Effect of Violence on Health Response

In Beni territory, attacks by the Ugandan rebel group Allied Democratic Forces (ADF) have intensified despite the spread of the Ebola virus in the area since early August *2018 *…+

These attacks, and the presence of armed groups, has greatly complicated the humanitarian operations against Ebola virus disease, whose epicenter is around thirty kilometers west of Beni.⁵⁵²

A report by ACLED in October 2018 stated that:

The North Kivu province is the site of a disproportionate share of the violent events and protests in the Democratic Republic of Congo (DRC). In 2018 thus far, 51% of violent events and protests have taken place in the province. Since August [2018], residents have also had to contend with another source of insecurity: an outbreak of the Ebola virus. The political dynamics of the North Kivu region have exacerbated the Ebola crisis. Not only is the crisis response impeded by the activity of armed groups, residents’ lack of trust in the government has put humanitarian aid workers in danger and has made it difficult to implement public health measures.⁵⁵³

In October 2018, UNOCHA reported that “In Beni *…+ repeated incursions by alleged non-state armed groups have regularly forced medical response teams to suspend their activities

*…+ Activities had already been suspended before in September *2018+ for several days due to direct threats against humanitarian actors. WHO was forced to suspend all activities for a

549 World Health Organization, Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 17 July 2019, 17 July 2019

550 World Health Organization, Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 17 July 2019, 17 July 2019

551 World Health Organization, Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 17 July 2019, 17 July 2019

552 Kivu Security Tracker, Monthly Report: August 2018, August 2018, p. 1

553 Hilary Matfess (ACLED), Layered Insecurity in North Kivu: Violence and the Ebola Response, 26 October 2018, para. 1

period of two days after attacks in late September [2018] in and around Beni, which left more than 20 dead”.

A news report by Reuters in October 2018 reported that:

Unidentified gunmen killed at least 14 people, including two health workers, on Saturday [the previous day] in an area of eastern Democratic Republic of Congo where militia violence has hampered efforts to contain an Ebola outbreak, authorities said. [...] Eleven civilians and one soldier were killed in the city of Beni, where scores of people have contracted the virus, Alloys Mbwarara, mayor of Beni’s Rwenzori neighborhood, told Reuters on Sunday. In the city of Butembo, 50 km south of Beni, militiamen killed two members of the medical unit of Congo’s army, Health Minister Oly Ilunga said on Saturday.⁵⁵⁵

In November 2018, the “ADF rebel group attacked the Boikene district in the north-east of Beni with rockets. An attic storey in the Ebola operations centre shared by the Congolese authorities and WHO collapsed in the attack. The building’s upper storey, containing rooms used by WHO staff, was destroyed. On security grounds, the government subsequently suspended operations to combat the Ebola epidemic, which is particularly prevalent in the city of Beni and the surrounding area”.

Peter Salama, then-WHO Deputy Director-General of Emergency Preparedness and Response, highlighted in November 2018 the critical importance of winning community trust for the success of the response, stating, “Whenever there is a violent incident, we see a major drop in contact tracing”.

A report by the Safeguarding Health in Conflict Coalition reviewing attacks against health facilities and health workers in 2018 noted:

In the DRC in 2018, we identified 24 attacks that affected health workers and facilities. Three health workers were killed, eight were kidnapped, two were assaulted, and two were sexually assaulted; at least 13 patients were also affected, with 12 stabbed and one raped. In the incident in which a patient was raped, armed men in plain clothes entered a health facility, looted it, and attacked and raped one nurse and a patient, before attempting and failing to rape another nurse. After beating some of the patients, they stole some unspecified items and left the facility.⁵⁵⁸

The same source noted that:

In September and November [2018], attacks on the Norwegian Refugee Council, the WHO, and the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO) personnel prompted the closure of medical facilities and paused the Ebola response, affecting access to health care for scores of people and heightening the risk of the disease’s spread. [...] Of the 24 recorded attacks, 23 took place in the east of the country, with eight attacks taking place in the Ebola hotspots of the North Kivu and Ituri

554 UNOCHA, DRC: Violent attacks continue to hinder response to Ebola outbreak, 24 October 2018, para. 2

555 Reuters, At least 14 killed in violence in eastern Congo's Ebola zone, 21 October 2018, para. 1, 4, 5

556 Bundesamt für Migration und Flüchtlinge, Group 62 – Information Centre for Asylum and Migration: Briefing Notes, 19 November 2018, p. 3

557 Center for Strategic & International Studies. “North Kivu’s Ebola Outbreak at Day 105: What’s Next?” 14 November 2018

558 Safeguarding Health in Conflict, Attacks on Health Care in 23 Countries in Conflict: 2018, May 2019, p. 26

provinces following the outbreak of Ebola in August. Eleven of the attacks took place between October and December 2018, with seven attacks perpetrated in November alone.

[...] We received sufficient contextual evidence to consider intent in 20 of the 24 cases.

Based on contextual evidence, we have coded 16 of these incidents as suspected intentional and four as suspected indiscriminate.⁵⁵⁹

In February 2019 the organisation ‘Security Council Report’ noted that “On 8 February [2019], two Médecins Sans Frontières staff members active in Ebola prevention were abducted in the Masisi health zone in North Kivu. While the staff members were returned unharmed, safety fears remain, and field operations were suspended at press time”.

Also reporting on a “violent attack” on the MSF ETC in Katwa MSF reported in February 2019 that the attack resulted in the facility being “partially burnt down” and the “brother of a patient died while reportedly trying to flee the scene. The exact circumstances of his death are still unclear”.

According to the same source following this attack MSF “decided to suspend activities at the centre”.

According to an infographic produced in March 2019 by UNOCHA, since the beginning of the epidemic there have been 317 security incidents that have had an impact on the response to the epidemic in Ituri and North Kivu.

A World Bank report from March 2019 described the health care situation in North Kivu in the context of Ebola crisis as follows:

In this context, the medical teams faced resistance from the communities they were trying to serve, where distrust of institutions sometimes hampered the humanitarian workers’ efforts.

The situation worsened in late December [2018], when residents of Beni and Butembo in eastern DRC, the two main epicenters of the epidemic, saw their participation in the presidential elections cancelled because of Ebola. More recently, following attacks on its Ebola treatment centers in the towns of Butembo and Katwa, now the epicenters of the epidemic in North Kivu, Médecins sans Frontieres (MSF) was forced to suspend its activities.⁵⁶⁴

The Kivu Security Tracker detailed in April 2019 that:

Between the end of February and mid-March [2019], within two weeks, several Ebola Treatment Centers (ETC) were attacked in the town of Butembo in eastern DRC. On February 11, 2019 *…+ there was an attack on the ITAV health center, where assailants killed a policeman, burned down part of the centre and scattered 12 patients who were under

559 Safeguarding Health in Conflict, Attacks on Health Care in 23 Countries in Conflict: 2018, May 2019, p. 27

560 Security Council Report, March 2019 Monthly Forecast, 28 February 2019, Africa, Democratic Republic of the Congo, Key Recent Developments

561 Médecins Sans Frontières (MSF), North Kivu: Ebola centre inoperative after violent attack, 26 February 2019, para. 1,2

562 Médecins Sans Frontières (MSF), North Kivu: Ebola centre inoperative after violent attack, 26 February 2019, para. 1, 4

563 UNOCHA, RD Congo – Ituri et Nord-Kivu: Etat de la riposte de la Maladie a Virus Ebola (Semaine 12:

due 18-24 March 2019), 28 March 2019 [unofficial translation provided by author of this report]

564 The World Bank, DRC: A Trip to the Front Lines of the Fight Against Ebola, 4 March 2019

quarantine. The second attack took place on March 11, 2019 *…+ an attack on the ITAV health center leaving a policeman dead and injured a health worker.⁵⁶⁵

ACLED reported in April 2019 that “tensions around the response to the Ebola outbreak persist and are set to continue as armed groups have threatened to target anyone involved in the Ebola campaign (including journalists). There were a number of attacks in Butembo [town in North Kivu] last week, including one by suspected Mayi Mayi fighters at the Ebola clinic of the Catholic University of Graben who killed a Cameroonian doctor (the Mayi Mayi told the medical staff that Ebola was not real and accused them of killing people); and one by unknown gunmen against the Ebola center in Katwa, which was thwarted by the security forces”.

The IRC issued a press release in April 2019 stating that “Three International Rescue Committee staff members have been caught up in an attack on an IRC supported hospital in Butembo, Democratic Republic of Congo (DRC), in which an Ebola response staff member was killed.”

According to The Global Observatory, “The April 19 [2019] murder of a World Health Organization (WHO) official in the Democratic Republic of the Congo (DRC) has brought to center stage the issue of escalating violence against Ebola responders. The WHO epidemiologist was killed and two others injured when gunmen stormed a hospital in Butembo, located in North Kivu province. Following the incident, doctors and nurses in Butembo threatened to strike unless government security forces did more to protect health workers”.

The UN Group of Experts report covering the period November 2018 to 18 April 2019 found that “Ongoing insecurity caused by armed groups continued to hamper the response to the outbreak of the Ebola virus disease in Beni territory. Challenges relating to community acceptance and trust, coupled with repeated attacks against treatment centres and medical staff, were exacerbating factors”

A recent MSF update in June 2019 also reported that on “25 May *2019+, a health worker was killed in Vusahiro while working to prevent the spread of Ebola”.

At the end of June 2019 The Guardian provided the following overview as to the contributing factors to this particular Ebola outbreak: “Mistrust of officials and foreigners is harming efforts to tackle the disease and conspiracy theories are rampant. Some believe the outbreak is fake news spread by rapacious NGOs and the UN to justify their presence in the country and allow the extraction of valuable mineral resources. Others believe the outbreak was deliberately created for the same reason. Some locals wonder why money is poured into fighting Ebola when many more people die each year of malaria without any similar international interest. Many people also fear going to Ebola treatment centres, choosing instead to stay at home and risk transmitting the disease to carers and neighbours.

565 Kivu Security Tracker, Ebola Treatment Centers Attacked by Armed Groups in Butembo, 9 April 2019, para. 1

566 Margaux Pinaud (ACLED), Regional Overview – Africa, 23 April 2019, p. 1

567 IRC, Attack on IRC supported hospital in DRC leads to loss of life; IRC Ebola responders caught in violence, 19 April 2019

568 IPI Global Observatory, Ebola Response in DRC Undergoes “Important Shifts” as Violence Intensifies, 22 May 2019

569 UN Group of Experts on the Democratic Republic of the Congo, Final Report of the Group of Experts on the Democratic Republic of the Congo, 7 June 2019, Summary, p. 2/3

570 Médecins Sans Frontières (MSF), DRC Ebola Outbreaks: Crisis Update June 2019, 13 June 2019

Insecurity also has prevented vaccination teams from getting to some areas, further limiting

the health response”.