Peace Operations at the Intersection of Health Emergencies and Violent Conflict: Lessons from the 2018–2020 DRC Ebola Crisis

IV. The 2018–2020 DRC Ebola Crisis, the Riposte, and MONUSCO’s Role

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Authors
Dirk Druet
Project
Rethinking the Humanitarian Health Response to Violent Conflict
 

On August 1, 2018, the Ministry of Health of the DRC reported an outbreak of Ebola virus disease—the country’s tenth—in North Kivu province, which was later expanded to Ituri and South Kivu provinces. By the time it was declared over by the WHO in June 2020, the outbreak had infected 3,470 people (probable and confirmed cases), killed 2,287, and become the world’s second most deadly Ebola epidemic after the 2014–2016 outbreak in West Africa.62

A major international health response mobilized to help stem the spread of the virus in the DRC, heavily influenced by the experience in West Africa. Though the response was initially effective, a surge in violence in the Beni area hampered efforts, and by October 2018 only 20 percent of contacts had been traced.63 Attacks resulted in localized lockdowns of health centers. Travel by workers to outbreak areas and the transportation of medical supplies was impeded when aid workers were unable to travel on roads that had suffered previous ambushes. This section describes how, amid these challenges, MONUSCO attempted to manage the crisis. It considers the state of the conflict at the time of the outbreak and MONUSCO’s role within it, how the mission and its partners applied the lessons from UNMIL and the West African epidemic, and how MONUSCO endeavored to implement its own mandate under these conditions. This analysis highlights questions and dilemmas that arose for peacekeeping and humanitarian officials at the time and offers insights relevant to those developing policies for peace operations during similar health emergencies.
 

 

Endnotes

a. Conflict Dynamics in the Eastern DRC on the Eve of the Ebola Crisis

After repeated delays of the DRC’s presidential election, on December 31, 2016, leaders of the Majorité Présidentielle (Presidential Majority) and opposition parties in the DRC signed a “Comprehensive and Inclusive Political Agreement” wherein President Joseph Kabila committed not to seek a third term in office, a path for holding elections was identified, and transitional arrangements were established to permit the functioning of the government until the polls were held. The agreement called on MONUSCO to provide support to the national electoral commission in organizing elections, with a date for the presidential election set for December 2018.64

The December 31, 2016, agreement put a shaky lid on a highly volatile political situation in the east of the country, where, at the time of the outbreak in the DRC, more than seventy armed groups were active.65 Long-standing armed groups, such as the Forces Démocratiques de Libération du Rwanda (Democratic Forces for the Liberation of Rwanda, FDLR), though weakened, continued to influence the conflict through support to younger armed groups, such as the Nyatura in the Rutshuru territory of North Kivu. In Walikale and Lubero territories the Nduma Défense du Congo-Rénové (Nduma Defense of Congo-Renovated, NDC-R) was growing in influence. Because the Forces Armées de la République Démocratique du Congo (Armed Forces of the Democratic Republic of Congo, FARDC) had no significant presence in this area, much of the population there perceived the NDC-R to be providing security and defending local interests despite a record of illegal taxation and other violations. Additional Mai-Mai groups were active around Lake Edward and near the town of Lubero, where they frequently clashed with the FARDC.

Beni territory, where the Ebola outbreak began, has been the base of operations for the ADF since it migrated from Uganda in the 1990s. At the time of the outbreak, the group was estimated to number 400–500 combatants operating from small bases to the east of the town of Beni, where it continued to recruit youth from Uganda.66 With obscure motives, and often working with other local armed groups, the ADF is notorious for its extreme brutality against civilians and since 2013 has been accused of participating in a series of mass atrocities in Beni.67 In January 2018, the FARDC launched “Usalama 2,” a major operation targeting the ADF and other groups in North Kivu. This led to a significant deterioration of the situation in Beni, with a major upsurge in attacks against civilians, the FARDC, and UN peacekeepers, though, as the UN Group of Experts on the Democratic Republic of the Congo pointed out, no armed group took responsibility for the attacks.68

The 2018 Ebola crisis thus broke out amid a complex, tense, and fragile moment in the Congolese conflict. All aspects of the Riposte—including the infusion of money, the presence of Congolese officials from outside the region, and the steps taken to ensure security—profoundly affected, and would be affected by, these dynamics. However, little evidence suggests that the WHO, in preparing its response to the Ebola outbreak, took steps to understand and plan in relation to them.
 

 

Endnotes

b. The Outbreak of Ebola, the Entry of the Riposte, and the Spread of Mistrust

The DRC Ministry of Health notified the WHO of an outbreak of Ebola in North Kivu on August 1, 2018.69 The announcement activated a large-scale, multisectoral response, formally led by the Ministry of Health and supported by the WHO and involving more than fifty international and national partners. Within weeks, the WHO, the ministry, MSF, the International Federation of the Red Cross/Red Crescent, and key international NGOs such as the International Medical Corps had collectively deployed more than five hundred personnel to what became known within the DRC as the Riposte.70

The strategic approach of the international community’s Ebola response—collectively, the activities of international agencies and NGOs that formed part of the Riposte—was heavily influenced by the WHO’s new Health Emergencies Programme. The stated goal of this program, established in 2016 as a direct result of the criticisms of the WHO’s response to the West African Ebola crisis of 2014–2015, was to deliver “more predictable, transparent and timely support to Member States.”71 In addition to internal reforms designed to detect and respond to disease incidents more quickly, the program pledged to embrace more nationally driven emergency responses, working through national systems wherever possible and striving to build local emergency response capacities before and during crises.72 The WHO and other key international agencies such as the UN Office for the Coordination of Humanitarian Affairs and, later, the Office of the UN Ebola Emergency Response Coordinator were more deferential to the Ministry of Health’s leadership, agreeing to participate in a coordination mechanism the ministry set up in Goma and coordinating activities based on ministry data. Still, the sheer size of the international response and tensions within the agencies over questions of approach, principle, and resources soon necessitated an exclusively international coordination mechanism, which was initially operated by the WHO and also met in Goma.73

This more nationally focused response created a dilemma for those NGOs and organizations, such as MSF and the ICRC, that most carefully guard their neutrality and independence and were thus deeply wary of any appearance of collaboration with the government, a party to the conflict. Still, in light of the lessons from West Africa, most agreed to the new approach. A senior official with one of these organizations later said she regretted this decision to “play the game,” since the organization later concluded that its affiliation with the national response was putting its operation and personnel at risk.74

Compared to the West African crisis, the Riposte had several important advantages in combating the virus. While institutionally weak, the Congolese health system had an established and tested response system, honed during the nine previous Ebola outbreaks in the country, to identify and contain outbreaks. This included a citizen alert system to report suspected cases and rapid reaction teams to investigate and track suspected cases and contacts. Critically, the response also had access to the rVSV-ZEBOV vaccine developed during the West African crisis. Though not yet licensed, it was authorized for emergency use, as were several new therapeutic treatments.75

Initially, the public health response to the outbreak was relatively effective. Using the rVSV-ZEBOV vaccine, workers adopted a “ring vaccination” approach wherein an Ebola patient’s interpersonal contacts and, in turn, those contacts’ contacts would be targeted for vaccination.76 When the virus was found to have spread to Ituri, authorities were successful in largely bringing transmission in the province under control by late August. Simultaneously, however, the virus spread to the commercial hub of Beni and then on to Butembo, raising concerns about possible spread over the border to Uganda.77 This development added to the international community’s sense of urgency, contributing to support for a “no regrets” approach to managing the emergency, which was broadly seen as heavily empowering the WHO to direct actions with only limited consultation with other parts of the UN system.78

The authorities in Beni and Butembo quickly encountered widespread community “resistance”—a term used as a catchall throughout the Riposte to describe “reluctance or refusal to cooperate with Ebola response efforts, including contact tracing, case management and safe and dignified burial activities; in addition to acts of active and violent hostility towards Ebola response teams.”79 While complex and in some cases opaque, community distrust during the Ebola response appears to have been motivated by a combination of three broad factors, the first of which was widespread discomfort with the public health measures employed to stop the spread of the virus. These included the isolation of the sick in health centers and emotionally and culturally insensitive safe burial practices.

A second factor was a suspicion of the motives of national and international health workers, who appeared in the expensive Toyota Land Cruisers ubiquitous among international NGOs and hired large numbers of national staff, though often not from nearby locations or linguistic groups. Local people questioned why so many resources were being committed to Ebola when other diseases caused far more deaths (for example, the DRC was experiencing a large-scale measles epidemic at the time of the Ebola outbreak).80 Some concluded that the health workers themselves, both national and international, had either brought the disease to the area or were propagating it to enrich themselves.81 A related conspiracy theory held that the government was spreading the disease to attract international aid dollars and create jobs and rents for its supporters. International health actors eventually took several steps to address these challenges—many of which had been identified during the West African epidemic—such as using motorcycles instead of large vehicles to reach communities and training community members to safely bury bodies.82

Third, and most important for our study of MONUSCO’s role in the crisis, is what one study attempting to better understand the causes of “community resistance” identified as “difficulty separating the persisting conflict from Ebola.”83 Many in the population associated the health response with the Congolese government as a whole and, by extension, with MONUSCO. This did not bode well for the legitimacy of the health response since, at best, the FARDC was widely seen as ineffective in protecting the population from armed groups and, at worst, was seen as a primary source of violence and corruption in many communities in the eastern DRC. MONUSCO was frequently accused of indifference in the face of attacks (whether by the FARDC or armed rebel groups) on civilians and, as it regularly took part in joint operations against armed groups, as complicit in the resulting reprisals inflicted on civilians by the ADF.84

These suspicions soon found their way into the supercharged political environment leading up to the December 2018 election. For example, a national opposition deputy representing Butembo released a widely shared audio message on WhatsApp and later broadcast on the radio: “We want the Minister of Health to tell us the real origins of Ebola. As long as we’re not told its real origin, we’ll believe that it was manufactured in a laboratory in order to exterminate the population of Beni.”85 Local politicians also claimed that the creation or propagation of the virus was a government strategy to avoid facing the opposition in the upcoming election, a suspicion reinforced when the government went ahead with the election but excluded Beni and Butembo, opposition strongholds, from the vote.
 

 

Endnotes

  • 69Oly Ilunga Kalenga, Matshidiso Moeti, Annie Sparrow, et al., “The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019,” The New England Journal of Medicine 381 (14) (2019): 373–383.
  • 70This paper adopts the conception of the Riposte defined by the Congo Research Group as the entirety of the political, institutional, infrastructural, and financial assemblage controlling the outbreak, including the Congolese Ministry of Health, the WHO, and a range of other medical and humanitarian actors, “and formally led by the Ministry of Health. . . . The notion of Riposte embodies both the self-conception of actors engaged in fighting the outbreak as well as the imagery and experience of Congolese with these actors.” See Congo Research Group, Rebels, Doctors and Merchants of Violence, 29.
  • 71WHO, WHO Health Emergencies Programme in the African Region: Annual Report 2016 (Geneva: WHO, 2017).
  • 72Fiona Fleck, “WHO’s New Emergencies Programme Bridges Two Worlds,” Bulletin of the World Health Organization 95 (1) (2017): 8–9.
  • 73Interview with former UN official involved in the Ebola response, October 8, 2021.
  • 74Interview with former senior NGO official, July 6, 2021.
  • 75Benedict Moran, “Fighting Ebola in Conflict in the DR Congo,” The Lancet 392 (October 13, 2018): 1295–1296.
  • 76Wells et al., “The Exacerbation of Ebola Outbreaks by Conflict in the Democratic Republic of the Congo.”
  • 77Kalenga et al., “The Ongoing Ebola Epidemic in the Democratic Republic of Congo.”
  • 78Brian McCloskey and David L. Heymann, “SARS to Novel Coronavirus—Old Lessons and New Lessons,” Epidemiology and Infection 148 (22) (2020): 1–4.
  • 79Noé Kasali, Community Responses to the Ebola Response: Beni, North Kivu (Belfast: Congo Initiative—Bethesda Counselling Centre, ca. 2020).
  • 80Malaria is the leading cause of premature death in the DRC, followed by neonatal disease, pneumonia, diarrhea, and tuberculosis. Kalenga et al., “The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019.”
  • 81Interview with former senior NGO official, July 6, 2021.
  • 82Moran, “Fighting Ebola in Conflict in the DR Congo.”
  • 83Kasali, Community Responses to the Ebola Response.
  • 84J. Stephen Morrison and Judd Devermont, “North Kivu’s Ebola Outbreak at Day 90: What Is to Be Done?” CSIS Briefs, November 2018.
  • 85Cited in Moran, “Fighting Ebola in Conflict in the DR Congo.”

c. Violence, the Securitization of the Riposte, and MONUSCO’s Role

In this volatile political context, violence became a regular feature of the epidemic almost immediately, with attacks and threats on health centers housing Ebola patients and health workers in the field an almost daily occurrence. On September 22, 2018, unidentified attackers killed twenty-one civilians in Beni and prompted five days of mourning that interrupted contact tracing and led the rate of Ebola cases to almost double.86 In November, a group of armed men attacked two hotels housing workers with the World Food Programme and other UN programs involved in the Riposte.87 Beyond acts of overt violence, hostility toward the Riposte, even from those working for it, was a fact of daily life. An NGO emergency coordinator based in Beni during the outbreak recalled regularly receiving threatening notes if payments to staff were late and regularly encountering mobs threatening violence when she would arrive to provide health services in a new community.88

Challenges in identifying and understanding the motives of the perpetrators of attacks on health facilities further fueled confusion among local civilians and security actors alike. Concerns grew of an alleged new alliance between the ADF and the Islamic State in Iraq and the Levant, though the UN Group of Experts on the DRC found no evidence of any cooperation between the groups.89 While the United Nations assessed that the ADF did not appear to be systematically targeting the Ebola response,90 the group continued its pattern of attacks on civilians in Beni, frequently limiting health workers’ access to affected areas and thus interrupting contact-tracing efforts and enabling the virus to continue spreading.91

Other explanations posited by UN officials at the time include the possibility that local opposition political figures were encouraging or even organizing the attacks as a way of undermining central government officials and their local allies. More simply, the attacks might have been acts of frustration in response to the perceived instrumentalization of the virus as a justification to suspend voting in the presidential election in Beni and Butembo.92

Perhaps the most important factor fueling violence against the Riposte was the perverse political economy created by the intervention in the Beni area and its link to security dynamics. Faced with an unprecedented security challenge and little in the way of conflict-sensitive operating procedures, the WHO reportedly engaged approximately 250 members of the Agence Nationale de Renseignements (National Intelligence Agency, ANR), a state security apparatus notorious for human rights violations, as “community liaisons” and followed their instructions on the most permissive locations for Ebola response activities. In addition to alienating local communities, this arrangement incentivized the ANR to portray the situation as one of continuing danger, which in turn motived stronger security measures. A senior UN official involved in the Riposte recalled, for example, that an alleged Mai Mai attack at the Bunia airport reported by the ANR turned out to be a small crew of MONUSCO workers cutting grass.93 As a 2021 report of the Congo Research Group alleges, the WHO also paid armed groups, either directly or indirectly, to “ensure security,” again creating a perverse incentive for armed groups to attack the health centers to preserve a climate of insecurity and justify continued security payments.94 A senior NGO official involved in the response suggested that the WHO naively thought it could “buy its way out of the situation,” resulting in a highly inefficient and ultimately counterproductive use of its ample budget on security.95

The size and modalities of the Congolese response also fueled resentment and violence. During an earlier, unrelated 2018 Ebola outbreak around Mbandaka, the government had instituted an attractive financial incentive schedule to encourage health workers to deploy to Ebola-affected areas, paying them as much as U.S.$200 per day, an enormous amount by local standards. As a result, government workers from around the DRC flocked to the reclusive Beni area to benefit from these payments. Many had little to do and even less reason to see the outbreak come to an end.96

The pace and severity of attacks on health workers and facilities became a major obstacle to containing the virus. Security incidents and resulting suspensions of health activities correlated directly with drops in the rate of contact tracing, leading to an ongoing pattern of new Ebola patients being identified without epidemiological links to known cases. In attempting to measure the impacts of this violence on the spread of Ebola, a study of contact tracing between April 2018 and June 2019 found that “violence against health workers compromised the speed of isolation of patients once infections were identified—with the average time between symptom onset and isolation rising from 8.1 days to 10.0 days after a disruptive event—and impeded the speed of the vaccination campaign. Collectively . . . conflict events reversed what was otherwise a declining epidemic trajectory during the period.”97

Security Council Resolution 2409 of March 27, 2018, authorized MONUSCO to field 16,675 military personnel and 1,441 police personnel, along with a considerable complement of civilian staff. Its top priorities, the resolution declared, were the protection of civilians and support for the implementation of the December 31, 2016, agreement and the electoral process, so that credible elections could be held and a political way forward for the country secured.

As the security situation escalated in late 2018, MONUSCO began to take a more explicit role in the response. On November 7, WHO Director-General Tedros Adhanom Ghebreyesus and Under-Secretary-General for Peacekeeping Operations Jean-Pierre Lacroix jointly visited Beni in a show of commitment to enhancing security for the Ebola response.98 Lacroix was quoted in the media as saying, “we will do our best to contain the Ebola outbreak despite the security environment that is being degraded by armed groups. . . . We promise to neutralize and hunt down these rebels because we have a mandate to keep the peace. Peace is one of the major elements of the Ebola response.”99 The following day a UN press release declared that MONUSCO “has contributed to a period of calm in and around the city of Beni, although some attacks have continued in surrounding villages.”100

Throughout the Ebola crisis, active hostilities unfolded in close proximity to disease-affected areas. Although MONUSCO’s offensive operations against the ADF decreased during the Ebola crisis, periodic operations were still carried out, usually jointly with the FARDC. Whether causally linked or not, operations were followed by a significant spike in ADF attacks on civilians, military targets, and peacekeepers. A year later, in 2019, an offensive against the ADF launched unilaterally by the FARDC and against the advice of MONUSCO caused the rebel group to splinter across the territory and sparked an intense series of attacks.101 The violence hit a breaking point for many in the population, resulting in violent protests against MONUSCO that culminated in the looting and torching of the MONUSCO office in Boikene, just north of Beni, destroying the office and forcing the staff to evacuate to the Beni airport.102

The violence against the Ebola response opened a schism in the humanitarian community between those advocating for more armed security and those demanding less. On April 19, 2019, a Cameroonian epidemiologist deployed by the WHO was killed in an attack on Butembo University Hospital, where he was participating in a coordination meeting.103 Following the incident, two hundred local doctors and more than one thousand nurses at hospitals and health centers in Butembo, who were responsible for initially evaluating potential Ebola patients and referring them to Ebola treatment centers, threatened to strike unless authorities prevented further attacks.104 At the request of the WHO, MONUSCO began stationing troops to guard hotels where health staff were residing and medical facilities where Ebola patients were being treated, in some cases establishing temporary operation bases to allow health workers to remain onsite in rural areas for days or weeks.105 The UN Department of Safety and Security (UNDSS), which dictates security measures for all UN civilian personnel, established a three-tiered security assessment of roads in the area. All “red coded” roads required an armed escort, often provided by MONUSCO. Even for “yellow coded” roads, however, as one UN staff member involved in the response recalled, WHO officials began to regularly request armed escorts—for example, on the road from Beni to Butembo—even though they were not formally required.106

Much of MONUSCO’s security support for the health response came from its Force Intervention Brigade, which was already concentrated around Beni and was mandated to offensively “neutralize armed groups” that had been established in the wake of the 2012 M-23 rebellion and more recently had been focused on addressing the threat posed by the ADF.107 The FIB deployed troops and vehicles to the response and was reinforced with a company normally based in Kinshasa, two police units, and individual police officers. Unsurprisingly, the security measures implemented as a result of the violence against health measures further amplified perceptions of links between the Ebola response and political motivations. Heavy security details for health workers arriving in affected localities compounded mistrust and fueled a reluctance to seek treatment.108

As a consequence, when assailants set fire to two nearby Ebola treatment centers run by MSF in February 2009, resulting in the suspension of its activities and the evacuation of staff, the organization called for an “urgent change in strategy,” arguing that the response had become overly militarized.109 In an interview with Reuters, acting MSF President Dr. Joanne Liu described the atmosphere as “toxic” and argued that Ebola could not be managed unless the community trusted the authorities and were treated humanely. “Using police to force people into complying with health measures is not only unethical,” she said; “it’s totally counterproductive. The communities are not the enemy.”110 Instead, the MSF argued, “we need to adapt our intervention to the needs and expectations of the population, to integrate Ebola activities in the local healthcare system, to engage effectively with the communities, and to further explore promising vaccinations to strengthen prevention. Choices must be given back to patients and their families on how to manage the disease—for example, by allowing people to seek healthcare in their local centres rather than in an Ebola Treatment Center (ETC). We owe this to our patients.”111

Other aspects of MONUSCO’s contributions to the Riposte were less controversial. In addition to its security activities, the mission provided a variety of logistical and substantive support. When the outbreak in North Kivu was announced, MONUSCO already had some experience in supporting a health response. Months earlier, when the ninth Ebola outbreak occurred in Equateur Province, much of the mission’s logistical and substantive resources were dedicated to preparations for the election. Some of these resources were immediately redirected to aid the government-led response, supported by the WHO. By the end of May, the mission had deployed thirteen staff members to Mbandaka to assist with the establishment of an emergency hospital. The mission redeployed aircraft to transport cargo for the Ministry of Health and the WHO, as well as helicopters to access remote villages. The experience was generally seen as a success, and one senior mission staff member observed that this support was critical to helping the government rapidly resolve the outbreak.112

Given the worsening situation on the ground, in May 2019 the UN secretary-general appointed then MONUSCO DSRSG David Gressly as the UN’s Emergency Ebola Response Coordinator. An official from UN headquarters was temporarily deployed to perform the DSRSG role during this period. The WHO, whose leadership of efforts on the ground had come into increasing question,113 described Gressly’s role as “overseeing the coordination of international support for the Ebola response and working to ensure that an enabling environment—particularly security and political—is in place to allow the Ebola response to be even more effective. Mr. Gressly will work closely with WHO, which will continue to lead all health operations and technical support activities to the government response to the epidemic.”114 Upon taking charge of the Ebola response, Gressly endeavored to get MONUSCO to more directly engage local armed actors and their political counterparts who were involved in influencing violence against health centers. “We have civil affairs officers who maintain close relationships with communities. We work with them all the time. That gives us a level of access to the population that WHO could never match,” he told National Public Radio at the time.115 One former senior UN official described Gressly’s appointment as intended to put an end to the “Ebola business”; that is, the insidious cycle of violence and “protection” that, according to some, had become the dominant logic of security in the Ebola response. MONSUCO provided administrative and security support for the setup and operations of Gressly’s small office, based in Goma.116

Endnotes

Authors
Dirk Druet
Project
Rethinking the Humanitarian Health Response to Violent Conflict
Previous Section
III. Learning from UNMIL and the 2014–2016 West African Ebola Crisis
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V. Reflections on the Role of Peace Operations in Responses to Health Emergencies
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