© Sara Creta/MSF

Democratic Republic of Congo

In 2018, we have responded to two Ebola outbreaks, in Equateur and North Kivu provinces respectively

The second largest country in Africa by area (after Algeria), Democratic Republic of Congo (DRC) is a country rich in natural resources but plagued by conflict.

Click the map to expand

The country has until recently been at the centre of what some observers call "Africa's world war", with widespread civilian suffering the result.

The five-year conflict pitted government forces, supported by Angola, Namibia and Zimbabwe, against rebels backed by Uganda and Rwanda.

We run some of our largest programmes in DRC, working in 20 of 26 provinces and responding to diseases outbreaks, conflict and displacement, and health problems such as HIV/AIDs.

People have little access to healthcare, and outbreaks are frequent due to poor surveillance and infrastructure.

Violence has led to crises in the Kivus, Tanganyika and Kasai regions and forced millions to flee. Three of our staff, abducted in North Kivu in 2013, are still missing.

With more than 1.7 million outpatient consultations carried out in 2017 – almost one fifth of all MSF outpatient consultations – DRC is our largest intervention in world.

For more about our work on the ground, follow @msfCongo on Twitter.

2018-19 Ebola outbreaks

Current outbreak: North Kivu AND ITURI

Ebola has now killed more than 1,200 people in the Democratic Republic of Congo (DRC) as the outbreak in the northeast of the country continues.

With a total of 1,877 cases and 1,248 deaths, as of 24 May 2019, this is the second worst Ebola outbreak in history - following the 2014 West Africa epidemic.

On 1 August 2018, we first began responding to an Ebola outbreak in North Kivu province in the northeast of the country – a region recently characterised by violence and instability. The outbreak has since spread to neighbouring Ituri province, to the north.

The epicentre of the outbreak has moved multiple times. Beginning in the town of Mangina, the outbreak spread to the larger city of Beni, with cases now in hotspots around Butembo and the rural area of Katwa.

Map of MSF's Ebola response in northeast DRC
New cases

A serious concern is that 82 percent of new Ebola cases in the region cannot be linked to previously known chains of transmission - for example, a new patient may have had no contact with someone already known to have had the disease.

Worryingly, this highlights that although the number of new Ebola cases being reported is high, the real number is likely to be even higher.

North Kivu's proximity to neighbouring Uganda also presents a risk of international spread, with regular trade and traffic across the border.

Stopping the spread

Since the beginning of the outbreak, the Congolese Ministry of Health has followed up with thousands of people who have been in contact with Ebola patients as part of a reactive vaccination campaign.

So far, 122,695 people have been vaccinated against the disease, including over 5,100 health workers.

To support this, we are also reinforcing health promotion and community engagement teams to help prevent and control the spread.

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Violence against healthcare

The response in North Kivu is the first time that MSF has faced an Ebola outbreak in a conflict zone, making our ability to limit the spread of the disease more challenging.

In February 2019, MSF was forced to suspend medical activities at Ebola treatment centres in Katwa, Butembo, Biena and Biakato following successive violent attacks on the facilities. This followed an escalation of tensions around the international Ebola response.

At several times, contact vaccination campaigns have been temporarily suspended because of threats to the safety of healthcare teams.

The security situation is also discouraging people from seeking care at treatment centres in the first place, increasing the risk of spreading the virus.

Latest: 11 April - Ebola: Running behind the outbreak >

Equateur outbreak

Between May and July, MSF teams ran a three-month long emergency intervention in Equateur Province of the Democratic Republic of Congo (DRC) to respond to the Ebola outbreak.

Congolese Ministry of Health teams supported by MSF in Bikoro, Itipo, Mbandaka and Iboko, provided care to 38 confirmed patients, 24 of whom survived and returned to their homes. Sadly 14 people died. 

MSF ended the response on 2 July, and the outbreak was officially declared over on 24 July.

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DRC: Key information

Conflict and displacement

Armed conflict has triggered massive movements of people and their needs are immense. We provide emergency responses in the areas affected, notably in North and South Kivu, Kasai, Ituri and Tanganyika among others. We treat the wounded, cover basic health needs and adapt our services accordingly.

DRC: "There is no health without mental health"
MSF staff in Democratic Republic of Congo are living through the same trauma as their patients

There is no health without mental health

MSF staff in Democratic Republic of Congo are living through the same trauma as their patients

KickerThis is a kicker.

> On the edge of a copse of eucalyptus trees, a play is under way. Its a familiar tragedy with an identifiable cast: a drunk abusive father, a put\-upon wife, and a daughter on the cusp of womanhood.

Whats not so typical about this theatrical display is its actors. When youre displaced from your home, your thoughts can be displaced too, says Sifa Clementine. Sifa oversees MSFs mental health activities in Mweso, a small town in the east of the Democratic Republic of Congo. Today, Sifa and her team are running a theatre production on sexual violence for the local community. The setting is the displacement camp that sits across the road from Mwesos General Hospital, where Sifa and her team work. The actors in the play are all MSF mental health counsellors. Over the course of the next three hours, the team connects with the 200\-strong audience through song, dance and drama. At the end of the play, theres a valuable moment for the audience to reflect on what theyve seen, as a form of group discussion. The event is designed to inform the people of the camp that MSF is in the community, and is there to listen. When we see a problem in the community, we act out these problems and educate in this way. Often, a person's behaviour is affected by what they have gone through. That is when behaviour changes." Referring to the character of the daughter in the play, Sifa goes on to explain: In her village, for example, she didn't drink alcohol, but now she does. She steals food in the house and she sells it for drinks. The sketches show people what can happen, and how they can overcome these problems.

MSFs mental health work in Mweso began in 2009, helping local communities and people displaced by conflict. The North Kivu region of Congo that borders Rwanda and Uganda, and home to Virunga National Park, has been in a state of constant unrest since the Great Lakes Crisis that began after the Rwandan genocide in the mid\-1990s.

The second largest country on the African continent by area, Democratic Republic of Congo is a fragile and conflict\-affected state and receives more aid from MSF than any other country in which we operate. The team of psycho\-social counsellors that Sifa supervises is drawn from the communities surrounding Mweso.

They connect with their clients using empathy, by creating a safe and secure environment where they are able to work through the traumas they have lived. Coming from the same communities as their clients, the Mweso team understand all too well the social taboos around mental health, as well as the traumatic events people are subjected to on an almost daily basis. Conflict, armed robberies, and sexual and domestic violence are just some of issues people face in North Kivu.

Theatre is one of the many interventions the team provides. Along with psycho\-educational activities such as this, Mwesos mental health team also provide therapeutic counselling for trauma related issues \- such as sexual violence, psychological first\-aid, psycho\-social stimulation for nutrition, individual counselling and support groups for people living with conditions such as HIV, TB and diabetes, as well as referrals for psychiatric care.

As counsellors, we help our clients by listening to them, but we can also connect with them over our shared experiences _\- Imani Stanley_

I was constantly worried and still occasionally have flashbacks, says Imani Stanley. Stanley began his MSF career in 2008 as a guard in our Kitchanga project, an hours drive south of Mweso. His intelligence and initiative saw him progress quickly to becoming a counsellor he studied Psychology at university in Goma and speaks six languages, including English, French, and four local dialects. He was recently promoted to an Assistant Administrator. In 2013, Stanley witnessed the horrors that many people in North Kivu have become accustomed to. In February of that year, the conflict reached Kitchanga. I was working in Mweso at the time, but my family were living in Kitchanga. We had two houses, one for me, my wife and children, and one for my mother, says Stanley. Thankfully, most of my family fled before the fighting, but five members of my family werent so lucky. I lost three of my cousins and my two sisters\-in\-law. Both my mothers house and mine were completely destroyed. Everything that we had invested in our family disappeared.

> **As counsellors, we help our clients by listening to them, but we can also connect with them over their shared experiences**

While Mweso and the surrounding area havent seen that level of fighting in the past four years, there is almost constant low\-level conflict between armed groups, and people are regularly subjected to violence. About two weeks ago, says Stanley, two of my cousins and my uncle came face\-to\-face with bandits on their way to their field, next to a small lake near Kitchanga, and were fired upon. They took refuge in the lake, but the bandits surrounded the shore. We found their bodies three or four days later and we buried them there. It hasn't even been two weeks since I experienced a death in my family. Its hard to imagine being able to psychologically come back from these events, but through Stanleys training, hes found ways to cope.

As counsellors, we help our clients by listening to them, but we can also connect with them over our shared experiences, he says. While this might not be common practice elsewhere, this method has helped to break down barriers in Congo, to connect with people initially sceptical to the benefits of mental healthcare. When someone comes to me despairing that he has lost his house, I say, Ah, you have lost a house, I understand that you are very deeply affected. I was like that too. Our sessions are, of course, for the benefit of our clients, but reflecting on our shared experiences allows us as counsellors to be comforted. We are reassured that other people are also affected .

We see that if were faced with the same problems as our clients, we can also cope and life can go on _\- Jaqueline Dusabe_

Jaqueline is a widowed mother of six children, and has been working as an MSF counsellor since 2009. She echoes Stanleys sentiments: Working with our clients really helps us. We see that if were faced with the same problems as them, we can also cope and life can go on. It helps us manage our emotions, especially as were in the same territory as them violence, traumas; we live them, too. In 1996, at the height of the Great Lakes Crisis, Jaqueline and her family were forced from their home. For five months, they slept in the bush, with nothing but a sheet of tarpaulin for bedding.

> **A lot of people \[in Congo\] display \[aggressive\] behaviour that, to the untrained eye, wont be seen as psychologically abnormal**

We slept on the ground, no mattresses, nothing else, Jaqueline explains. My little sister died during the war, along with her baby. We never found her body. At that point I was affected, for sure. I wasnt sure she was dead. I held on to the belief that she was alive. But what makes me happy, what helps me is that she left a son, her first child, who stayed with my father. Hes a big boy now. Thats something that makes me feel better, I can see her presence in him.

As a counsellor, Jaqueline has a fervent belief in the power of mental healthcare. However, shes not oblivious to the fact that mental health problems are sometimes a taboo subject in the community. When we say someone has a mental health problem, people right away begin to talk about madness or craziness. But I see that everyone, nearly all Congolese, are concerned by mental health problems in some way. Its a service thats neglected across the country. A lot of people display \[aggressive\] behaviour that, to the untrained eye, wont be seen as psychologically abnormal. But if services were multiplied all over to help people, perhaps aggressive behaviour and other problems would diminish, and there would be less violence in the community.

Back at the displaced persons camp in Mweso, the play is halfway through its three\-hour run and a distressing scene is taking place. The daughter of the neglectful father is out collecting firewood, when she is approached by two armed men. They chase her through the woods, catch her and hold her down. What follows isn't shown, but many people in the audience know what comes next. Some wipe tears from their cheeks.

> **Not everyone accepts the idea that people can be cured with words**

Sometimes, people cry when we tackle things they have experienced in their own life, says Sifa Clementine. In mental healthcare, when it comes to tears, they are a very good thing. Since they experienced these problems they may not have had time to cry. It is through tears you can relieve yourself. Traumatised, the daughter returns home. The next day, an MSF outreach worker comes to her village to promote the services MSF provides, including counselling for survivors of sexual violence. With the help of her mother, the daughter makes her way to Mweso hospital to talk with an MSF doctor and psychosocial counsellor.

As Sifa says: Not everyone accepts the idea that people can be cured with words. "But I will always say to people that there is no health without mental health.

> [**Find out more about MSF's work with mental health around the world >**](\-health)



We support the national HIV/AIDS programme, which is implemented by the country's health authorities. Our teams work on improving access to screening and treatment, reinforcing treatment adherence, and patient retention.

Awareness-raising through community-based activities is an important part of our projects.


According to official statistics in DRC, malaria causes four times more deaths per year than conflict, meningitis, cholera, measles and respiratory diseases combined.

Children are the most severely affected. Most of our projects include malaria care. We also carry out emergency interventions to contain outbreaks.

Outbreak response

DRC is prone to outbreaks of infectious diseases, such as measles, yellow fever and cholera. We run mobile teams, which can be quickly deployed in emergencies.

Among our responses to outbreaks of communicable diseases are vaccination campaigns, case management (including surgeries), health promotion and water and sanitation activities.

Ebola outbreaks are also recurrent in DRC, and we support local authorities in the response.

© Caitlin Ryan/MSF

Women's health

Many of our projects have an important component of women's health. Sexual violence is also a major issue in DRC, affecting men and boys as well as women and girls.

We provide medical and psychological support, organise family planning activities, antenatal and postnatal consultations, and treat patients for sexually transmitted diseases.


In 2017, we observed an increase in admissions for malnutrition in all our medical structures. This is due to violence-triggered displacement, a bad agricultural season, and less funding. We are treating malnutrition in North Kivu, South Kivu and Kasai provinces.

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