Emergency Humanitarian Response ≠ Public Health Epidemic control: Recentering the African & Global Response to the Ebola Emergency (Guest Essay)

Newsletter Edition #389 [The Files In-Depth] 

Readers,

Swiftly responding to a health emergency in a conflict setting is challenging and complex, a situation that we are currently witnessing in the Democratic Republic of Congo.

In this edition, we bring you reflections from a public health practitioner offering a critical assessment of the response to the ongoing Ebola emergency.

The piece points out that the global health system currently defaults to a humanitarian emergency architecture. While this architecture is necessary, it is not sufficient. (This also makes for essential reading for anyone engaged in the process on the reforms of the global health architecture.)

In the current outbreak in the DRC, security and rural access are treated as external constraints rather than as the central epidemiological variable, argues author Sivakumaran (“Shiva”) Murgasampillay. Shiva is a global public health physician with decades of experience in strengthening health systems at district, national, regional and international levels.

He calls for shifting the WHO universal normative standards and norms, and country operational service delivery systems away from episodic crisis management, and towards building foundational public health architecture.

There are two parts to this essay, first reviews the status of the epidemic; the second offers an assessment of what is not working and what needs to change. He emphasizes public health and field epidemiology - not appeals cycles - as the core of successful model operating system of the response; and negotiating peace corridors to also strengthen primary health care.

(See also his previous piece for us - one of the most read in the last few months: WHO’s Next DG Should Be A Medical Doctor, Public Health Leader & Health-Systems Expert)

Thank you for feedback and engagement.

Finally, watch out for our missive from Berlin later this week. I am back from the World Health Summit, and there is plenty to ruminate over.

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Priti Patnaik, Founder & Publisher, Geneva Health Files

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Presenting our weekly in-depth analysis on global health that captures the big picture and the nuances like no one else does. This is an exclusive edition for our subscribers.

I. GUEST ESSAY:

Emergency Humanitarian Response ≠ Public Health Epidemic control: Recentering the African & Global Response to the Ebola Emergency

An African public health security and primary health care review

By Sivakumaran (“Shiva”) Murgasampillay  

Shiva is a veteran public health physician with over 40 years of experience across national and regional levels. He has also worked towards global public health and universal health service delivery. He can be reached at shivapublichealth@gmail.com.

The current African and global health architecture remains heavily weighted toward short-term Public Health Emergency Humanitarian Preparedness and Response (PHE-HPR).

While reactive short term humanitarian models are critical during acute crises, however they fail to address the fundamental national (sovereign) health system and service delivery weakness that allow pathogens to emerge, create outbreaks, spread, and become endemic.

This Public Health and Primary Health Care policy analysis outlines the urgent strategic imperative to reset national, African and global health architectures. This can be done by shifting the WHO universal normative standards and norms, and country operational service delivery systems away from episodic crisis management.

There are a few pathways to do this: countries have to show public health leadership, governance and management supported by national faith-based health and civil society organizations; coordination between the three levels of World Health Organization (WHO), two levels of Africa Centres for Prevention and Control (Africa-CDC) and sub-regional organization such as the East, Central and Southern Africa Health Community & Colleges of Health Sciences (ECSA-HC). Finally, there needs to be cooperation between international health development agencies. They need to urgently pivot toward a long-term orientation rooted in Public Health Epidemiology and Epidemic Prevention and Control (EPC), and Primary Health Care (PHC), driven by institutional health systems strengthening at community, district, provincial, and national levels.

PART I

The status of the Ebola epidemic

As of 6 October 2026, the Democratic Republic of the Congo (DRC) had reported to WHO 8,728 confirmed cases and 4,205 confirmed deaths (crude case fatality ratio [CFR] 48.2%), with 2,269 recoveries, from 64 health zones in seven (Bas-Uélé, Haut-Uélé, Ituri, North Kivu, South Kivu, Sud Ubangi and Tshopo ) of the country’s 26 provinces [14].

This is the country’s seventeenth Ebola outbreak, reportedly may have begun in February, according to African authorities, but only detected at provincial and national level in last week of April 2026. The current outbreak is caused by the Bundibugyo ebolavirus, a species of the filovirus family of haemorrhagic fevers that are endemic in East and Central Africa. Roughly 5,000 cases accumulated in the first 100 days, making this the fastest-growing Ebola epidemic ever recorded, the largest ever in the DRC (having surpassed the 2018–2020 epidemic) and the second largest worldwide after West Africa 2014–2016 [4,14]. Ituri accounts for about three-quarters of confirmed cases, and 48 of the 64 affected health zones reported at least one case in the previous 21 days [14]. Both WHO and Africa CDC joint field analysis in early September 2026 characterised the epidemic trajectory as “uncontrolled expansion,” citing a high share of deaths occurring outside Ebola isolation and treatment units, persistent gaps in case investigation and low contact-tracing completeness.

The latest WHO assessment is more nuanced: transmission remains intense but uneven, with clear signs of slowing in some areas and continued growth in others, and national weekly incidence flat at 475–487 cases over the last three completed weeks [14]. (WHO Weekly epidemic surveillance-situation reports do not share information on reporting completeness and timelines.)

The outbreak continues within chronically weak district public health and primary health care structures and systems, amid a lack of peace and a struggle for basic survival in a context of armed conflict (120+ armed groups, M23 clashes), mass displacement, and increased internal and cross-border mobility for essential trade and mining, where the majority of the population faces extreme poverty.

The outbreak has not been only confined to the DRC: WHO Risk Assessment Report of 20th August indicates risk remains very high in the DRC, high for neighbouring countries, particularly those sharing land borders with the DRC, (Uganda, South Sudan. Burundi, Rwanda, Central African Republic and low at the regional and global levels. Uganda’s imported outbreak (20 cases, 2 deaths) during May and June 2026 was declared over on 27 August 2026 [23,34], but on 5–6 October Kenya confirmed its first imported case, who died in Nairobi after travelling by road to Kampala and flying on to Nairobi, and a health worker from the response was medically evacuated to the Netherlands on 1 October [14,29].

Such a trajectory, six years after the 2018–2020 North Kivu outbreak—which generated an extensive WHO after-action review and a substantial body of scientific and operational literature represents a sentinel failure of Africa’s and global public health security, health sovereignty, and socio-economic development.

It demonstrates that the African and global health architecture built around Ebola and other filovirus threats over the past decade has not yet translated into sustained, functional, basic public health and primary health-care capacities at district and community levels.

These essential capabilities include health protection, promotion and prevention; continuous weekly epidemiological surveillance; functional district hospitals with laboratory, isolation and infection-prevention capacities; effective district health teams supported by health observatories and epidemic operations centres; and district rapid response teams equipped with the communications, transport and logistics required for timely case investigation, contact tracing, risk communication, targeted area-based quarantine where necessary, isolation, safe and dignified burials, and other essential outbreak-control measures.

They must be complemented by field-based environmental and public health officers, community health workers, and a network of accessible, functioning primary health-care facilities.

These are not optional surge capacities; they constitute the foundational public health infrastructure required to detect, contain and interrupt filovirus chains of transmission particularly in fragile, conflict-affected and resource-constrained settings.

Update: situation reports from WHO and Africa CDC (6–8 October 2026)

The table and bullets below update the situation using the WHO Disease Outbreak News of 8 October 2026 [14], the situation reports no. 144–145 of the DRC National Public Health Institute (INSP) of 5–6 October [27], Africa CDC’s statement of 6 October [29], the US CDC situation summary of 7 October [4], and the earlier WHO and European CDC updates [17,28]. WHO was notified of 775 further confirmed cases and 379 deaths between 25 September and 6 October, and on 6 October 62 new confirmed cases were reported in 24 hours (Ituri 33, North Kivu 30), against a seven-day average of 72 new cases a day [14].

Confirmed Bundibugyo virus disease cases and deaths by province, DRC, as of 5 October 2026:

Sources: WHO DON, 8 October 2026 (provincial figures as of 5 October) [14]; INSP SitReps 144–145 [27]; US CDC, 7 October 2026 [4]. National totals on 6 October were 8,728 confirmed cases and 4,205 deaths (CFR 48.2%) [14]. Crude CFR calculated from reported counts; CFRs for Bas-Uélé, South Kivu and Sud Ubangi rest on very small numbers, and their death counts are carried over from 23 September (they reconcile with the national total). No new cases in South Kivu since 29 May 2026.

• Geographic expansion, uneven intensity. Between 25 September and 6 October one further health zone was affected (Alimbongo, North Kivu), after Bulu (Sud Ubangi) and Dungu (Haut-Uélé, on the South Sudan border) in late September [14,28]. National weekly incidence is flat (475 to 487 cases over three weeks) and weekly deaths are stable at about 224 [14]. Provincial trajectories diverge: Ituri has declined gradually since its mid-August peak, North Kivu peaked in mid-September (Beni and Katwa most affected) and Tshopo shows renewed transmission [14,28]; Africa CDC’s emergencies lead reported on 24 September that over three weeks new cases fell 25% in Ituri and rose 56% in North Kivu [18].
• Mortality. The national crude CFR is 48.2%, but North Kivu is 57.7% [14]. Of the 372 deaths reported since 25 September, 264 (71%) occurred in the community and 108 in treatment centres, pointing to delays in identifying illness and reaching care [14]. Africa CDC reported on 24 September a CFR of 62% in children under five and 43% in people over 65, and 239 health-worker infections with roughly 50 deaths [18].
• Case Investigation and Contact follow-up. Contact follow-up has fluctuated below the 85% response target: 87.6% on 16 September, 74.7% on 25 September, 82.0% on 27 September and 80.4% on 4 October (23,741 of 29,535 contacts) [14]. More importantly, Africa CDC reports that more than 70% of new cases are still detected in the community among people not previously listed and followed as contacts, so transmission chains continue to escape the response system [29]. This falls short of the >90% contact-tracing completeness target proposed in Section 3.
• Index Case and Transmission Chains: First known/suspected index case: a health-care worker with symptom onset on 24 April 2026 in Rwampara Health Zone but probable epidemiological origin: Mongbwalu Health Zone, both in Ituri Province well known as the Ebola Province of Eastern DRC . The zoonotic source and true index case have not been definitively established. The subsequent explosive and prolonged transmission appear not well mapped out and driven not by a single continuous chain, but by repeated generation of interconnected transmission chains through delayed active case detection, prolonged community exposure, household and social contact, unsafe burials, traditional healing practices, health care facilities associated transmission, population mobility and insecurity.
• Regional risk and exportation. WHO’s rapid risk assessment (v4, 14 August) rates the risk as very high nationally, high for neighbouring countries, and low for the rest of Africa and globally; a Kenya-specific assessment is under way and WHO continues to advise against travel or trade restrictions [14,15]. Kenya’s imported case was an adult resident in the DRC who had been ill for about a month and treated in several facilities there; he reached Nairobi by air on 3 October via Kampala, was isolated, tested positive on 5 October and died; 28 contacts and the passengers and crew of his flight are being traced, and WHO presumes he was infected in a health facility or the community while seeking care for another ailment [14,30]. By 6 October Kenya had screened 652,584 travellers and trained 4,971 health workers [30].
• Emergency Health and Humanitarian Financing. Africa CDC reports that approximately US$2.9 billion has been mobilised after about US$700 million of new G20+ pledges on 23 September, including US$887 million already provided and US$267 million newly pledged by the United States, €500 million from the EU and contributions from 27 African countries [18,21,29]. This compares with Africa CDC’s June appeal for US$1.4 billion [24]. On 6 October Africa CDC supported the DRC authorities’ call for greater transparency on resources pledged, disbursed, received and used, and stressed that every dollar mobilised must be traceable to results on the ground [29]; mobilised or pledged funds are not the same as funds disbursed and delivered.
• Medical countermeasures. There is still no licensed vaccine or treatment for Bundibugyo virus. WHO issued emergency guidance on 31 August on the licensed Zaire-ebolavirus vaccine Ervebo [16]; the advisory panel recommended research use initially and clear communication of its unknown efficacy against Bundibugyo [19]. Of 70,000 doses allocated in August, 50,000 are for frontline and health workers and 20,000 for a Phase 3 trial; use began on 27 August, vaccination expanded to Ituri on 19 September, and more than 3,700 people had been vaccinated by 20 September [22]. A first-in-human Phase 1 trial of an Oxford Bundibugyo-specific candidate vaccine began in July [26], and a WHO-coordinated therapeutics trial has been enrolling patients since early July, with children eligible with parental consent [19,25].  As of the 8 October WHO update there are still no approved vaccines or specific treatments for Bundibugyo virus disease [14] despite high priority given by both Africa and WHO CDC and large-scale financing allocated or mobilized by the global health industry.
  CEPI has positioned itself to become the principal international R&D financier. Within weeks of the outbreak, CEPI mobilized a portfolio of vaccine candidates; the United States Department of State committed US$50 million to CEPI; the European Union activated emergency research financing; the Pandemic Fund mobilized up to US$220.6 million for the broader continental response; WHO and Africa CDC established clinical research platforms; and African governments and institutions contributed directly to clinical trials. 

Taken together, the latest DRC, WHO and Africa CDC data reinforce the central argument of this paper: the binding constraint is no longer simply the headline level of gaps in Emergency humanitarian health and development financing led by Africa CDC and WHO. It is crucial to prepare for humanitarian response fatigue, and make choices to shift investment into sustained affordable capacity to deliver the three essential pillars of public health: protection, promotion and prevention with core elements of primary health care at district level.

There are gaps in surveillance and district-level field epidemiology, including case investigation and contact follow-up remaining below target, persistent community deaths, and divergent provincial epidemic trajectories that can only be identified, analysed and contained through timely, granular district-level public health intelligence and response.

The first reported imported case in Kenya on 5–6 October demonstrates that the consequences of these persistent subnational capacity gaps are no longer confined to individual provinces or national borders. We continue to be haunted by previous experiences with the COVID-19 pandemic and the ongoing HIV crises. The epidemiological and economic costs will continue to become regional and global.

PART II

Why the current model is failing: humanitarian emergency response ≠ public health epidemic control