MUNIGI, DEMOCRATIC REPUBLIC OF CONGO — Esther Mwema assumed her 4-year-old son had chicken pox. He was lucky enough to get a medical exam at this camp for displaced people, where many families live in tents and even clean water is at a premium.
But the diagnosis was something else: mpox, a virus that’s sweeping through eastern DRC, into Uganda and beyond. This is the second strain of mpox to hit DRC hard. The first gained steam in 2022 and was primarily transmitted through sexual contact. The new strain spreads quickly through close contact in daily life, this time infecting adults but, increasingly, children, too.
Data from various health and government sources is often contradictory, but one thing is clear: Children now bear the brunt. United Nations Children’s Fund data found that 84% of the people who have died from mpox in DRC since January have been children. That’s based on a total of about 15,600 cases of the virus.
Tam Berger of Medair, an aid group that provides medical assistance in countries in crisis, says 70% of the more than 300 people in Munigi thought to be infected with mpox are children under the age of 10.
From DRC, the virus has spread across the border into Uganda, where officials say the outbreak is well under control, but local health workers view the situation as dire.
“You find one that has blisters all over the body that are passing out pus,” says Jovia Biira, a midwife the Ugandan government deployed to the border with DRC as part of an mpox surveillance team. “Some have very high temperatures of 38 degrees Celsius [100.4 degrees Fahrenheit] and above.”
But Emmanuel Ainebyoona, spokesman for the Ministry of Health in Uganda, told Global Press Journal to ignore information that people at the border provided. There have been only four cases of confirmed mpox, he says.
More than 7 million people in DRC, a country of about 105 million, are displaced, and many live in camps like Munigi, where Mwema is one of thousands of residents. It was created for people who escape violence between armed groups and DRC’s formal military, which has resulted in killings and the destruction of property with near or total impunity. Social distancing in the camp is difficult. Raw sewage runs through troughs along roads and walkways. Water is scarce, so hand-washing is a challenge. It’s an ideal place for mpox and other dangerous viruses to emerge and spread.
While 35 countries around the world have reported mpox cases in the past month, DRC has been hardest hit, accounting for an estimated 90% of all cases in Africa this year, according to the European Centre for Disease Prevention and Control. Around the city of Goma, some health centers are overwhelmed, with patient intake soaring to 4,000% beyond their capacity, according to a report by Save the Children, an international nongovernmental organization.
Mwema and her family moved to Munigi a year ago from Rutshuru, a town about 70 kilometers (43 miles) to the northeast. Violent clashes between the notorious M23 armed group and the Congolese army, known by its French initials, FARDC, forced them to leave their hometown.
In the camp, the family found a fragile peace but another danger: a highly infectious, potentially deadly virus that can only be prevented by avoiding infected people.
This has happened before. A steady stream of viruses, infections and diseases have emerged here or spread quickly once they arrived. Among them is Ebola, which has broken out more than a dozen times in recent decades. Deforestation, and the pathogen spillovers that result when humans and wild animals come into close contact, is one reason for outbreaks. Severe armed conflict that pushes people into overcrowded camps is another. Ongoing lack of and delays in delivery of vaccines is yet another. The strain on the fragile health system, already battered by other health emergencies as well as severe shortages of staff and supplies, is immense. Altogether, people in DRC face overwhelming odds against viral outbreaks.
Mpox comes in two major strains, or clades. Clade I, which is endemic to central and east Africa and spreads through close contact in daily life, causes more severe illness. In past outbreaks, it’s killed some 10% of people who were infected. Clade II, endemic to west Africa, can also spread through close human contact or contact with animals, but it typically spreads through sexual contact. It’s milder, too, as 99.9% of people survive.
The current outbreak of the more dangerous clade I comes after a global outbreak of clade II in 2022.
While mpox is in the same viral family as smallpox, it’s not nearly as deadly. But it holds different challenges.
Eradicating smallpox in 1980 was possible in part because the virus only infected humans. Animals were never part of the spread, says Jessica Malaty Rivera, an epidemiologist and senior science communications adviser at the de Beaumont Foundation, a United States-based public health organization. Mpox, on the other hand, has a broad spectrum of animal reservoirs.
“If mpox becomes something catastrophic like smallpox, which I hope it never does, it could never be eradicated because it affects animals as well,” she says.
Along the DRC-Uganda border, the shift from clade II to clade I is clear, health workers say. Hellen Kabugho, a nurse at a CARE PLUS drugstore in Bwera, a border town in Uganda, says she’s seen people with mpox symptoms for several months now, but the situation is changing. While just two cases have been confirmed at the hospital in Bwera, more and more people are suspected of having the virus.
Both strains can easily spread, Kabugho says. “We use the same latrines in the market, so it’s easy to get it.”
Border activity makes it difficult to track symptomatic people.
“Body-to-body contact is common, as there’s a lot of squeezing at the border, [with] a large population of people coming in and out,” she says. “We mix a lot.”
Health officials in Kampala, Uganda’s capital city, downplayed the outbreak and told Global Press Journal that it’s well in hand. A major public awareness campaign is effective in educating people about how to guard against mpox, Ainebyoona, the Ministry of Health spokesman, says.
Early fears of the virus among people in border towns have dissipated.
“People here are still mingling as usual,” says Mariam Mbabu, a nurse at the Haki Medical Center in Uganda, just over the border, adding that many don’t know how easily clade I is transmitted.
Rosaria Masika, a Congolese woman who has been in Uganda for three months, says she went to a hospital in Bwera in July for antenatal care. She told a health worker there that she had lesions on her body. Staff tested her, then sent her home to isolate.
There are no mpox vaccines yet available in Uganda, says Dr. Amon Bwambale, the district health officer of Kasese district, along the DRC border. Once they’re available, he adds, pregnant women, children and people with immune deficiencies will be prioritized.
In DRC, a vaccination effort might be wishful thinking. On Aug. 14, the World Health Organization declared the mpox outbreak a “public health emergency of international concern,” a move meant to unlock resources to stop its spread. The DRC government approved the use of mpox vaccines, but they haven’t arrived.
The country has historically struggled to deliver vaccines to those who need them. DRC received millions of COVID-19 vaccine doses but returned 1.3 million of them in April 2021 because they couldn’t get them where they needed to go, according to CARE, a humanitarian relief agency. Only 60% of DRC’s COVID-19 vaccination sites were functional, CARE reported.
The country’s experience with COVID-19 doesn’t bode well for the mpox outbreak, and global health professionals are watching the spread in alarm.
“Mpox cascading like this is something that we’ve been dreading,” Malaty Rivera says, “but it’s not that shocking.”
Meanwhile, Mwema and her family have no place to go. There’s no sign that decadeslong conflicts will end. The armed groups and the FARDC are known for operating in ways that show no concern for the people in areas where they fight. For Mwema, safe options aren’t just few; they’re virtually nonexistent. For now, and possibly for many years, she’ll remain in the camp.