crossed the border from Guinea with what health workers didn’t recognize was Ebola. Five other people became infected and died and experts are now tracking close to 500 people who either treated him, were at two funeral ceremonies in Mali and Guinea, or were in contact with one of the other victims.

In Nigeria, authorities stopped an outbreak with contact tracing and isolation.

Genetic testing makes clear the West African outbreak started locally — probably when someone hunted and slaughtered an infected animal. So the virus is in the forest and could pop up again.

This is why it’s worth building up health systems everywhere, say experts from WHO, the CDC and other agencies.

“Anywhere you have marginalized populations that rely on wildlife, this kind of stuff happens,” Monroe said. “It can happen anywhere. So long as we have these weak public health systems and the world is not investing in them, this kind of thing can occur.”