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By Tom O'Connor

Deputy Editor, National Security and Foreign Policy

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Multiple conflicts ravaging the Democratic Republic of the Congo (DRC) are undermining efforts to rein in a worsening Ebola outbreak and risk fueling the spread of both instability and disease beyond the country's borders.

The DRC is home to more than 120 million people across a sprawling land mass the size of France, Germany, Italy, Poland and the United Kingdom combined. It also hosts dozens of insurgent groups vying for power in a nation that bore the brunt of one of Africa's largest and deadliest wars through the turn of this century.

More than 6 million people have died over the course of three decades since the onset of the First and Second Congo Wars and the many conflicts that have ensued. The majority perished not at the hands of weapons, but due to various diseases, malnutrition and the collapse of healthcare services still today struggling to meet the growing demands of the overlapping crises.

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Now an Ebola outbreak adds to these woes, with more than 1,000 confirmed dead and over 2,500 infected. Already, the disease has spread to neighboring Uganda, and the crisis shows little sign of improving.

"The security situation in DRC is severely complicating efforts to contain the Ebola outbreak by limiting access to affected communities, disrupting surveillance and vaccination, increasing distrust of responders, and forcing people to move or resist public health orders," Jennifer Nuzzo, professor of epidemiology and director of the Pandemic Center at Brown University School of Public Health, told Newsweek.

The result, Nuzzo warned, is that "the risks extend beyond the DRC’s borders," and "the more countries that experience cases, the harder it becomes to stop the outbreak and the greater the possibility of importation of cases to other parts of the world, including the U.S.."

"But even if the cases stay in DRC," she added, "it will mean a perpetual state of vigilance for countries, which carries a cost, and it increases the possibility of political and economic instability in places where countries have long worked to bring peace and security."

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Who's Fighting Whom

Unlike most conflicts raging across the globe, even in some of the most complex regions, the DRC's front lines can hardly be mapped. Rather than appearing as traditional zones of control, factions often occupy ill-defined, fragmented and fluid swathes of territory, with much of the most violent clashes taking place in the country's east, which borders Uganda, Rwanda and Burundi, each of which has played a role in the DRC's past and current conflicts.

Allegiances are similarly opaque. Both state and non-state actors have records of shifting loyalties based primarily on pragmatic gains rather than traditional ideological aims.

Answering to the government, led by President Félix Tshisekedi, are the DRC Armed Forces, which are currently in the throes of overlapping conflicts that sometimes involve troops relying on irregular militias to bolster the war effort.

"In the Kivu provinces (North & South Kivu), the main actors are on the one hand the M23 rebel group, supported by Rwandan troops; and on the other hand, the Congolese government, supported by a range of non-state armed actors under the ‘Wazalendo’ umbrella," Kristof Titeca, chair of research at Antwerp University's Institute of Development Policy and senior associate fellow at the Egmont Institute's Africa Program, told Newsweek.

"Ituri and North Kivu have a whole range of armed groups, of which the ADF rebel group (which swore allegiance to ISIS) and CODECO are the two most important," Titeca said.

Ugandan intelligence has claimed tactical coordination between the ADF, or Allied Democratic Forces, which is an Islamist movement originating in Uganda and operating under the umbrella of the Islamic State militant group's Central Africa Province, and CODECO, or Cooperative for Development of the Congo, which is a loose coalition of ethnic Lendu militias.

But the two groups maintain largely distinct aims. The ADF engages in a jihadi style insurgency emphasizing mass-casualty attacks, while CODECO is waging sectarian war against rival groups such as the ethnic Hema-affiliated Ituri Self-Defense Popular Front.

M23, officially the March 23 Movement, is assessed to be the most powerful of all. The group, established among ethnic Tutsi militiamen opposed to a 2009 peace deal, has direct support from Rwanda and has proved the most persistent and challenging foe for the government, whose resources are perpetually spread thin on multiple fronts.

U.N. health agencies, such as the World Health Organization, and peacekeepers, represented by the U.N. Organization Stabilization Mission in the DRC (MONUSCO), are also struggling to keep pace, leaving a dangerous blind spot for an invisible foe penetrating the ranks of all sides and civilians alike.

"The presence of armed conflict and armed groups has indeed made the response more complicated: it makes the tracking of those infected much more difficult," Titeca said. "Fragmented territorial control and competing authorities also makes this more difficult. The M23 rebel group (supported by Rwanda) tries to use Ebola to showcase its governance model; by attempting to show it is more effective. This creates a risk for underreporting."

The Cost of Neglect

The M23 captured rare attention from the White House last year, when the Trump administration sought to negotiate an ambitious peace deal between the DRC and Rwanda. The deal was supposed to involve both top Rwanda-backed factions: the M23 and another formation known as the Democratic Forces for the Liberation of Rwanda (DFLR).

Despite ongoing disagreements among the various parties, the deal was signed by the heads of the DRC and Rwanda in December, with the U.S. also securing cooperation on the DRC's vast wealth of critical minerals. Little changed on the ground, however, as the M23 never joined the accord, Rwanda did not withdraw troops and the DFLR has signaled readiness to resume operations.

While negotiations remain open, they have been moved from Qatar to Switzerland as a result of the war launched by the U.S. and Israel against Iran in February. Washington's focus has also been largely diverted.

In the meantime, Titeca warned that the impact of other U.S. policies has only deepened the humanitarian crisis in the DRC. He said that "the fact that the U.S. had cut support for neglected tropical diseases, was one of the factors—or even better, a major one—which allowed the virus to spread."

So far, the only documented cases of Ebola outside of the DRC—save for a returning doctor diagnosed in France—have been detected in Uganda, a country with more robust resources to combat the disease. But the growing outbreak is now making its way toward more vulnerable nations.

"Ebola is, however, spreading north from the infected provinces in the DRC, which is in the direction of South Sudan, and potentially Central African Republic," Titeca said. "If it starts spreading there, the risks are much higher."

The broadening scope of various armed factions and the Ebola outbreak across the DRC itself does not inspire confidence, either.

The DRC's worst-hit region by Ebola is Ituri, accounting for roughly 88 percent of confirmed cases. Here, fighting mostly involves CODECO and another rebel group known as the Convention for the Popular Revolution, founded by militant leader Thomas Lubanga, who became the first person to be arrested by the International Criminal Court in 2006.

"Both of these groups claim to defend particular local communities and may remain open to humanitarian responses in order to bolster their own legitimacy," Ladd Serwat, Africa senior analyst at the Armed Conflict Location and Event Data (ACLED) monitor, told Newsweek. "Armed actors in Ituri have historically complicated humanitarian access, particularly where populations are perceived as aligned with rival ethnic communities,"

Elsewhere in Ituri, Serwat noted that the DRC's announcement of the outbreak on May 15 was followed by an uptick of attacks carried out by the ADF, which has expanded its operations and "has also frequently conducted attacks on health workers."

"In November of last year, ADF attacked a health center in Biambe, reportedly killing at least 17 patients, looting hospital goods, and burning down the facility," Serwat said. "This targeted violence against health facilities threatens responders seeking to curb Ebola's dangerous spread into new areas.”

And while militants deliberately targeting health workers marked one dangerous trend, he warned that "the majority of violence directed at Ebola responders involves mobs and violent demonstrations upset with the strict methods of handling Ebola patients and the deceased."

A Grim Prognosis

Neither the decline in public faith in national and global health institutions nor the intersection of security and health crises are unique to the DRC.

The relationship between war and disease has been noted since antiquity. More recently, in what was the world's largest pandemic a century before the emergence of COVID-19, the transmission of the so-called Spanish flu—which most experts now believe began in the U.S.—was famously accelerated by the largest conflict in history at the time, World War I, likely killing more people than the war itself.

Studies indicate that in World War II as well, disease and famine killed roughly as many people as those suffering military-related deaths.

This correlation is far better understood today than in the past, yet solutions have not arrived equally across the modern world. The largest and deadliest-ever Ebola outbreak that swept through West Africa from 2013 to 2016 and killed more than 11,000 people found fertile ground in nations caught in the throes of armed conflict, poverty and distrust toward governing bodies.

The trend has proven even more lethal in the DRC in the wake of the Second Congo War, the world's deadliest conflict since World War II. It's sometimes referred to as Africa's World War given the shared multi-million death toll, involvement of multiple nations and a lesser-discussed link of disease transmission that lives on today with the ongoing unrest.

"Human movements are one of the most important transmitters of disease," Debby Guha-Sapir, director of research on the epidemiology of disasters at the Université catholique de Louvain and senior fellow at Johns Hopkins University, told Newsweek.

Now in the DRC, Guha-Sapir pointed out "we face not only major and frequent displacement but also highly vulnerable communities with low or very low levels of vaccination and many with serious malnutrition," risking not only spreading disease but more "severe forms" of it.

"Personally, I am truly surprised that the disease has not received more attention from the international health community, especially private entities such as Gates or other such foundations," Guha-Sapir said. "Governments have been sadly absent from this entire story almost since the start of previous Ebola outbreaks."

It's "all the more surprising since the case fatality rate is so astoundingly high."

And the threat does not lie with Ebola alone, as Gilbert Burnham, a physician and professor emeritus at Johns Hopkins University's Bloomberg School of Public Health, said. The DRC struggles to sustain adequate control measures to address a range of "neglected" diseases, including river blindness, which, paired with the parasitic loa loa co-infection, warrants specialized epidemiological measures as traditional treatments could produce fatal reactions.

There is also the dreaded sleeping sickness, which is considered one of the world's most lethal parasitic diseases when left untreated.

Ebola is not traditionally placed in the same category as such "neglected tropical diseases," which Burnham notes are classified as such "not because people don't have them and because there's not lots of them, but because there's not so much interest from the funders, there's not so much interest from the drug people, there's not so much interest from public health programming."

But the current outbreak has exposed a fatal insufficiency in tackling even better-known diseases that have already claimed scores of lives in the least-equipped stretches of the world, with no guarantee that other more comfortable regions would remain immune from both the sickness and instability that ensues.

"This particular strain, the Bundibugyo strain, is something that we've known is around, but it didn't seem to be very common," Burnham told Newsweek. "And so, all the efforts that we put into developing the vaccine for the principal strain for Ebola virus, we didn't do it for this, and even the testing equipment, we didn't do it for this because it was not so common."

"And it's also because, where are the financial interests, where are the political interests, and so forth in this, and it didn't seem like that was a major interest," Burnham said. "But then, when these things happen, they have a way of coming back and biting us."

Contact Newsweek editors on this story: Frances Mao, John Feng, Edward T. Cummins.

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