Fever in the Mist

‘Under what conditions do you close the border?’

I’ve asked this question dozens of times in recent weeks, without any clear answer. To be reasonable to the people I’ve been speaking to - healthcare and humanitarian workers up and down the Rwanda – DRC border - there is no real way they could know. If it happens, it will happen quickly, and the decision will be made at the top.

The Ebola crisis in eastern Democratic Republic of Congo (DRC) is getting worse, embedded in a political environment of postponed elections, mass refugee movements, and violent attacks on treatment centres. To date there have been 879 confirmed cases and 553 deaths from the disease. These numbers have doubled since December and the outbreak is now the second largest in history. Considering the extreme difficulty involved in contact tracing and effective quarantining, hemorrhagic fever is looking increasingly endemic in eastern Congo.

This is not being translated into attitudes away from Beni and Butembo, the worst affected territories. Even where hand-washing stations and efforts to monitor temperatures and travel histories are in place, many of those crossing the regions’ borders see them as a nuisance and the virus as a distant threat. In international news coverage, Ebola in DRC is being treated like the re-run of a TV series from 2014. People reassure themselves that the disease has somehow been ‘figured out’. In reality, although a vaccine does exist, it remains in extremely short supply, and far too many frontline staff have died as a result.

The WHO remains confident that the disease can be controlled and eradicated, and a lot of exceptionally brave people are risking their lives to that end. Nevertheless, in hushed conversations after policy briefings some of the confidence gives way to the stark facts: it is spreading, and there is currently no end in sight.


The wake up call could come quickly. As of 1 March 2019, a number of people on the road to North Kivu’s capital, Goma, have been turned back after triggering alerts. Several of these cases have later been confirmed as EVD, and contact tracing is already taking place in the city.

Goma’s size and connections throughout the region make it a particularly dangerous context for Ebola. It houses approximately one million people, many of them unregistered residents living in informal settlements or in the remnants of old refugee camps. Regular boats connect the city to its sister-capital, Bukavu, in South Kivu – a ‘big jump’ in terms used by the Centre for Disease Control. Both cities have international airports that act as hubs for much of the wider eastern DRC region. They also sit at the westernmost end of the Northern Corridor, a two thousand kilometre freight trading route that arrives at the Kenyan coast via Kampala and Nairobi.

To make matters worse, the DRC-Rwanda border is one of the most crossed in the world. Both Goma and Bukavu are perched on it, and their urban districts fuse into those of Rubavu and Rusizi, smaller Rwandan towns on the other side. Every day, as many as fifty thousand people cross between Goma and Rubavu alone.

Most are local traders carrying foodstuffs to the larger Congolese markets. It is a survival economy, conferring several dollars a day to those involved. Very often the money goes towards dependents as well as the traders themselves, and at a guess, several hundred thousand live off the border.

Stark differences between the political and economic environments on either side are what fuel this cross-border interaction. Weak, locally contested state authority, insecurity, minimal economic regulation, and greater opportunities for employment on the DRC side are pitted against strong, centralised political authority, physical security, heavy regulation (both social and economic), and a smaller job market in Rwanda.

Rwanda is better prepared to deal with Ebola than its Congolese neighbour. The country’s dense population and decentralised administrative structure allow for healthcare surveillance to take place at the most local level. The government has sprung into action, and its EVD campaign is omnipresent in posters, digital billboards, radio and TV broadcasts, and town hall meetings. Ebola Treatment Centres (ETCs) have been set up in the larger border towns, and the training of medical staff has been tireless since the outbreak was first recorded in August 2018.

Although significant efforts have been made on the DRC side, the political environment makes it more difficult to install effective prevention measures. Violent instability involving armed militias still plagues the region. Some groups have found it advantageous to foster rumours about the disease’s origin and the ulterior motives of the teams working to combat it. This has produced resistance to the Ebola Response, most tragically in recent days when two healthcare centres in Butembo were attacked and destroyed, and four people confirmed to have the disease fled back into the community at large.


This brings things back to the original question – under what conditions will the border be closed? Even the idea is anathema to groups such as UNHCR and IoM, who work with refugees and encourage the free movement of people out of conflict zones. Similarly, the general consensus among healthcare organisations is that it is better to carefully manage checkpoints – even those that see extremely high population flows – than to shut them and force people onto routes than are less easily monitored.

There is very little precedent for sealing the border, and even during periods of heightened tension between the two states it has proven difficult. Congolese authorities temporarily went through with it in 2012 at the height of the M23 militia crisis, but were forced to back down quickly due to popular unrest. In September 2013, Rwandan authorities partially closed the border between Goma and Rubavu following a mortar attack, but reopened it almost immediately once the situation had been clarified.

Closing the border would be devastating for local residents on both sides. In the event, thousands of people could quickly find themselves out of money and out of food. In the wider region, short border closures have seen misery arrive in the space of a few days. For closing the DRC border to make sense, it would have to run on for months. The standard measure for declaring an area Ebola free is the so-called 0+42 rule: zero cases for forty-two days. That’s a very long time for those who live off what they can carry on their back.

In the event of Ebola arriving in Goma and of person-to-person transmission taking place in its backstreets, these calculations may start to change. In informal conversations, there is a disturbing appetite in parts of Rwanda for sealing its borders and bunkering down. ‘We would rather starve than die of Ebola’, one contact told me. We can hope that this decision never needs to be made, but a lot more work still needs to be done to prevent it.

Hugh Lamarque is a Post-Doctoral Research Fellow at the University of Edinburgh