What’s causing the mysterious outbreak in Congo?

Beginning in late October in a remote, conflict-afflicted region of Democratic Republic of Congo, choked off by the rainy season, hundreds of people began falling ill with a particular constellation of symptoms: fever, aches, cough, and runny nose. Health officials don’t yet know the cause of the outbreak, whether it is a “Disease X,” the name the World Health Organization (WHO) has taken to calling a hypothetical future pandemic or a familiar disease like measles, influenza, COVID-19, or malaria exacting a severe toll on a vulnerable population. At any rate, the month it took for a report of the outbreak to reach global health authorities highlights the fragility of a patchwork system meant to quickly detect potentially worrisome outbreaks.

What happened? The mysterious illness began afflicting people in Kwango Province in southern Democratic Republic of Congo during the last week of October, according to a WHO report. By December 5, the WHO had logged more than 400 infections and 31 deaths. That means 7.6 percent of the sick died; for COVID-19, the case fatality rate has been pegged at about 1 percent. Most of the Congo cases were in children, many under five years old.  Of the severe cases, all were malnourished, the health organization said. While cases appeared to peak in early November, the outbreak is ongoing.

Could this be “Disease X”? The WHO coined the term “Disease X” in 2018 to raise awareness of the threat that posed by unanticipated pathogens. Of course, the following year, a novel coronavirus began circulating in Wuhan, China. That said, experts say most outbreaks are caused by familiar pathogens. The WHO said Tuesday that ten samples have tested positive for malaria, according to a report in The Guardian published late Tuesday.  WHO Director-General Tedros Adhanom Ghebreyesus said there could be multiple pathogens involved in the outbreak. Authorities are continuing to test samples, he said.

Why did it take weeks for reports to come out? The director-general of Africa Centres for Disease Control and Prevention (Africa CDC) bemoaned the lag between when people started getting sick and the Democratic Republic of Congo government alerting the WHO at the end of November. “We do not want to see another disease that will be another five to six weeks before official notification,” Jean Kaseya said recently, according to Voice of America.

According to the recent WHO report, the outbreak is occurring some 48 hours by road from the capital Kinshasa. The region has no laboratory capable of running the diagnostic samples, meaning officials must transport them back to the capital. A recent survey by the Africa CDC, which didn’t include the Democratic Republic of Congo, found many countries on the continent lacking in the laboratory infrastructure necessary to diagnose epidemic disease. In 2023, there were 180 public health emergencies, mostly stemming from infectious disease. These included Marburg, mpox, polio, and other illnesses. Most of the 15 countries in the survey said they lacked consistent access to supplies, like the chemicals used in tests.

Why are so many people dying? While it’s unclear what the pathogen causing the outbreak is, there are factors that could be contributing to making it so lethal. The Democratic Republic of Congo is rife with conflict, and since 1996, some six million people have died in armed violence in the country’s eastern section alone. In the western part of the country, including Kwango, inter-communal violence has been flaring, according to Amnesty International. And conflict in the country is exacerbating what the UN’s World Food Programme has deemed one of the worst hunger crises in the world. Millions have left their livelihoods as they have fled violence. Overall, some 25.6 million people are suffering from emergency levels of food insecurity, including nearly 4.5 million children who are critically malnourished. Food insecurity in Kwango rose from acceptable to crisis levels between April and September, the WHO report said. Malnourished children are more likely to suffer severe consequences from measles and other diseases. The province also has low vaccination rates, leaving people in Kwango more susceptible to bad outcomes.

The situation in the Democratic Republic of Congo exemplifies what a struggle it will be to thwart another pandemic. Long-standing high levels of conflict and poverty have left large parts of the country without the health care and diagnostic infrastructure necessary to both care for the sick and ring the alarm over suspicious outbreaks. The outbreak in Kwango is a warning: Five years after the start of the COVID pandemic, a pandemic early warning system is not nearly as airtight as one might have hoped.