The Shadow of the Next Pandemic Looms in a Virus Hotspot

NSELE, Democratic Republic of the Congo—Nana Ibumbu noticed that 8-year-old Daniel Mwanza was burning up. Ibumbu is the nutritionist at an orphanage on the outskirts of Kinshasa, the capital of the Democratic Republic of the Congo, and oversees all aspects of the children’s health. Last fall, Congo faced a major mpox (previously known as monkeypox) outbreak, as well as a persistent threat from measles. She decided to give Daniel antibiotics, hoping his fever would die down. But then the vomiting started, and soon afterward blotchy rashes appeared on Daniel’s skin.

Days later, two younger children, Chris Matondo and Benicielle Tshitenge, showed the same symptoms. Ibumbu thought they all might have measles; few of the 35 kids living in the orphanage were vaccinated. She took the three to a nearby health clinic, where Dr. Tresor Gulefwa had another theory: mpox. To be sure, he had to send samples to the National Institute of Biomedical Research (INRB), located in central Kinshasa, about 18 miles away—the only lab able to test for infectious diseases in either Congo or the neighboring Republic of the Congo.

Ibumbu stands in a doorway in Kinshasa on Aug. 24.

Congo struggles with a string of annual epidemics: Measles, polio, cholera, plague, malaria, Ebola, and mpox are just some of the diseases that have threatened children, many of whom are unvaccinated. In Congo, only 35 percent of children are fully vaccinated before their second birthday. This follows an unfortunate trend: Before the COVID-19 pandemic, global immunization rates were slowly increasing, but in 2021 almost 25 million children around the world missed their routine vaccinations, the largest backslide in more than three decades.

Congo has long been a ground zero for infectious diseases. Low vaccination coverage—as well as reduced trust in vaccines—and poor sanitation put the country at risk of exporting viruses across its borders. During a 2018 Ebola outbreak, which became the world’s second-largest, related cases were reported in Uganda. Although Congo’s government has taken steps to improve immunization rates, the country’s large size and limited financial resources make controlling nationwide outbreaks difficult. Without comprehensive vaccination campaigns, diseases can spread and adapt undetected and threaten the rest of the world, too.

Orphanage workers hold 2-year-old Benicielle, who exhibits symptoms that could be mpox or measles, at Bethesda Health Clinic in Kinshasa on Aug. 23 and on Aug. 24 at the orphanage. 

But whether the children at the orphanage had measles or mpox still mattered: Although a more effective mpox vaccine, Jynneos, was approved by the FDA in 2019, it is not yet publicly available in Congo. When the virus reached Europe and the United States last year, causing short-lived but sizable outbreaks, they received the available vaccines. But Congo is among the countries most affected by both viruses. Between 2020 and 2022, the World Health Organization recorded more than 10,000 cases of mpox in Congo, with more than 360 deaths. Congo also experienced its worst-ever measles epidemic between 2018 and 2020, with more than 460,000 cases. The true figures are likely much higher.

Given Congo’s history with the disease, just one case of mpox is enough to declare an epidemic, according to Gulefwa. Last year, 22 of the country’s 26 provinces experienced mpox epidemics. But the lack of capacity for rapid testing in Congo often renders test results useless, as the orphanage staff learned. “The biggest challenge is the time between when we receive the samples and when we find the results,” Placide Mbala, INRB’s lab manager, said.

Lab workers investigate test tubes in the mpox laboratory at the National Institute of Biomedical Research in Kinshasa on Aug. 23.

Congo struggles to immunize millions of children under ordinary circumstances. A lack of infrastructure, fuel shortages, and the centralization of vaccines in the capital have contributed to the problem. Keeping the vaccines at the necessary temperature in the tropical climate is the biggest challenge, said Devos Kabemba, the head of the Nsele health zone. He added that the Nsele health zone doesn’t receive enough annual funding to develop adequate vaccination campaigns—only $3 per child, when it really needs $15. Support from international partners isn’t enough to cover it.

The government has focused on education. At the Mervedi medical center in Nsele, mothers stood in line with their newborns waiting for them to be vaccinated. Many women said they have no access to clean, running water—another factor exacerbating epidemics in the country. Outside the clinic, Ortane Manligo, a community volunteer, spoke to people about vaccines. Her work is key, as rampant disinformation following the COVID-19 pandemic has made people wary of vaccination.

Mothers wait for their children to receive routine vaccinations at the Mervedi health center on Aug. 23.

Community volunteers “were doing well with convincing parents to vaccinate children against polio and other diseases,” Manligo said. “But when COVID came, disinformation spread on WhatsApp.” A study by the government and international partners showed that 45 percent of disinformation about COVID-19 is transmitted by word of mouth and 20 percent through social media; while the government has involved community leaders in its fight against disinformation, rumors remain hard to control. COVID-19 made it harder to convince citizens to get vaccinated, undermining preparedness for future pandemics.

Another major barrier to immunization efforts is low-level corruption. Many health workers responsible for vaccinating children around the country say they have not been paid for years. Jacques Belly, a health worker in Kinshasa who administers vaccines, said he has not been paid beyond his $75 monthly risk bonus since 2008, adding that the situation in the Nsele health zone resembles that of most of his colleagues. “We are Congolese, and we care about our children. We continue to work, and we continue to ask the government to pay us through strikes and protests,” Belly said.

The VillageReach COVID-19 vaccinodrome is constructed at Place des Artistes, a busy square in central Kinshasa, on Aug. 24, in an attempt to attract locals to be vaccinated.

Most funding for vaccines and medical utilities comes from partners like UNICEF, the World Health Organization, and the Gates Foundation, but health workers’ salaries are the responsibility of the state. Veronique Kilumba Nkulu, Congo’s deputy health minister, said the issue stems from a lack of digital payment infrastructure that could allow the money to reach health workers in remote areas. She said in an interview with Foreign Policy that they are trying to introduce more mobile payments, but the situation on the ground shows that even in Kinshasa, health workers aren’t receiving their salaries.

This precarity has led some local health workers to extort the population by asking parents for money in exchange for vaccines. Kamy Musene, a former program field manager for the University of California, Los Angeles, infectious disease program in Congo, monitored the government’s efforts between 2018 and 2022. He found that some mothers were collecting sugar cane to pay for vaccination cards for their children. “We heard in some villages that mothers had to buy vaccination cards for their babies, which can cost almost $1,” he said. Some mothers said their children still did not receive vaccines, and in some cases not even their cards.

“The problem is they know what is happening, but they are not reacting to what we are telling them. Nothing is changing,” Musene said.

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David Inana, a community outreach health worker, calls villagers to the vaccination site after the nurse and vaccines arrived to Lugunga island via boat on Aug. 26.

Villagers make their way to the vaccination site on Lugunga island after hearing that vaccines had arrived and would be administered that morning on Aug. 26.

Although the COVID-19 pandemic laid bare the importance of global health security, the inequity and disinformation that followed have affected the ability of some governments in the global south to immunize children against other threats. As new diseases emerge, countries like Congo remain on the front line of eradication—and without the appropriate resources, they risk fueling other outbreaks and other pandemics.

A woman carries her child home on the remote Lugunga island after visiting the health center where the little girl received routine vaccinations on Aug. 26.

This reporting was supported by a press fellowship from the U.N. Foundation.