In 2014, the world watched in horror as West Africa was ravaged by an outbreak of Ebola virus. The epidemic lasted two years and left over eleven thousand people dead. Last week, global health workers gathered at the 2018 Global Health Exchange Conference, hosted by the Irish Forum for Global Health, to discuss UN Sustainable Development Goals. They sipped coffee and scribbled notes as Michael Ryan, Assistant Director General of Emergency Preparedness and Response for the WHO, called in via Skype from the Democratic Republic of Congo to report on Ebola’s return.

The Democratic Republic of Congo (DRC) is in the midst of its second Ebola outbreak this year. The first began in April in the Équateur Province and resulted in 54 cases before its containment in July. The current outbreak, which began in the North Kivu Province and has since spread to Ituri, was officially declared by the DRC Ministry of Health on August 1^st. As of November 4^th the WHO recorded 300 cases and 186 deaths. “Unfortunately the early situation is difficult,” Ryan reported over the loudspeakers. “We’re extremely fragile. There’s a large-scale conflict with a number of armed militants against the government. We’re in the midst of a UN peacekeeping operation.”

Ryan is referring to the ongoing humanitarian crisis in DRC. A weak central government and a wealth of natural resources has for decades made DRC a prime target for militia groups, from within the country and from neighbouring Uganda and Rwanda. Violence was exacerbated two years ago when President Joseph Kabila, who gained power in 2006 after the country’s first elections in four decades, refused to leave office at the end of his term. According to the Council on Foreign Relations 70 armed groups currently operate in the eastern regions where Ebola is spreading fastest. The room grew still as Ryan described how violence and militant rule complicate Ebola control efforts.

“Frankly, the communities are completely traumatized by the ongoing violence over the years, by the massacres, the kidnappings, and the executions,” Ryan said. “Unfortunately, community engagement in the places we work can be difficult.” Ryan explained that the violence has made communities distrustful of outside organisations. He noted that outbreaks of violence have occasionally disrupted field operations.

“The situation demonstrates true complexity as an epidemic in an unstable security environment. Delivering effective risk communication, surveillance, vaccination, case management, and operations in this context is difficult, but we are getting the job done.”

There were nods of appreciation.

Despite the incredible challenges, Ryan emphasised that progress is being made. He was hopeful that 24,000 vaccinations and preparedness measures in surrounding countries will stem transmission. “We’re relying heavily on partners from the NGO and international community,” Ryan said. He noted that UNICEF, MSF, and NGOs such as Oxfam and Medair have been instrumental. Yet he also underlined the importance of domestic support. “This is an epidemic that’s not driven by a virus. It’s driven by human behaviour, by the systems.” He called for a greater integration of development interventions and humanitarian aid. “Many of us need to wake up and realize that the best global epidemic prevention and mitigation is a health system that can deliver essential health services.”

A question from the audience allowed Ryan to highlight that the affected community themselves determine the course of an epidemic. “In my opinion a community-based approach is the only way to get rid of Ebola. Yes, the vaccines help, the surveillance helps, the drugs help, but without an engaged and participating community, you’ll always struggle in situations like this.” On the ground, Ryan says he is seeing that engagement. “The community here are really beginning to understand what Ebola is, and they have the solutions. We’re just here to provide them with support.”