🟡 Preliminary Evidence
The true scale of the Ebola outbreak in North Kivu, Democratic Republic of the Congo (DRC), may be substantially larger than reported cases suggest, according to Yap Boum II, head of emergency preparedness and response for the Africa Centres for Disease Control and Prevention (Africa CDC). Speaking to The BMJ, Boum described the visible caseload as the “tip of the iceberg,” highlighting how armed conflict and community mistrust are crippling outbreak surveillance and response efforts in one of the world’s most volatile regions.
Key takeaways
- Ebola cases in DRC’s North Kivu province represent only a fraction of true infection burden, warns Africa CDC
- Armed conflict and mass casualties from violence are creating barriers to disease reporting and community engagement
- Trust between health workers and communities is being undermined by insecurity, complicating containment efforts
- Outbreak surveillance systems are failing to capture many cases in conflict-affected areas
Barriers to Ebola Response in Conflict Zones
Primary obstacles to outbreak control identified by health authorities, DRC 2026
Source: Africa CDC emergency response assessment, 2026 | Georgian Medical Journal News
Invisible cases in a conflict zone
The outbreak, which The BMJ reports emerged in mid-May 2026, is unfolding against a backdrop of extreme violence in North Kivu. When Boum visited an Ebola treatment centre in Beni in early June, the region was reeling from coordinated attacks that left more than 30 people beheaded in nearby villages just days earlier. This context, he explained, fundamentally changes how communities relate to health authorities.
“When you listen to that, you change your perspective on what your role is in the response,” Yap Boum II, regional incident manager for the Ebola response at Africa CDC, told The BMJ. “The most important thing we have is the trust of the community—which is not a given.” Boum’s assessment underscores a critical public health challenge: outbreak response cannot succeed when populations are more afraid of armed groups than of disease. See our coverage of migration and health challenges in unstable regions for context on how conflict affects disease control.
Counting deaths in a war zone
The scale of undercounting remains unclear from available data, but Boum’s characterisation of reported cases as merely the “tip of the iceberg” suggests that deaths occurring outside formal treatment facilities—whether from Ebola or violence—are going unrecorded. In conflict settings, many patients either avoid healthcare systems entirely due to insecurity, or die before reaching diagnostic facilities. Post-mortem transmission risk further complicates case identification, as bodies may not be safely collected or examined.
This mirrors patterns seen in the 2014–2016 West African Ebola epidemic, where outbreak estimates were revised upward repeatedly as epidemiologists applied capture-recapture methods and community-based surveillance. Global Health officials at the World Health Organization have previously documented how conflict-affected regions systematically underreport infectious disease burden.
Trust as the frontline intervention
Boum’s emphasis on community trust reflects a lesson learned from past Ebola responses: surveillance and containment depend on populations voluntarily reporting cases and accepting isolation. When armed groups are active, communities rationally prioritise immediate physical safety over public health cooperation. Health workers themselves become targets, further eroding system capacity.
The Africa CDC is tasked with strengthening disease surveillance across the continent, but outbreak response in active conflict zones tests the limits of that mandate. Boum’s visit to Beni suggests that Africa CDC is attempting to maintain presence and engagement despite insecurity, though the human cost to responders—and the vulnerability of health facilities—remains acute.
Reported Ebola cases in DRC represent only the “tip of the iceberg” of true infection burden, with armed conflict and community fear creating invisible caseloads beyond detection systems.
— Yap Boum II, head of emergency preparedness and response, Africa Centres for Disease Control and Prevention, speaking to The BMJ (2026)
What this means
Frequently asked questions
Why would violence reduce case reporting for Ebola?
In conflict zones, communities lose confidence in authority and institutions, including health systems. When armed groups are active and killing civilians, people may hide suspected cases to avoid exposure or move to informal shelters outside health systems. Health workers themselves may be unable to safely travel to report cases or reach patients.
What is “capture-recapture” method for disease surveillance?
Capture-recapture is an epidemiological technique that uses multiple incomplete lists of cases (e.g., hospital records, lab reports, death certificates, community reports) to estimate total disease burden. By identifying overlaps and gaps, researchers can estimate how many cases each system missed independently.
Why does Africa CDC say community trust is the most important factor?
Without trust, people will not report cases, seek care, or cooperate with quarantine measures. Ebola control depends on rapid identification and isolation of cases. If communities hide sick people out of fear—of violence, authorities, or stigma—the virus spreads undetected and the epidemic grows exponentially.
The Africa CDC’s candid assessment signals that Ebola response in the DRC will be a long-term challenge defined not only by viral epidemiology but by political stability and community resilience. As long as armed conflict persists in North Kivu, outbreak data will remain incomplete and containment efforts compromised. International partners must address both the disease and the insecurity driving it.
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