In eastern DRC, mpox is a new challenge on an already urgent list

For months, the MPOX epidemic has been raging in the Democratic Republic of Congo (DRC), with more than 20,000 suspected and confirmed cases and more than 630 deaths recorded from January to early September. On August 14, 2024, the Director-General of the World Health Organization, Tedros Adhanom Ghebreyesus, declared that this increase in MPOX cases in the DRC and a growing number of other African countries constitutes a public health emergency of international concern. The emergency was declared following the advice of an expert committee that warned that the disease could spread further across the continent and possibly beyond its borders.

In Goma, many people I spoke to recently seemed to sense that something new, uncertain and frightening was coming. But no one can yet predict what it will mean for them or how deeply it will affect their lives.

Mpox, originally known as monkeypox, is not new to the DRC. This contagious viral disease is endemic in the northwestern and central provinces, where it mainly affects people who have come into direct contact with infected squirrels. Common symptoms of mpox include skin lesions, fever, headache, muscle pain, exhaustion and swollen lymph nodes. Most people who are infected recover from their symptoms within four weeks after receiving medical support.

Over the years, outbreaks have been sporadic and confined to certain areas. However, the number of cases has increased dramatically over the past two years, with more people affected not only in traditional endemic areas but also in new areas in eastern DRC, such as South Kivu and North Kivu.

In these regions, a new strain of the virus, known as “clade Ib,” has been identified. While the lethality of clade Ib appears to be significantly lower than that of the strain affecting humans in traditionally endemic areas, it appears to be more easily transmissible between people without contact with affected animals. This has led to a more rapid spread of the disease among humans. A similar phenomenon occurred a few years ago in Nigeria, where a new form of the endemic clade II also emerged (known as “clade IIb”), leading to increased transmission and the global outbreak in 2022.

But the situation in DRC is worrying, particularly as cases have been reported in densely populated areas such as Goma, a city of two million people, and in surrounding towns, where hundreds of thousands of people have sought refuge from the ongoing armed conflict in North Kivu. The conditions necessary to prevent the spread of mpox in and around Goma are simply not in place, and the capacity to provide care to patients most at risk of complications – such as young children or people with weakened immune systems – remains severely limited.

How can we expect families living in small shelters, without adequate water, sanitation or even soap, to take preventive measures? How can malnourished children have the strength to ward off complications? And how can we expect this new variant – which is mainly transmitted through sexual contact – not to spread in displaced areas, given the dramatic levels of sexual violence and exploitation that affect girls and women living there?

MSF Health Promoter Aristote Saidi Wanyama uses a poster and megaphone to spread information about mpox prevention strategies in Buhimba refugee camp, on the outskirts of Goma. Credit: Michel Lunanga, MSF

Doctors Without Borders (MSF) has repeatedly criticized the inhumane living conditions of people in the displacement camps and the glaring shortcomings in the humanitarian response. More than two years after the start of the mass displacements caused by the conflict between the armed group M23 and the Congolese army, supported by non-state armed groups, families living in the overcrowded camps still lack basic necessities: food, water, safety, hygiene items, and access to sanitation and healthcare.

During a counseling session I attended with rape survivors, one woman told me that she lives under a plastic sheet with her seven children. Her partner abandoned her after the rape. For women like her, the tried and tested solutions to prevent the spread of the epidemic are unimaginably difficult to implement. When she gets a rash from mpox, she is told to change her linen, wash everything thoroughly, disinfect her belongings, and isolate herself until she recovers. But how can she wash without soap and with only a few liters of water a day? How can she isolate herself and protect her children while living together under their tiny plastic sheet? If she isolates, who will go get food for the children? Who will collect firewood? Who will comfort the newborn?

For her and the many others who have sought refuge in the refugee camps, the mpox epidemic feels like a new challenge in the midst of a flood of problems. And honestly, mpox is not even the most pressing concern given the daily battles they face, including other life-threatening diseases such as measles, malaria and cholera.

However, mpox remains a threat that must be addressed. To address this additional challenge, we must make survival easier for those displaced by violence through a response that is tailored to their specific needs and real-life challenges. This starts with listening to people, understanding their needs, and providing them with the essentials for infection control: water, soap, disinfectant, proper sanitation. These simple but essential measures are crucial. Relying on the arrival of vaccines alone will not solve the problem; improving living conditions is also a crucial factor in combating such outbreaks.

Together with the health authorities, our teams are doing their utmost to care for patients and raise awareness for those living in the sites, as we are doing in other parts of the country affected by the outbreak. Since June, MSF has set up several emergency operations to address the MPOX epidemic in four provinces of the DRC (North and South Kivu, South Ubangi and Equateur) and in neighbouring Burundi. These support MPOX prevention and treatment, awareness and infection control. Like many others, we hope that the long-awaited vaccines, now arriving in the country, will be quickly shipped to the affected areas to protect those most at risk, including patients’ families, to contain the spread of this outbreak and save people from potentially fatal complications.

But vaccines will not be a panacea: for MPOX, as with other viral diseases, both state and non-state actors must urgently address the factors that contribute to the spread of the disease. This starts with listening to people’s needs and adapting responses accordingly. MPOX is just one of many challenges that people in eastern DRC are facing. The effort to combat this new outbreak must be sustained, but it must not overshadow or negatively impact the response to other critical issues in this region.

This blog is published as part of a partnership between the Development Policy Centre and Doctors Without Borders (MSF) Australia. It is an edited version of a blog previously published on the MSF website. MSF provides medical assistance to people affected by conflict, epidemics, disasters or exclusion from health care. Its actions are guided by medical ethics and the principles of impartiality, independence and neutrality. MSF Australia receives no public institutional funding. Read the MSF Australia blog series.