Ebola in the Democratic Republic of the Congo: time to sound a global alert?

The Lancet
Feb 16, 2019  Volume 393  Number 10172p611-716, e29

Ebola in the Democratic Republic of the Congo: time to sound a global alert?

Lawrence Gostin, Alexandra Phelan, Alex Godwin Coutinho, Mark Eccleston-Turner, Ngozi Erondu, Oyebanji Filani, Tom Inglesby, Rebecca Katz, Allan Maleche, Jennifer B Nuzzo, Oyewale Tomori, Matthew Kavanagh

[See Milestones above for full text]

We call upon the WHO Director-General to reconvene the EC to review the grounds for a PHEIC declaration. He should invite states, the UN, and NGOs to attend and submit evidence. 10  The United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO), UNHCR, the UN Refugee Agency, and civil society could provide critical information. The EC should recommend proactive measures on health, diplomacy, security, and community engagement. Concrete recommendations could specify the level and kind of resources needed and composition of security and diplomatic assets.

A PHEIC is a clarion call to galvanise high-level political, financial, and technical support. A PHEIC would provide a clear signal from the world’s global health body that UN leadership is urgent. A PHEIC also empowers the WHO Director-General to make temporary, non-binding recommendations that have normative force.10

The IHR do not specify any surge in authority or financing when declaring a PHEIC. In the past, states did not heed WHO warnings that travel and trade restrictions are harmful. During the west African Ebola epidemic, 58 states restricted travel from affected areas, and during the 2009 influenza A H1N1 pandemic, states imposed trade and travel restrictions.12,13,14]

Trade or travel barriers in the DRC would have devastating impacts. WHO, with UN support, should take active steps to prevent unlawful and harmful restrictions. In 2009, WHO and the World Trade Organization (WTO) criticised governments that took non-evidence-based actions; going forward, WHO and WTO could publicly name non-compliant countries. Governments should also agree to dispute resolution, including binding IHR arbitration.10

If a PHEIC escalated conflict by raising the profile of the international response, it would be deeply concerning. Recent elections in DRC were clouded by concerns about vote-rigging, unsettling lines of power and legitimacy. Armed groups have used violence to generate chaos. A PHEIC could increase incentives to target Ebola responders to gain leverage. As in South Sudan, armed groups could manipulate aid for non-humanitarian purposes.15 Like any complex multilateral negotiation, cultural competence and smart diplomacy are required. Outsiders are unlikely to be privy to all on-the-ground realities and risks.

The IHR were designed to respond to a health emergency like the DRC Ebola epidemic. We urge the WHO Director-General to reconvene the EC and re-assess the declaration of a PHEIC. The UN and governments should increase support for WHO and partners. If the IHR fails, or worse, increases political instability, it will require urgent reform.

State non-compliance should not obscure the value of the IHR in establishing norms of rapid identification, notification, and response. The IHR require states to develop health-system capacities, assessed by WHO’s Joint External Evaluation. IHR reform should focus on technical and financial assistance for national health capacities. A PHEIC should trigger surge capacity in relation to authority and finances, with effective mechanisms to gain state compliance.

WHO has shown leadership and operational endurance, working tirelessly to combat the DRC Ebola epidemic. But WHO and partners cannot succeed alone. We live at a political moment when international solutions to collective threats are increasingly hard to achieve. But WHO and the UN system will be called upon with ever-greater frequency in the future to manage complex humanitarian crises. We must plan for a future in which political violence and instability become the new abnormal.

[References at title link above]