Faulty reasoning signals

• Confirmation Bias - 0.9% (18 hits)
• Anchoring Bias - 2.5% (48 hits)
• Availability Heuristic - 10.7% (206 hits)
• Representativeness Heuristic - 1.9% (37 hits)
• Hindsight Bias - 1% (20 hits)
• Overconfidence Bias - 3.4% (65 hits)
• Framing Effect - 0%
• Loss Aversion - 1.4% (28 hits)
• Status Quo Bias - 0.8% (16 hits)
• Sunk Cost Effect - 0%
• Optimism Bias - 3.2% (62 hits)
• Pessimism Bias - 6.1% (117 hits)

Article text

Managing DRC’s Ebola Crisis

A dangerous Ebola outbreak of the unfamiliar Bundibugyo species is unfolding in the eastern Democratic Republic of the Congo (DRC), centered in the remote, violently disordered, and difficult to access Ituri province and its neighboring North and South Kivu provinces.

The crisis has triggered repeated allegations that the delayed and weak international response stems to a significant degree from Trump administration decisions to dismantle the U.S.

Agency for International Development (USAID), reduce bilateral staffing and funding, withdraw from the World Health Organization (WHO), and cut scientific research.

It has also prompted predictions that the epidemic will grow exponentially and spread geographically.

Both of these claims have a measure of validity yet are oversimplifications that can be misleading or distracting.

One month into the outbreak, it is time to focus on the evolving big picture and a concrete way forward.

That means insisting upon realism, humility, close attention to evolving facts on the ground, and a clear understanding of the acutely difficult security environment.

It is essential to keep the following realities front of mind:

* **A Broken Global Response:** In the aftermath of the Covid-19 pandemic, the system of international response has become geopolitically fractured and profoundly weakened in terms of organizational capacities, staffing, finances, and fundamental functionality.

This decay is true of the WHO, the United States, other major donors, UN agencies, and international NGOs.

Donors are fatigued and stressed, balancing emergency health assistance against growing security demands related to conflict in Ukraine and the Middle East.

Compounding matters are widespread mistrust and skepticism stoked by Covid and other prior Ebola outbreaks.

This is the new reality.

It will not be fundamentally fixed in the projected two years required to arrest the outbreak.

There will be far less money and far more fragmentation of effort.

Nonetheless, the WHO and the Africa Centres for Disease Control and Prevention have distinguished themselves in this period in their joint leadership, including a new $518 million continental response plan.

Incremental improvements in international coordination are within reach if there is sufficient high-level political will by all donors to turn pledges into action and if the United States can find its way to integrate with others.

* **The Centrality of Insecurity:** Insecurity dominates the operating environment far more than in the 2018–2020 outbreak in the eastern Congo, and vastly more than the 2014–2016 outbreak in West Africa.

It imperils the health and humanitarian response by introducing major logistical barriers—including recurring airport closures—creating enormous uncertainty about what interventions are truly possible.

Insecurity should not be expected to diminish any time soon despite the existence of a U.S.-negotiated peace agreement between the DRC and Rwanda.

The longstanding UN peacekeeping mission, MONUSCO, remains important to the security environment in eastern Congo, but it is no panacea and has a mixed record.

There is little evidence thus far of any updated strategy that will effectively address the drivers of violent insecurity in Ituri, nor in the North and South Kivu provinces.

The Allied Democratic Forces and other armed militias are deeply linked to illicit gold mining, in excess of $3 billion per year, an export industry at the heart of the outbreak that runs through Ugandan circles and on to the Gulf.

Access by emergency responders is a direct threat to these operations and an invitation to abuse and diversion.

Similarly, the armed Congolese Tutsi movement, M23, a proxy and dependent vassal of the Rwandan government, controls Goma and most of North and South Kivus.

M23 serves the interests of the Rwandan government, which achieves dominance and security benefits along with the considerable financial gains from illicit movement of critical minerals into Rwanda.

Insecurity will likely impede scaling many critical interventions known to reduce transmission and improve survival: isolation, testing, contact tracing, infection prevention and control, treatment, community education, and safe and dignified burials.

That work will be led by trusted community leaders, long-standing humanitarian actors, and UN partners supported by skilled, largely African experts with deep experience in past Ebola outbreaks.

That type of mobilization was what proved most significant in the 2018–2020 outbreak.

UN Peacekeeping operations in the eastern Congo also played a modestly important role.

* **An Uncertain Outbreak:** There is considerable uncertainty as to whether the outbreak will scale or be exported to distant capitals.

That did not happen in 2018.

There are strong arguments that 2026 is different, given delayed detection; comparatively high early caseloads; infections in urban centers, including in Uganda; insufficient testing amid a lack of rapid diagnostics and field laboratory capacity; poor contact tracing; and unclear fatality rates.

It will be necessary to actively prepare for two potential scenarios: (1) containment and slow burnout, and (2) exponential growth and migration outside the hot zone.

In either event, it is imperative to prepare for the likelihood of a few hysteria-inducing cases in the United States.

* **Centrality of the United States**: The United States remains vitally important and has swung into action after some stumbles, demonstrating muscle memory, according to established response playbooks.

The Trump administration expedited emergency funding that now places the United States in the lead of the international response, with money flowing to support partner organizations’ border screening, contact tracing, and procurement work on the front lines.

The Centers for Disease Control and Prevention (CDC) has mobilized its experts and flexible financing mechanisms, including $107 million in emergency funding, while the State Department has committed more than $270 million for response activities, making use of inherited contracts with key global health partners—including the International Organization for Migration, World Food Programme, UNICEF, International Medical Corps, and FHI 360 among others.

Even though USAID no longer exists, the Department of State deployed a Disaster Assistance Response Team.

At the same time, it has used the crisis to re-establish a formal partnership with the Coalition for Epidemic Preparedness Innovations with a $50 million commitment to expedite the development of vaccine candidates.

It has also used its funding to the UN Office for the Coordination of Humanitarian Affairs to advance an additional $350 million in regional humanitarian assistance.

In some respects, this should not be surprising.

Early in this term, the Trump administration signaled that resolving the conflict between the DRC and Rwanda was a priority, particularly given its relevance to critical minerals and reducing China’s sway in the region.

The DRC and Uganda also remain priority partners for CDC health security cooperation and U.S. foreign assistance, evinced by their newly signed bilateral memorandums of understanding.

Even so, the United States is working with under-resourced CDC country offices and a dearth of deployed staff, with its experts and nongovernmental partners operating outside of the WHO-Africa CDC incident management structure.

This risks duplication and inefficiency antithetical to U.S. national security interests.

* **The Kenya Debacle**: The U.S. proposal to establish a quarantine facility on a Kenyan military base rapidly fueled suspicion and angry protests in Kenya, covered widely in the international press.

Such damaging missteps left the impression, still uncorrected, that the United States would not permit the repatriation of Americans who were exposed to and infected by Ebola to the United States, despite legal precedent and domestic capabilities built after the 2014 Ebola outbreak for that explicit purpose.

U.S. experts may be dissuaded from service if they fear they will not be allowed or assisted in returning home.

**Next Steps for the U.S.

Response**

As of June 17, the outbreak has climbed to 896 confirmed cases and 232 confirmed deaths in the DRC and 19 confirmed cases and 2 deaths in Uganda.

In the protracted and uncertain struggle ahead, the U.S. response should include the following steps:

1.

**Strengthen U.S. coordination capabilities.

** The administration should institute a true interagency process that reconciles tensions between the Departments of State and Health and Human Services and integrates the assets of the intelligence and defense communities.

This is the moment to fix the glaring absence of a White House command capacity.

That might involve the appointment of an Ebola czar, as happened during the 2014–2016 West Africa outbreak.

Better still, it will rest on appointing a senior director for biopreparedness at the White House National Security Council and a director of the now vacant Office of Pandemic Preparedness and Response Policy.

Congress should simultaneously expedite approval of a CDC director and assistant secretaries of the Bureaus of Global Health Security and Diplomacy and Disaster and Humanitarian Response.

2.

**Devise a two-year plan and budget.

** The response should focus on surging the most urgently needed resources to the front lines as close as possible to patients: contracted health care workers and community engagement experts to deploy to the epicenter of the outbreak; mobilized U.S. government experts and partners to provide technical support that strengthens contact tracing, investigations, lab networks, and testing capacity; personal protective equipment and infection prevention and control supplies; and cooperation to develop and deploy rapid tests, experimental treatments, and vaccines, including through re-established partnership with Gavi.

There is a role for U.S. technical experts at the Department of Defense, National Institutes of Health, Administration for Strategic Preparedness and Response, and Biomedical Advanced Research and Development Authority, and there is a critical need for CDC global offices to be sustained at full strength, with long-term capability to support work on emerging viral hemorrhagic fevers.

3.

**Engage in international coordination mechanisms.

** The United States should acknowledge the leadership of the WHO and Africa CDC on the response and engage in regular international consultations, without restrictions on technical cooperation that might yield inefficiencies.

The G7 leaders’ call for a coordinated response signals that these powers recognize the need to coordinate in a more strategic way.

U.S. experts should also elevate bilateral diplomacy to encourage other partners to commit more meaningful resources to the response.

4.

**Advance diplomacy on the security situation.

** The goal is to negotiate safe, protected access for healthcare workers and the sustained reopening of the airports in Bunia and Goma for daily humanitarian flights.

The United States should focus on how best to leverage MONUSCO and press for the appointment of an international lead on the Great Lakes regional security environment.

Bilaterally, the administration should leverage its relationships with the DRC, Rwanda, Uganda, and the United Arab Emirates, while exploring whether UN peacekeepers might play a constructive role.

5.

**Drop Kenya plans and affirm repatriation.

** This is a matter of principle and legality—that Americans who serve in the response cannot be denied the opportunity to return to the United States for care.

Limited alternative options can be explored as a matter of pragmatism.

Americans could be evacuated to Europe for emergency care as needed.

It may also be wise to build facilities near the hot zone for exposed healthcare workers before they are evacuated, as was done by the U.S. military in Liberia in 2014.

**The Way Forward**

Arresting this outbreak will be difficult and require patience, sustained commitment, and a multiyear outlook.

There are fewer resources and weaker institutional capabilities than in past emergencies.

There will be a painful struggle with vexing and dangerous security challenges.

But past Ebola responses have been similarly plagued by delayed detection, challenging operating conditions, deep community mistrust, and dysfunctional coordination.

Ultimately these outbreaks were brought to heel.

There is reason to be hopeful that order will emerge from the chaos, and that U.S. leadership can remain central and meaningful.

J.

Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C.

Michaela Simoneau is a fellow with the Global Health Policy Center at CSIS.