It was the news they'd been dreading. Last week, world health officials learned that a doctor's wife had contracted Ebola. She is from Oicha, a town in the eastern part of the Democratic Republic of Congo that is surrounded by a violent insurgent militia called the Allied Democratic Forces.
Her case is one of many in an outbreak that's been ongoing since the start of August. But it was the first to be confirmed in a location that is difficult for health workers to reach because of the conflict raging in that part of the country.
So far, the number of confirmed cases — more than 80 since the start of this month – has been in line with previous flare-ups in that country that were controlled in a matter of months. But the dangerous twist to this outbreak is requiring health workers to come up with creative strategies to reach those in need.
To get a sense of just how insecure this part of the DRC can be, consider the experience of a top official in the World Health Organization — Dr. Peter Salama, deputy director-general of emergency preparedness and response. Just over a week ago he stopped at a town called Beni near the epicenter of the outbreak.
"The night we were there, there was an attack on civilians — about 20 kilometers [about 12 miles] from where we were staying," he says. "And at least four or five people were murdered."
There are at least 20 armed rebel groups active in the area, notes Salama. And he adds that several of them have also made a practice of kidnapping and killing humanitarian workers.
Until last week's case in Oicha, says Salama, nearly all Ebola cases in this outbreak have been in locations that health workers can get to relatively safely. As soon as they confirm a case they've been rushing to the sick person's town or village to find and vaccinate everyone that the patient has had contact with — and anyone who's had close contact with those contacts. The vaccine is experimental, and the strategy is called "ring vaccination."
"You form in a sense a protective ring around that confirmed case," says Salama.
The Oicha case complicated that approach.
It's likely that the doctor's wife wasn't the only person there who had gotten infected. According to Salama, sometime earlier the doctor himself had been ill with what health officials now suspect was Ebola – although he had already recovered and is now testing negative. And a third person who had died in Oicha is considered a probable Ebola case.
A WHO team was able to travel to Oicha – and identify and start vaccinating nearly 100 people who had contact with the infected person. But to get there they needed an armed escort of U.N. peacekeepers. That's not ideal says, Salama: "There certainly is risk with being too closely associated with any fighting force." Health workers need to be perceived as impartial in order to operate in areas where multiple sides are battling each other.
And Salama says WHO has already decided they'll have to suspend ring vaccination if a case surfaces in a village or town that's too dangerous to visit long enough to meticulously trace the sick person's contacts. Instead they'll move to a less effective strategy: basically making a much briefer visit to vaccinate anyone and everyone they come across before it's time to leave.
"Because we may only have access for a couple of hours with armed vehicles and armed escorts," says Salama. In such places, the longer you stay, the greater the risk.
Another group that's having to tweak its usual Ebola-fighting approach is Doctors Without Borders, which has opened a treatment facility in a town called Mangina, not far from Oicha.
A critical challenge in stemming this outbreak involves the homes of patients, says Karin Huster, an emergency coordinator with the group. If this were a typical Ebola outbreak, she notes, for every patient that comes in Doctors Without Borders would be sending a team back to their house to decontaminate it — specially-trained staffers wearing protective suits who would spray every single surface with chlorine.
"To make sure that it's safe for the family to live in this place," Huster explains.
But that's often proving impossible to do because many of these families live in areas that are too dangerous for Doctors Without Borders to travel to — especially since it's against the group's policy to go in with armed guards.
One alternative under consideration, says Huster, is to build a model of a typical house near the Ebola treatment center so that Doctors Without Borders can use it to teach families how to decontaminate their homes safely with a take-home kit.
"It might not be professionally done the way we would do it," says Huster. "But it would be much better than having nothing done to the house."
Doctors without Borders is also considering training patients who recover from the virus to become ambassadors of a sort — educating their communities about the disease when they go home. Again, says Huster, it's not a perfect solution. Among other reasons, calling attention to Ebola survivors could stigmatize them.
"You always have to do this in a careful way," she says.
But when it comes to responding to an Ebola outbreak in a conflict zone, says Huster, "if we don't find creative ways to deal with it, we'll never control it."
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