In June 2016, the World Health Organization (WHO) declared that the worst Ebola outbreak in history — which claimed the lives of over 11,000 people in West Africa — was finally over. The agency spent two years providing an unprecedented amount of support and resources to control the outbreak. And yet, the response was widely criticized for being too slow, revealing gaps in the WHO’s capacity to handle global health scares like Ebola.

“Sometimes, the world has got to learn things the hard way. There are going to be more of these, no matter what we think,” Bruce Aylward, assistant director general for emergencies at the WHO, told FRONTLINE in 2015’s Outbreak, which explores the efforts to stop the spread of the virus in West Africa.

Three years later, another potentially catastrophic Ebola epidemic has gripped the Democratic Republic of Congo. Over the past year, there have been 2,600 confirmed cases and more than 1,800 deaths, which already makes it the second deadliest Ebola epidemic. FRONTLINE spoke to a range of global health experts about the lessons that were learned in West Africa, and what is being done to avoid making similar mistakes with the current outbreak — and future ones.

The World Health Organization needs to rethink emergency strategies

Nine months into the Ebola outbreak in West Africa, the WHO declared an international public health emergency of international concern (PHEIC). The agency was widely criticized for not making the declaration sooner, especially after early warnings from international aid groups like Doctors Without Borders.

Although the public health emergency declaration caused problems for the affected countries (more on that later), it also triggered resources critical to recovery.

“The PHEIC sounds a global alert, mobilizes funding from high income countries like the U.S. and in Europe, while the United Nations is also likely to be more quickly engaged,” said Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown Law.

An independent review of WHO’s response to the West Africa outbreak revealed that the lag time in declaring a global health emergency was only one of the agency’s missteps. The report recommended a number of suggestions for reform, including creating a system that would alert the international community to a health crisis before an emergency is declared, setting up a $100 million contingency fund to allow the WHO to respond to emergencies faster, and increasing the agency’s capacity to respond to health emergencies. 

Since the report, the WHO has put a number of these measures in place, including setting up a health emergencies program with a dedicated response unit for dealing with Ebola. The proposed contingency fund is now being used in Congo.

Dr. Marie-Roseline Bélizaire, the deputy incident manager for the WHO who was also part of the efforts to stanch the outbreak in West Africa, said her team is constantly changing the ways they approach the epidemic to avoid repeating old mistakes.

“In the current outbreak, we frequently have risk evaluations so we can adapt our ability to respond to the epidemic to avoid the massive disaster that Ebola caused in West Africa,” Bélizaire said. “We’re constantly adapting.”

However, at least one problem has persisted. Gostin, who was critical of the time it took for the WHO to declare an emergency in West Africa, began asking the agency to declare one in Congo last year. The WHO finally did so 11 months after the outbreak was reported.

More effective tracking of the virus to contain cross-border spread

When a handful of cases were first reported in Guinea in 2014, it took health officials about three months to identify them as Ebola. Guinea and some other countries in West Africa had never experienced an Ebola outbreak, and local health care workers didn’t initially realize that they should report it to WHO. Meanwhile, the virus quickly spread to the densely populated capital cities of Guinea, Liberia and Sierra Leone.

Tom Koch, a professor at the University of British Columbia who closely studied the spread of Ebola in West Africa, explained that effective data collection is essential for containing the spread of the virus. When he studied the spread of Ebola in 2014, he recalled getting sparsely collected medical data, often handwritten.

“The problem was that we didn’t know how best to use modern technologies to track, trace and predict the expansion,” Koch said.

With more widespread use of technology, data collection will be more extensive and make Ebola easier to contain. Response teams, like Bélizaire’s, have made technology a central part of their work in the Congo outbreak.

“We have improved the tools to collect the data based on what we experienced in West Africa,” Bélizaire said.

Bélizaire said the WHO has developed a data system that is used to share data about the virus in real time. She added that the WHO has also established a new department to handle health information regarding Ebola cases and analyze information they are receiving from health care workers on the ground.

Keep borders and trade routes open

The WHO’s global health emergency declaration in 2014 spurred border closings, trade restrictions and flight cancellations. The fallout resulted in substantial losses to private sector growth, agricultural production and cross border trade. According to the World Bank, the Ebola outbreak in Guinea, Liberia and Sierra Leone caused $2.8 billion in loss. The economies are still recovering.

“It devastated the economy and actually made the response much more difficult, because you couldn’t really bring in health workers and supplies very easily,” Gostin said. “You can isolate somebody who’s currently infectious and you should, but you shouldn’t quarantine a whole country or a geographic area. That just creates seething dissent and unrest.”

So when the WHO declared a global health emergency declaration in Congo, the organization warned against unnecessary closures of borders and transport routes to protect an already fragile economy.

“It is also crucial that states do not use the PHEIC as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region,” said Robert Steffen, chair of the World Health Organization’s emergency committee.

Hours after a third Ebola death was confirmed in nearby Goma, Rwanda closed its border with Congo. The border, which hundreds of people cross daily, was reopened after several hours. Rwanda’s health ministry has increased cross-border monitoring and warned citizens against unnecessary travel to Goma.

Better community outreach to understand local cultures

The WHO and other aid organizations on the ground say that emphasizing community engagement is the key to controlling the outbreak. Several measures have been taken to address culturally sensitive practices for burials and fight misinformation about the virus.

In West Africa, it’s customary for the loved ones of deceased individuals to be able to touch them before they are buried — when an Ebola victim’s body is most contagious. According to Guinea’s Ministry of Health, 60 percent of Ebola cases in the country were linked to traditional burial and funeral practices. The WHO estimated that 80 percent of cases in Sierra Leone were tied to burial practices.

However, it isn’t as simple as just stopping the rituals. According to Gostin, the WHO and other organizations on the ground initially forbade this type of high-risk behavior and buried the dead without any kind of ceremony, leading to backlash among people who were already grieving.

“That was an enormous affront to the community, and it made them very hurt and distrustful. The lesson here is that you need to use community leaders, anthropologists, and others with knowledge and influence in the community to find ways that are safe but also consistent with their respect for the dead,” Gostin said.

After the outbreak in West Africa began, the WHO developed a new protocol to ensure that burials are both safe and dignified. Bélizaire noted that a similar approach to burials, aided by community feedback, is being carried out in Congo.

Treating Ebola during the West Africa outbreak was made more difficult due to a lack of local understanding about the virus. In 2014, Doctors Without Borders had to stop working in a treatment center in Guinea after being chased out by local residents who believed that the organization had brought the virus with them.

In some places in Congo, vast misperceptions about the virus still exist. According to a recent study conducted in Congo, about 25 percent of respondents didn’t believe that the Ebola outbreak is real. If people aren’t properly informed about the virus, they are less likely to seek treatment and could potentially spread it.

“What I’ve found is that most people don’t care about the virus until they are infected. Sometimes people need to encounter information several times in order to believe it,” Bélizaire said.

Bélizaire’s group is attempting to engage with the community by establishing care centers closer to affected communities and Ebola outreach committees, and training local health care staff to be able to identify Ebola in patients.

Still, Bélizaire cautioned against treating the current outbreak exactly like the one in West Africa — there are distinct challenges health care workers face in Congo. For instance, when Ebola hit West Africa, the region was recovering from wars and civil unrest. However, an armed conflict is still ongoing in Congo.

There have been about 198 attacks on Ebola clinics and response teams so far, according to the World Health Organization, killing seven people working on response teams. These attacks make it harder to reach and treat communities suffering from the virus.

“I have to face a generation of young people between 20 and 30 years old who don’t believe in anything because they’ve only seen war and conflict in their lives,” Bélizaire said.

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