© Sara Creta/MSF

Democratic Republic of Congo

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

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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.

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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 outbreak

Map of MSF Ebola activities in northeast DRC

Ebola has now killed more than 2,100 people in the Democratic Republic of Congo (DRC) as the outbreak in the northeast of the country continues.

With over 3,100 cases, this is the second-worst Ebola outbreak in history – following the 2014 West Africa epidemic. 

On 1 August 2018, we began responding to an outbreak in North Kivu province in the northeast of the country – a region recently characterised by violence and instability – marking the first time that MSF has faced an Ebola outbreak in an active conflict zone. The epidemic has since spread to the neighbouring provinces of Ituri and, most recently, South Kivu.

On 17 July 2019, the World Health Organisation officially declared the current outbreak "a public health emergency of international concern".

MSF has more than 530 staff deployed in DRC for the Ebola emergency, as of July 2019, and is supporting 745 staff from the Ministry of Health.

Urgent action is needed

More than a year since the Ebola epidemic was declared on 1 August 2018, the outbreak is still not under control and continues to exacerbate an already dire humanitarian situation in east DRC.

During the first eight months of the epidemic, around 1,000 cases of Ebola were reported. However, between April and June 2019 this rate dramatically increased.

In July 2019, between 80 and 100 people were diagnosed with the disease each week, while Uganda saw its first Ebola patients who had travelled from DRC in June.

By September 2019, the rate of transmission appeared to decrease slightly. However, the disease remains far from under control as the hotspots shifted from North Kivu to Ituri province  with around 60 percent of new cases being reported in Mambasa, Komanda and Mandima.

“We must place local communities at the heart of the emergency response. All organisations must work together in this direction to put an end to this terrible outbreak.”

Tristan Le LonquerMSF emergency coordinator

“As the number of people killed by the Ebola outbreak in the DRC passes 2,000, this is a grim reminder that, after more than one year, the Ebola response is failing to tackle the epidemic,” says Tristan Le Lonquer, emergency coordinator in North Kivu.

“Despite having new treatments and an experimental vaccine, all of which have proven effective, communities are still not on board and continue to express hostile sentiments towards the response. They won’t support the Ebola response if their most basic non-Ebola healthcare needs are being ignored.

“We must place local communities at the heart of the emergency response. All organisations must work together in this direction to put an end to this terrible outbreak.”


Insecurity in the region is still a significant challenge for the Ebola response, as northeast DRC has been an area of active conflict for the past quarter-century and is rife with armed groups.

Alongside this, healthcare workers associated with the Ebola response are still not trusted by the community. They have been specifically targeted, sometimes forcing crucial activities such as contact tracing or vaccination campaigns to be suspended, limited or cancelled.

MSF itself was forced to leave Katwa and Butembo in February 2019, after violent attacks on Ebola treatment centres.


Currently, an average of five days passes between the onset of the symptoms and the time a patient is admitted into an Ebola treatment or transit centre – a time during which a patient’s conditions deteriorate and the virus can infect others.

However, neither the fear induced by this highly lethal, little-understood disease, nor the pre-existing tension in the area can explain the inability of organisations to win the local population’s support. Instead, the overall approach of all involved has to be questioned and improved.

Part of this includes integrating Ebola treatment into existing local healthcare centres, rather than creating a "parallel system" of facilities that are shrouded in mystery and seen by the community as places where people go to die.

MSF was already working in this volatile region long before the current Ebola epidemic – responding to recurring violence, endemic malaria and outbreaks of measles or cholera. However, the massive mobilisation of resources associated with this Ebola response marks a striking contrast to the neglect this region has suffered from over the decades.

This has added to the widespread belief that the priority of many organisations is not in the best interests of the community. 

The Ebola response must urgently adapt to the needs and expectations of the population if we are to gain control of the epidemic. 

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MSF joins the calls of many experts who recommend expanding the use of the current experimental vaccination.

As of 28 September 2019, over 230,000 people have received the vaccine so far through “ring vaccination” – an approach that targets people who have had contact with confirmed Ebola patients, as well as frontline workers.

However, access to the vaccination must be expanded to cover the entire population that is at risk.

Such steps are needed urgently if we are to prevent the epidemic from lasting another year.


Worryingly, Ebola is only one of many crises in northeast DRC. In Ituri province, the current epidemic has arrived at the same time as a massive measles outbreak, the seasonal peak in malaria and long-term mass displacement due to violence in the region.

For many people, the main concern is not Ebola, but how to obtain care for their children who are dying of measles and other illnesses, as well as how to find shelter from the unrest.

All these needs, including Ebola, are public health risks that must be responded to.

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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 >**](https://www.msf.org.uk/issues/mental\-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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