Mpox Outbreak in Congo: The Political Roots of Today’s Most Pressing Global Health Crisis

Photo via Reuters

SARA MEDINA: Identified as a global emergency by the World Health Organization, the uncontrolled outbreak of mpox in Congo and its neighboring countries is a product of Congo’s persistent political violence and policies promoting discrimination against groups most at risk of contracting the virus. Control of the outbreak in the face of instability requires a bottom-up approach, working to educate communities to inform social change and promoting collaboration of external aid sources with community members. 

Congo was a Belgian colony from 1908 until its independence in 1960. Its history as an independent nation since then has been riddled with violence and disease. During the Rwandan genocide in 1994, millions from the Hutu ethnic group fled to eastern Congo (known as Zaire at the time), staying in refugee camps through which cholera spread rampantly. Two years later, the Rwandan army attacked these camps, spurring the involvement of other African nations in years-long warfare. This conflict began a series of further disputes in the region that persist today.

Congo’s most recent elections in December 2023 failed to reach a political consensus, resulting in severe clashes between the military and insurgent groups. These clashes heightened in February, creating a state of extreme political instability. The most prominent insurgent groups include M23, a Tutsi rebel group tied to the Rwandan government, and the Allied Democratic Forces (ADF), a militant group affiliated with ISIS. At least 7 million people have been internally displaced, making the situation one of the world’s most critical humanitarian crises. 

Mpox is a viral illness caused by the monkeypox virus and can be transmitted through close contact with infected persons, contaminated surfaces, or infected animals. It can also be transmitted mother-to-child during pregnancy or birth. People with multiple sexual partners are at highest risk of contracting the disease. Clinically, mpox presents as a skin rash with generalized febrile symptoms. 

Congo faces the majority of the burden of the mpox outbreak in Africa, with about 31,000 suspected cases of mpox and almost 1,000 deaths. Of these deaths, 62% occurred in children. On Aug. 14, the outbreak was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO). Outbreaks must meet a set of specific, severe criteria in order to warrant this classification. Only five other diseases (swine flu, polio, Ebola, Zika, and COVID-19) have been declared a PHEIC in the past 20 years. 

The outbreak has different features by region. In some areas, cases are associated more with contact with infected animals or nosocomial transmission. In other areas, cases are highly associated with sex work or with sexual contact among men who have sex with men. This demographic feature of mpox epidemiology has led to stigmatization of the virus, actively undermining outbreak response efforts. Same-sex marriage remains illegal in Congo, and there is no anti-discrimination law protecting those identifying as LGBTQ+. The cultural taboo surrounding same-sex sexual conduct promotes violence and harassment against these groups. In the healthcare setting, explicit or implicit bias can impede treatment. In the broader prevention effort, the effect is missed vaccination among the groups who are most at risk of contracting the virus, in turn making it virtually impossible to contain the outbreak. 

This issue of stigmatization is not much different from the stigma surrounding human papillomavirus (HIV) in Congo and other African countries. Like mpox, HIV spreads primarily through sexual contact, and was initially reported in high numbers among men who have sex with men. HIV remains a large burden in Congo, with an estimated 520,000 people living with HIV. However, many people living with HIV report hesitancy in seeking treatment or even leaving their home due to fear of being stigmatized. 

Policy changes addressing this stigma have the potential effect of containing both mpox and HIV. Ideally, NGOs and national governments should work more directly with Congolese authorities to propose anti-discrimination laws, ensuring that individuals identifying as LGBTQ+ are adequately included and supported in the crucial areas of mpox response. However, due to the ongoing conflict and leadership uncertainty, it is unlikely that such laws could be implemented in a timely manner.

Thus, a more social approach would be more effective––hosting conversational workshops for hospitals, clinics, and vaccine dissemination centers to underscore the importance of preventing discrimination in containing the mpox outbreak. These workshops should be focused on hearing the concerns of healthcare workers and community members and addressing them, rather than delivering a preplanned lecture. 

One large barrier to equitable vaccine rollout is cold chain storage. The mpox vaccine must be stored at –130°C until it is administered. In Congo, vaccines are stored at a solar powered warehouse in Kinkole, but transportation delays stemming from poor infrastructure can hinder appropriate dissemination to remote areas.

Vaccination also poses a significant financial challenge. Considering that at least 2 million people need to be vaccinated to control the outbreak, the vaccine alone costs $460 million based on the price set by manufacturer Bavarian Nordic. This does not include additional costs, such as cold chain storage: the standard sub –80°C cooling box costs between $10,000 and $20,000 per unit. These costs have been partially covered by donations from national governments and NGOs, such as the European Union and the WHO. The issue is that humanitarian concerns like food insecurity and poverty, which have worsened in the past year, also need to be addressed, making allocation of funds a difficult task.

One argument is that global health security relies on the containment of mpox more than the alleviation of the humanitarian crisis, so more funds should be allocated towards vaccination. But one could also argue that humanitarian issues are actually heightening the mpox outbreak by aggravating issues of water, sanitation, and hygiene. For example, hospitals in Congo have reported shortages of beds, medication, and food, necessitating makeshift isolation wards in tents. Because these settings are less sterile, they promote nosocomial spread of mpox.

In order to decide how to effectively allocate funds and successfully disseminate vaccines to the majority of the Congolese population, both governmental and non-governmental organizations must work directly with healthcare workers and community leaders who are dealing with the issue firsthand. Only they can provide an informed opinion on what is necessary. With an unsteady national government, Congo is relying on external sources of aid to control mpox, but in order to be effective, those external sources must understand what is happening on the ground.

The lack of a coordinated response to the mpox outbreak in Congo is a result of its political climate and discrimination towards at-risk groups. If more efforts are not made to contain the virus, it is only a matter of time before it spreads across continental lines, as was the case with the Ebola outbreak in 2014. Thus, a smooth response spearheaded by international aid organizations collaborating with Congolese communities, coupled with cultivating social change with regards to stigma, is imperative to maintain global health security.

Sara Medina is a sophomore majoring in Global Health and minoring in Government, interested in the impact of world politics on population health. She is from Southborough, Massachusetts.