© Gabrielle Klein/MSF

Democratic Republic of Congo

COVID-19 brought an additional burden to the Democratic Republic of Congo (DRC), a country with immense medical needs caused by years of overlapping crises and a weak, underfunded health system.

In the Democratic Republic of Congo (DRC), we are working to tackle the country’s largest outbreaks of measles and Ebola to date, while continuing to address its many other health needs. 

In 2019, Médecins Sans Frontières (MSF) teams worked in 21 of DRC’s 26 provinces, providing a wide range of services including general and specialist healthcare, nutrition, vaccinations, surgery, paediatric care, support for victims of sexual violence, as well as treatment and prevention activities for HIV/AIDS, tuberculosis (TB), measles, cholera and Ebola. 

Measles is a vaccine-preventable disease but the failure to cover all health zones with routine vaccination and the delay in organising supplementary campaigns are among the reasons this outbreak is so big.

In DRC, factors contributing to low coverage include the lack of vaccines, vaccinators and access to healthcare facilities, as well as logistical difficulties such as transport. The outbreak occurred at the same time as the Ebola epidemic, which complicated the response. 

 

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MSF's work in DRC: 2020

Despite repeated upsurges in violent conflict and restrictions imposed by the pandemic, Médecins Sans Frontières (MSF) provided vital humanitarian and medical assistance in 16 of DRC’s 26 provinces.

Our services included general and specialist healthcare, nutrition, vaccinations, surgery, paediatric and maternal care, medical and psychological support for victims of sexual violence and vulnerable people, as well as treatment and prevention activities for HIV/AIDS, tuberculosis (TB) and cholera.

In 2020, we also responded to DRC’s largest measles epidemic and two simultaneous outbreaks of Ebola, in addition to COVID-19, which had claimed 591 lives by the end of the year. 

COVID-19

The impact of the pandemic was felt in all of MSF’s 14 projects and 28 emergency interventions in DRC.

In the capital, Kinshasa, the city hit hardest by the disease, emergency support, including providing treatment, in Saint-Joseph hospital was offered between April and September. In addition, our teams launched a campaign on Facebook to address the lack of information that had led to mistrust, rejection and sometimes violent reactions towards medical staff.

In the provinces where we run regular projects, facilities were adapted to ensure continuity of care, including for the 2,093 patients at the MSF-supported Kabinda hospital, which is dedicated to the treatment of advanced HIV/AIDS and TB. 

Measles 

While much of the world’s attention was focused on the COVID-19 pandemic, DRC was still in the grips of the world’s biggest active outbreak of measles, which started in mid-2018.

Members of an MSF emergency team transport measles vaccines by motorbike to Boso Manzi, Mongala province. Democratic Republic of Congo, February 2020.

Although the outbreak was declared over on 25 August, there was a rise in cases after this date in Mongala, Équateur, North Ubangi and Sankuru provinces, and MSF continued to carry out mass vaccination campaigns and treat patients with complications.

According to the Ministry of Health, 70,652 confirmed cases and 1,023 deaths were reported between January and August 2020. 

Ebola

In the east, the tenth, and the biggest, Ebola outbreak in the country’s history was declared over on 25 June. By then, it had infected 3,470 people and claimed 2,287 lives. MSF supported the response by providing care in treatment and transit centres, offering non-Ebola care, collaborating in the vaccination programme and distributing health promotion information.

MSF’s Dr Tathy consults a patient, who is not suspected of having Ebola, at a mobile clinic in the village of Bobua, Équateur province. Democratic Republic  of Congo, October 2020.

When the eleventh outbreak was declared in Équateur province on 1 June, all responders knew from past experience that a high degree of decentralisation and strong logistical resources would be required, due to the widespread distribution of cases, accessibility and acceptance issues, and a strong preference for community-based healthcare. A decentralised model of care was gradually implemented, in which mobile teams were sent to treat patients in difficult-to-reach areas. The joint response effort used the latest medical tools, increased laboratory capacity and set up temporary isolation units at community level.

By the time the outbreak was declared over, on 18 November, there were 118 confirmed cases, and 55 people had died – a 42.3 per cent case fatality rate, which was significantly lower than the 66 per cent observed during the previous outbreak. In 2020, MSF treated 199 Ebola patients. 

Sexual violence

The level of sexual violence remains extremely high in DRC, both in provinces affected by active conflict and in those considered more stable.

During 2020, MSF provided medical and psychological care to victims of sexual violence in Kasai-Central, Ituri, North Kivu, South Kivu, Maniema and Haut Katanga. Although the number of victims who seek care in the facilities we support is high, we believe the scale of the problem is significantly under-reported.

In 2020, more than half of the people who received medical and psychological care in an MSF-supported facility, or from MSF community outreach teams, had been assaulted by armed aggressors. In the areas where we work, we observe obstacles that hinder access to care for patients, such as armed conflict, a lack of infrastructure and drugs, stigmatisation, shame, and fear of reprisal.

During the third quarter of the year, 66 per cent of victims of sexual violence sought care within 72 hours of the assault. This enabled them to have access to post-exposure prophylaxis to prevent HIV; emergency contraception; antibiotics to prevent sexually transmitted infections; and vaccinations for tetanus and hepatitis B. They also received psychological support and treatment for physical injuries. 

General and specialist healthcare

In Ituri and Kivu provinces, which have been plagued by conflict for many years, MSF has maintained general and specialist healthcare in long-term projects, ensuring continuity of lifesaving care while responding to epidemics and mass displacement, among other emergencies.

However, the escalation of violence in 2020 and its impact on our teams operating in some of the affected areas led to a reduction in our activities and our ability to reach patients.

In North Kivu’s Masisi territory, where we have worked for more than a decade, the delivery of healthcare through mobile clinics, community-based outreach and ambulance services was reduced after an incident that affected patients and health teams.

In South Kivu, MSF teams experienced several incidents in Fizi territory in 2020. These were the latest among many in recent years, and they forced us to make the reluctant decision to reduce our presence in Fizi and hand over all our activities except essential services to the authorities.

During 2020, we started to consider how to adapt our way of working so that we can maintain our assistance to people in need, without exposing our patients and staff to the high risks we currently face.

MSF’s work in DRC: 2019

Médecins Sans Frontières (MSF) ran 54 medical projects in 17 of the country’s 26 provinces in 2018. With services ranging from basic healthcare to nutrition, paediatrics, treatment for victims of sexual violence and care for people living with HIV/ AIDS, we provide comprehensive medical assistance where it is needed most. We responded to nine measles outbreaks and two successive outbreaks of Ebola in 2018, including the country’s largest ever, which was still ongoing at the end of the year.

Assisting displaced and host communities

Longstanding intercommunal violence in Ituri flared up again in Djugu and Mahagi territories, displacing over a million people. At the end of the year, around 200,000 people were sheltered in some 80 makeshift sites, where the living conditions were extremely poor. Our teams provided medical care and distributed water, mosquito nets and relief items at around 30 sites.

Until February, we continued supporting health facilities in Mai-Ndombe, following two days of intercommunity violence in December 2018, during which there were many casualties. We treated injuries and burns, ran mobile clinics and distributed relief items to around 2,850 displaced households. In North Kivu, we assisted displaced people in four camps through mobile clinics and water, hygiene and sanitation activities. In Kasai Central, we ran mobile clinics and health promotion activities to assist Congolese people pushed out of neighbouring Angola.  

A doctor listens to a patient at one of the health centres in Beni, North Kivu, where MSF provides medical staff support and treatment, and donates medical supplies. Democratic Republic of Congo, June 2019.

At the end of the year, we sent an emergency team to assist many thousands of people fleeing extreme violence in the region around Yumbi, in Mai-Ndombe province in the west of the country. To assist refugees from the Central African Republic who had crossed into northern DRC, we supported hospitals and health centres in Gbadolite and Mobayi-Mbongo, North Ubangi province, and ran mobile clinics that also served the local community.

In Bili, in the same province, we supported emergency, paediatric and neonatal services in the referral hospital and in 50 health centres and health posts with an integrated community approach. Over to the east, along the border with South Sudan, we treated more than 48,000 refugees in the informal sites of Karagba and Ulendere.

Comprehensive care in the Kivu provinces

In the Kivu provinces, which have been plagued by conflict for many years, MSF has maintained some long-term projects that ensure continuity of care, while also responding to epidemics, mass displacement and other emergencies.

In North Kivu, our teams operate in Goma, Mweso, Walikale, Masisi, Rutshuru, Bambu and Kibirizi health zones to support the delivery of general and specialist healthcare in hospitals, health centres and posts, and through mobile clinics and community-based outreach activities. 

Our services include emergency and intensive care, surgery, referrals, neonatal, paediatric and maternal healthcare, mental health support, HIV and TB programmes, vaccinations, nutrition and treatment for sexual and gender-based violence. In South Kivu, we support hospitals and health centres in Baraka and, Mulungu, Kalehe and Kimbi-Lulenge health zones, offering treatment for malnutrition, HIV, TB and other infectious diseases, mental health support, and maternal and reproductive healthcare.

In Baraka and Kimbi we work closely with communities to respond to the three main illnesses affecting the population; malaria, diarrhoea and respiratory tract infections. In 2019, we started constructing a new hospital in Baraka and upgraded Kusisa and Tushunguti hospitals by installing a solar energy system.  

Treating victims of sexual violence

We have teams working in clinics in both Kivu provinces, as well as Kasai Central, Maniema and Ituri, offering reproductive healthcare, including safe abortion care, and medical and psychological treatment for victims of sexual and gender-based violence.

With multiple forms of violence often perpetrated at community level, MSF is training people to be first responders, or trusted focal points, for victims in their own communities. In Kimbi-Lulenge and Kamambare health zones (South Kivu), and in Salamabila (Maniema), Masisi (North Kivu) and Kananga (KasaiCentral), MSF works with 88 such focal points. Most are female, as the majority of victims are women and girls. MSF tries to tackle the prejudice that leads to stigma and even family rejection, and tries to organise referrals to other organisations who can offer socioeconomic assistance.

Responding to epidemics

Throughout the year, our teams supported the national response to large cholera outbreaks across both Kivu provinces. Our teams treated patients in cholera treatment centres (CTCs) and ensured that they and their carers were made aware of good hygiene and sanitation practices to reduce the risk of spreading. We also carried out epidemiological surveys and donated medicines.

During an outbreak between May and September, we opened a temporary CTC in Kyeshero (Goma), Lubumbashi (Katanga) and four more in Masisi, where we treated almost 700 patients in one month, most of them displaced people living in precarious conditions in camps. Malaria also continues to be a major health issue in DRC. At Baraka hospital in South Kivu, we increase treatment capacity every year with 100 beds to respond to the seasonal peak.

In 2019, we introduced larvicide spraying in mosquito breeding hotspots as a preventive strategy. In Bili health zone, North Ubangi, where malaria is hyper-endemic, our teams ran a project across 62 health facilities focused on treating young children. HIV/AIDS remains another deadly threat in DRC, with less than 60 per cent of people living with the disease having access to antiretroviral (ARV) treatment. Limited ARV supply, lack of information and prevention services, stigma and cost are some of the obstacles to care. In the capital, Kinshasa, and Goma, we support 11 healthcare facilities to expand access to HIV treatment and screening, strengthen follow-up and ensure a steady supply of ARVs.

Papa Lazard, health promoter supervisor, sings a song to promote the measles vaccine at Kweba village, Lungonzo district. Democratic Republic of Congo, May 2019

In Kinshasa, we provided medical and psychosocial care for 3,167 HIV-positive patients at Kabinda hospital and seven other facilities. At Misisi health centre in South Kivu, MSF community health educators are part of an HIV support group called the Social Committee for Health Promotion, which raises awareness and fights stigma in the community. In 2019, the group followed 1,821 patients registered in HIV programmes in Misisi, Lulimba and Nyange health centres. Throughout 2019, we continued our advocacy efforts to address the lack of bed capacity for advanced HIV/AIDS patients, tackle ARV stockout problems and enhance specialist care for paediatric patients.

Our missing colleagues

On 11 July 2013, four MSF staff were abducted in Kamango, in the east of DRC, where they were carrying out a health assessment. One of them, Chantal, managed to escape in August 2014, but we are still without news of Philippe, Richard and Romy. We remain committed to obtaining their release.

Ebola Outbreaks

The Ebola outbreak declared on 1 August 2018 in the Democratic Republic of Congo continued throughout 2019, although the number of new cases decreased significantly towards the end of the year. 

3,800 people admitted to Ebola treatment centres, of whom 170 were confirmed as having Ebola.

In July 2019, the World Health Organization declared the Ebola epidemic a public health emergency of international concern. By 31 December, there had been approximately 3,300 confirmed cases and 2,200 deaths, making it the second-largest outbreak ever recorded, after the one in West Africa in 2014-2016. Over 1,000 patients survived the disease.

During the year, MSF teams continued to provide assistance to people in North Kivu and Ituri, including medical care for confirmed and suspected Ebola cases and vaccinations for people who had been in close contact with those diagnosed with the disease. In addition, we worked to reinforce access to general healthcare in the region, develop community engagement and integrate Ebola care into local healthcare 

facilities. The aim was to adapt our activities to address the full medical and humanitarian needs of the population, which go well beyond Ebola. In February, the Ebola treatment centres we supported in Butembo and Katwa came under violent attack, forcing our teams to leave the area. Over the following months, we scaled up our support to hospitals and health centres at a time when the contamination of facilities and the reassignment of local health staff to Ebola activities was reducing their capacity to provide healthcare.

Between July and August, confirmed Ebola cases were reported in Goma city and South Kivu province, as well as in neighbouring Uganda. In each location, we supported the health authorities to manage the response. These occurrences, which could have signalled a major expansion of the outbreak to new areas of the country and across the border, turned out to be short-lived, and North Kivu and Ituri continued to be the hotspots for the rest of the year.

 Progress was made in 2019 with respect to the new medical tools being used to tackle the virus; preliminary analyses indicated that the rVSV-ZEBOV vaccine, in use since the start of the outbreak, is effective in preventing infection, while two of the four developmental treatments subject to the randomised controlled trial gave positive indications and remained the only two treatments in use.

A clinical study of a second potential Ebola vaccine was launched in September. In a context marked by violence against Ebola responders – over 300 attacks were recorded in 2019, resulting in an increased presence of security and military forces around Ebola treatment facilities – our ongoing challenges are gaining the trust of the population and getting local communities to participate in the response effort. These are crucial for an effective response strategy.

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