Ebola Healthcare at Gunpoint – the New Normal?

[This piece was originally published on MSF Analysis]

Emmanuel Lampaert and Heather Pagano

The latest deadly attacks on Ebola response teams in eastern DRC were horrific. Assailants killed four people and injured others in Biakato Mines and Mangina on 28 November. MSF condemns these attacks and extends its condolences to the families and friends of the people that were so brutally murdered. This attack made stark the dangers of responding to an epidemic in an active conflict zone.

In response, WHO Director General Dr. Tedros Adhanom Ghebreyesus called for increased security, declaring that the disease can’t be stopped unless more armed protection is provided for patients and health workers. The UN peacekeeping force MONUSCO and Congolese health authorities have since announced the deployment of more troops and an airbridge to resume activities. While this may be a pragmatic response to a dangerous situation, his response does not yet offer any insight into how and why things got so bad.  How did the Ebola response arrive at the point where WHO feels lifesaving treatment can only be delivered with the protection of armed forces?

The Ebola response has been caught in a vicious cycle for many months now. There are multiple dynamics at play. One is that mistrust breeds insecurity, which is responded to with deploying more military and police, which breeds further mistrust. The latest WHO and their government partners’ proposal for more armed protection is another iteration in this endless cycle and comes at a time where the UN-wide Ebola emergency coordination has worked for many months to somehow ‘demilitarise’ it.

Indeed, there has been great hostility against the whole of the Ebola response – hundreds of security incidents are marring medical efforts to contain the virus. Following the attacks two of the  Ebola treatment centres where MSF was working in February 2019, MSF spoke out against the toxic environment characterizing the Ebola response. People suffering at the epidemic’s epicentre increasingly viewed the Ebola response as the enemy, not the solution.

When elections were cancelled in Ebola hotspots in December 2018 and health centres including Ebola triage points were burnt to the ground in response, the signal was clear that the political dynamics of the region and the response to this epidemic were fatefully intertwined. The huge amount of money and resources subsequently poured into the response, not least by the World Bank in support of the new government, only made people suspicious of the massively visible response to a problem no one had prioritised in their long list of grievances ignored for many years.

Trust can’t be bought, especially when resources aren’t perceived to address the main concerns of the communities – concerns that go beyond the Ebola epidemic. These resources do however fuel complex struggles for control and for the chance to build, or undermine, political legitimacy in polarised environments. Those firing bullets at health workers, in all senses, go beyond our narrow, binary understanding of ‘armed groups’ or ‘communities’. “Mai-Mai” has become a catch-all label attached to everything ranging from low-level grass roots community violence to well organised armed groups, often supported by different factions of the complex Congolese political spectrum. After nearly a billion dollars has been poured into a highly visible and deeply politicised response, who stands to benefit from the Ebola outbreak continuing?

What we do know is that for many months, there has already been extensive military and police present outside medical facilities, accompanying ambulances, at burials, and at vaccination points. Their presence has at times created further fear and tension and is often perceived by communities as proof that Ebola is a political plot rather than a dangerous virus. After all, there haven’t been guys with guns at cholera treatment centres or in measles vaccination campaigns in the same communities in the past. Meanwhile, the ongoing measles outbreak in DRC – which has killed far more people than Ebola – has received nowhere near the same level of resources, nor political attention.

One definition of madness is repeating the same thing but expecting different results. Would further increasing the military engagement in this response address the underlying politics and mistrust playing out in the epidemic? Until now, increasing military presence has not stopped attacks on the Ebola response nor the outbreak itself.

What Dr. Tedros proposes, protecting the health workers and facilities in the ‘riposte’ offers a lot of stick but very little carrot to the population. Although he suggests that the deployment of the army go hand in hand with community engagement, it’s difficult to create dialogue and trust standing next to soldiers – especially when parts of the communities have been actively engaged in a conflict against these same soldiers for years.

After decades of working in conflict, MSF tries to utilize its independence from governments, armed groups or political interests as one of the different ways to build trust and ensure acceptance. In the DRC today, that approach has been put under significant strain by a response that has integrated us from the start on the side of the state and its military apparatus. There is no easy solution: MSF itself was unable to stay in such an environment, taking the difficult decision to close down activities in Biakato because of the presence of military inside the hospital. This left the Ministry of Health and WHO Congolese staff to cope with the situation on their own.

In such an environment, it’s understandable that WHO staff call for armed protection when they stay behind to continue responding to this epidemic. Providing security for the general population is of course one of the main duties of the state. Current proposals however go much further than that. Besides direct presence of soldiers in health facilities, direct medical care by Congolese army doctors are suggested. Such militarizing of the provision of healthcare itself is a genie that’s nearly impossible to put back in the bottle.

What is needed in this response is that patients are placed above politics. This may sound overly simplistic when health workers are already being targeted. And indeed, no health actor can fix this situation – political will is the only answer. This needs to include the will to disentangle this Ebola response from the various struggles for power within DRC.

How can that be done at this stage of the epidemic? Firstly, by showing that medics are not military. That they stand separately from the failures, and even the successes, of the governments that came before, the government that is here today, and any that will come in the future.

For WHO this means developing an operational model that doesn’t mix health provision with wider goals such as promoting the legitimacy of a state. It also means not promoting a militarisation of healthcare in response to the dangers caused in part by the already overly militarised riposte.

Hard lessons will need to be learnt, including by MSF, on this Ebola response. Never have we seen a response to an Ebola epidemic with an operational WHO, a government determined to assert its full control of an epidemic of this scale, and in an active conflict zone where trust and acceptance are easily undermined. We can’t accept that the current approach becomes the new normal.

Trust is hard to build and easy to destroy. In the DRC, we need to keep rebuilding our acceptance from the ashes of the destroyed treatment centres and the lives of the people and communities affected by the attacks. This will take time. But we can continue to embark on true engagement and dialogue. Ask the people of Biakato, Lwemba, Aloya how they’d like to see the Ebola response besides the obvious call for more security. What do they think is needed?

There are no simple answers here. We’ve seen from experience that militarised aid often backfires and escalates insecurity. The solution to any epidemic, Ebola or otherwise, cannot be to provide care at gunpoint.

[This article expresses the opinion of the authors and does not necessarily reflect the position of MSF]

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