The emergence of Marburg virus disease (MVD) in a conflict-affected border region of Ethiopia presents a formidable public health security challenge, mirroring and in some ways exceeding the complexities faced during the 2018–2020 Ebola outbreak in the Democratic Republic of Congo (DRC)Responding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih +1. MVD, a filovirus like Ebola, is characterized by an abrupt onset of severe illness, a long incubation period of 2 to 21 days, and a high case fatality rate that has ranged from 24% to 90% in past outbreaksMarburg virus diseasewho +2. Transmission occurs through direct contact with the bodily fluids of infected individuals or contaminated materialsMarburg virus diseasewho +1.
Containing such a pathogen requires a robust public health response, but in politically unstable environments, this response is systematically undermined by the dynamics of conflict, pre-existing structural weaknesses, and deep-seated socio-political barriers. The DRC experience serves as a critical case study, demonstrating that even with the availability of vaccines and therapeutics, armed conflict and community mistrust can prolong an epidemic for yearsResponding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih +1. For Ethiopia, where no licensed Marburg vaccine or treatment is available, these systemic challenges are magnified, demanding significant adaptation from international health governance frameworks that have historically been state-centric and ill-equipped for the realities of active war zonesMarburg Virus Medical Countermeasures | SpringerLinkspringer +1.
Systemic Challenges to Outbreak Containment in Ethiopia
An MVD outbreak in Ethiopia's borderlands would confront a confluence of four primary, interconnected challenges that severely degrade the capacity for effective containment.
1. Direct Impact of Armed Conflict on Health Operations
The most immediate challenge is the direct effect of violence on the ability of public health teams to operate. The 2018-2020 DRC Ebola outbreak, which occurred amidst conflict involving dozens of militia groups, provides a stark quantitative precedent for this disruptionResponding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih .
- Attacks on Healthcare Infrastructure and Personnel: Violence directly targets the tools of outbreak response. During the DRC Ebola outbreak, there were 42 attacks on health facilities in the first five months of 2019 alone, wounding or killing 85 health workersKivu Ebola epidemic - Wikipediawikipedia . Another report documents 450 cases of violence against healthcare workers during the outbreak periodNational burden of Ebola virus disease in Democratic Republic of the Congo: the urgency to act - PMCnih . This dynamic is already present in Ethiopia, where 59 incidents of violence against healthcare were documented in 2024, including 26 attacks that damaged or destroyed facilitiesETHIOPIA Protection Analysis Updateglobalprotectioncluster . Such attacks force the suspension of activities, as seen when Médecins Sans Frontières (MSF) evacuated treatment centers in the DRC epicenters of Katwa and Butembo following lethal assaultsThe Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019 | New England Journal of Medicinenejm .
- Interruption of Core Public Health Activities: The insecurity created by conflict cripples fundamental containment measures like surveillance, contact tracing, and case isolationThe exacerbation of Ebola outbreaks by conflict in the Democratic Republic of the Congo - PMCnih . Quantitative analysis from the DRC shows that conflict events increased the time from symptom onset to case isolation by an average of 1.91 daysThe exacerbation of Ebola outbreaks by conflict in the Democratic Republic of the Congo - PMCnih +1. During community-wide shutdowns (
ville morte), response teams could only trace 20% of case contactsThe exacerbation of Ebola outbreaks by conflict in the Democratic Republic of the Congo - PMCnih . The effectiveness of ring vaccination plummeted from 90% of contacts to as low as 30-40% due to violenceViolence hinders Ebola response in Congoyoutube . Crucially, conflict has a direct, measurable impact on transmission; one study found that conflict increased the risk of reported Ebola cases by a factor of 1.88 in the DRCQuantifying the Risk of Conflict on Recent Ebola Outbreaks ...medrxiv +1. Another analysis found that 16 violent events over a 21-day period were associated with a 60% relative increase in the Ebola transmission rate (Rt)The Impact of Different Types of Violence on Ebola Virus Transmission During the 2018–2020 Outbreak in the Democratic Republic of the Congo - PMCnih .
- Forced Displacement and Cross-Border Transmission: Conflict drives mass population movement, rendering containment lines meaningless🚨 Progress in jeopardy🚨
In eastern Democratic Republic of Congo (DRC), armed conflict has forced millions from their homes. Cuts in health funding mean 70% of people in need will be left without aid, and diseases like cholera, mpox, and Ebola are on the rise.
📷 Muhawe Myriam Charmante fled her home and now lives in a displacement site. “We lost everything, once again,” she says. Oxfam gave her essentials like a jerrycan, bucket, and soap, but resources are running out, leaving many without help.
💔 The world cannot look away.
#DRC #HumanitarianCrisis #LivesOnTheLine #Dochasx . The conflict in eastern DRC has displaced millions of peopleResponding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih . This uncontrolled movement directly facilitates the geographic spread of a virus, as demonstrated when an Ebola case was confirmed in Uganda in a child who had traveled from the DRC for a funeralEbola Virus Disease Outbreak — Democratic Republic of the Congo ...cdc . Ethiopia faces a similar dynamic, with over 11,000 people recently displaced by conflict in the border areas of Oromia and Benishangul Gumuz, and border regions like Amhara and Gambela are strained by an influx of over 186,000 refugees fleeing the war in SudanEthiopia - Conflict displaces over 11000 people (DG ECHO ...reliefweb +1.
2. Pre-Existing Weaknesses in Ethiopia's Public Health Infrastructure
The Ethiopian health system, particularly in peripheral and conflict-affected zones, is fragile and lacks the resilience to absorb the shock of a major hemorrhagic fever outbreak.
- Inadequate Border Surveillance: A 2016 Joint External Evaluation (JEE) noted that Ethiopia's border surveillance system was not comprehensive and was particularly weak in border regions due to limited resources2 Ethiopiaghsindex . The COVID-19 pandemic further exposed these gaps, highlighting porous borders and a lack of cross-border collaboration and surveillance mechanisms that impeded outbreak investigationsTurning challenges into opportunities: Lessons from Ethiopia’s COVID-19 response for strengthening health systems and health security - PMCnih +1. This is compounded by inadequate laboratory capacity for rapid diagnostics in remote areasFrontiers | Infectious Disease Control and Management in Ethiopia: A Case Study of Cholerafrontiersin .
- Systemic Collapse in Conflict Zones: Recent conflicts have decimated Ethiopia's health infrastructure. A 2022 assessment across six conflict-affected regions reported 76 hospitals, 709 health centers, and 3,217 health posts as damaged, looted, or destroyedDecember 2022 ETHIOPIA DAMAGE AND NEEDS ASSESSMENT – Volume Aworldbank . In Tigray, over 80% of health facilities were damagedConflict and fragmented public health emergency management system in Tigray region of Northern Ethiopia: A double burden to accommodate resilient and advanced public health emergency management. A commentary review for policy-makers and a call to action | Health Research Policy and Systems | Full Textbiomedcentral . In Amhara, over 40% of facilities are looted or damaged, limiting access to health services amidst outbreaks of cholera and malariaEthiopia - Situation Report, 13 December 2024unocha . This destruction cripples health information systems, impeding disease trend monitoring and epidemic predictionExploring health system challenges and gaps for crisis response in Ethiopia: a scoping review of publications and reports from 2020-2024 - PMCnih .
- Human Resources Crisis: Ethiopia is experiencing a significant "brain drain" of medical professionals due to conflict and poor working conditions, with a 60% increase in visa applications from healthcare workers seeking employment abroad compared to pre-conflict yearsThe Marginalization of Medical Professionals and the Deterioration of Healthcare in Ethiopia: A Crisis of Governance, Corruption, and Military Prioritization"borkena . This exodus hits rural and conflict areas hardest, leaving facilities without physicians, surgeons, or midwivesThe Marginalization of Medical Professionals and the Deterioration of Healthcare in Ethiopia: A Crisis of Governance, Corruption, and Military Prioritization"borkena .
3. Socio-Political Barriers to Public Health Interventions
Technical capacity is insufficient where the socio-political context is hostile to public health efforts. Deep-seated mistrust and a complex conflict landscape present formidable barriers.
- Pervasive Community Mistrust: In the DRC, mistrust was a primary driver of response failureResponding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih . Responders were perceived as outsiders linked to recent massacres, and aid was suspected of being poisonedResponding to the 2018–2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches - PMCnih . The use of military escorts for health teams further associated the response with state-led violence, causing civilians to hidePublic health intervention amidst conflict: Violence, politics, and knowledge frames in the 2018-20 Ebola epidemic in Democratic Republic of the Congo - ScienceDirectsciencedirect . Similar seeds of mistrust exist in Ethiopia, rooted in historical grievances. For example, during the TPLF-led government, health policies were allegedly used to enforce contraception and depopulation efforts in the Amhara region, weaponizing healthcare and eroding trust in public institutionsEthnic Tensions and National (In)Stability in Ethiopia: Analyzing Risks of Ethnic Cleansingmdpi . Studies in Oromia show that trust in health facilities and providers is a significant determinant of participation in health insurance schemes and, by extension, engagement with the formal health systemDeterminants of community-based health insurance ...nih +1.
- Fragmented and Volatile Conflict Environment: A Marburg response would have to navigate a complex web of armed actors with shifting alliances and objectives. This includes the Ethiopian National Defense Force (ENDF), the Tigray Defense Forces (TDF), Eritrean troops, Amhara Fano militias, the Oromo Liberation Army (OLA), various regional special forces, and cross-border militias from Sudan and South SudanRenewed Tension Between Ethiopian Regime and Tigray Forces | Atlas Institute for International Affairsatlasinstitute +1. Key transport routes are fragmented by checkpoints controlled by a mixture of official and irregular armed actors, complicating logistics and aid deliverySecuritizing the Ethiopia–Sudan border: How cross-border conflict is shaping trade and the control of landchathamhouse . Gaining access and security guarantees from this diverse array of actors is a monumental diplomatic and logistical challenge.
- Politicization of Community Structures: In Ethiopia, community health platforms have at times been linked to political activities, fostering negative attitudes among the populace and undermining their effectiveness as neutral channels for health engagementCommunity Health Transformation:chwcentral . This politicization mirrors the DRC experience, where the government's decision to ban Ebola-affected regions from participating in a presidential election fueled conflict and resistance to the responseEvaluating the risk of conflict on recent Ebola outbreaks in ...biomedcentral .
4. Absence of Licensed Medical Countermeasures
A critical distinction between the DRC Ebola response and a potential Marburg outbreak in Ethiopia is the availability of proven medical tools.
- No Approved Vaccine or Therapy: There are currently no licensed vaccines or specific therapeutics for Marburg virus diseaseMarburg Virus Medical Countermeasures | SpringerLinkspringer +1. This is in stark contrast to the later stages of the DRC Ebola outbreak, where the rVSV-ZEBOV-GP vaccine was a cornerstone of the response, with over 303,000 people vaccinatedEbola outbreak 2018-2020- North Kivu-Ituriwho .
- Total Reliance on Non-Pharmaceutical Interventions (NPIs): The absence of a vaccine means containment would rely exclusively on NPIs: rapid case identification, isolation, comprehensive contact tracing, and safe burial practicesExploring the Epidemiology, Transmission Dynamics and Public Health Interventions of Marburg Viral Disease: A Scoping Review of Global Evidence.nih . However, as established, these are precisely the activities most severely hampered by armed conflict. Without a vaccine to create population immunity "firebreaks," every single breakdown in NPIs due to insecurity carries a much higher risk of propagating the outbreak.
- Investigational Status of Current Options: While promising candidates are in development and some have been deployed under emergency use protocols—such as the ChAd3-MARV vaccine, remdesivir, and monoclonal antibody MBP091 during the 2024 Rwanda outbreak—these are not globally stockpiled or licensed countermeasuresMarburg Virus Disease in Rwanda, 2024 — Public Health ...nejm . Deploying them would require complex regulatory approvals, logistics, and clinical trial protocols in the midst of a crisis, adding another layer of difficultyDeveloping Vaccines to Improve Preparedness for Filovirus Outbreaks: The Perspective of the USA Biomedical Advanced Research and Development Authority (BARDA) - PMCnih .
Adapting International Health Governance for Political Instability
The challenges inherent in responding to an outbreak in a conflict zone like Ethiopia demand a fundamental adaptation of international health governance, which has traditionally been designed for politically stable environments.
1. Reforming the International Health Regulations (IHR)
The IHR (2005) is the primary legal framework for global health security, but its state-centric design and lack of enforcement power limit its effectiveness in conflict zonesSustainable strategies for Ebola virus disease outbreak ... - PMCnih +1.
- Current Limitations: The IHR lacks formal penalties for non-compliance and includes no financial mechanism to assist low-income countries in meeting their core capacity obligationsThe International Health Regulations (2005), the threat of populism and the COVID-19 pandemic | Globalization and Health | Full Textbiomedcentral +1. Nations face strong economic disincentives to report outbreaks, as it can trigger damaging travel and trade restrictions with little recourseThe International Health Regulations: The Governing Framework for Global Health Security - PMCnih +1. Furthermore, its provisions are difficult to apply where non-state actors, not the state, control territory and populations.
- Proposed Adaptations:
- Develop a Framework for Engaging Non-State Actors: The IHR must be amended or supplemented with protocols that recognize the reality of de facto authorities in conflict zones. This includes creating legal and operational space for health agencies to negotiate directly with armed groups for access, surveillance, and response activities.
- Incentivize Transparent Reporting: Create a "safe harbor" mechanism that provides immediate financial and technical support to countries that report an outbreak, while protecting them from automatic and scientifically unjustified trade and travel restrictionsWhat are the World Health Organization and International Health Regulations?youtube . This would rebalance the risk-reward calculation for early reporting.
- Incorporate Conflict-Sensitive Monitoring: The IHR monitoring and evaluation process, including the Joint External Evaluation (JEE), must include specific metrics and methodologies for assessing public health capacities in fragile and conflict-affected settings, recognizing that national-level capacity may not exist in contested regions.
2. Operationalizing the Humanitarian-Development-Peace Nexus (HDPN)
The HDPN, or "triple nexus," is a strategic approach to integrate immediate humanitarian aid with long-term development and peace-building effortsWHO EMRO - Humanitarian-development-peace nexuswho . While widely endorsed, its implementation is hampered by conceptual ambiguity, siloed funding, and cultural clashes between different actorsThe future of humanitarian aid in a new context full of challenges Authors:europa +1.
- Current Challenges: Humanitarian actors are concerned that aligning with development and peace (state-building) goals compromises their neutrality and independence2.1 The Humanitarian-Development-Peace Nexus - Issuuissuu . Short-term humanitarian funding cycles (often 12 months) are incompatible with the multi-year timelines needed for health system strengthening and trust-buildingHumanitarian–development nexus approach to health systems strengthening in Sudan—a policy analysis - PMCnih +1. There is a lack of clear guidance on how to operationalize the nexus in the health sector specificallyBridging the Divide A guide to implementing the Humanitarian-Development-Peacewho .
- Proposed Adaptations:
- Adopt Dual-Purpose Funding Models: Emergency response funding should be designed to simultaneously meet immediate needs and build long-term resilience. This includes investing in local health worker training, strengthening local supply chains, and reinforcing community-based surveillance systems as part of the outbreak response itselfWHO's 2025 Emergency Response to outbreaks, conflicts ...bmj .
- Embed Conflict Expertise in Health Teams: Public health emergency teams must become multidisciplinary, embedding conflict analysts, anthropologists, and humanitarian negotiation specialists alongside epidemiologists and clinicians to ensure that response strategies are politically and culturally informedSeven practical tips to negotiate healthcare in humanitarian contexts - Frontline Negotiationsfrontline-negotiations .
- Shift to Flexible, Multi-Year Financing: Donors must move away from rigid, short-term project cycles towards more flexible, multi-year funding that allows organizations to build trust, adapt to changing security dynamics, and bridge the gap between emergency response and system recoveryThe humanitarian–development–peace nexus and UN 2.0odihpn .
3. Professionalizing and Systematizing Humanitarian Negotiation
In conflict zones, humanitarian access is not a given; it is a negotiated outcomeWhat is humanitarian negotiation? - Frontline Negotiationsfrontline-negotiations . The ability to successfully negotiate with armed groups is a core competency for public health response.
- Current Approach: Negotiations are often ad hoc, reliant on individual skills, and lack a consistent institutional approach. Many organizations are uncertain about legal permissibility and lack clear operational guidance for engaging with non-state armed groups (NSAGs)Humanitarian access negotiations with non-state armed ...gppi .
- Proposed Adaptations:
In conclusion, successfully containing a Marburg outbreak in a setting as complex as Ethiopia's border regions requires a paradigm shift. It necessitates moving beyond a purely biomedical response to one that is deeply integrated with conflict analysis, sophisticated diplomatic engagement, and long-term community trust-building. International health governance must evolve to become more agile, less state-centric, and operationally equipped to handle the political and security realities that are the primary drivers of failure in modern public health emergencies.