Can public works help fight Ebola in the Democratic Republic of Congo?

A Congolese health worker administers ebola vaccine to a child at the Himbi Health Centre in Goma, Democratic Republic of Congo, July 17, 2019. REUTERS/Olivia Acland - RC1FDEE57DA0

Consider this hypothesis: What if social safety net programs, such as cash-for-work, could help turn around the struggling efforts to contain the Ebola outbreak in the eastern Democratic Republic of Congo (DR Congo)? This unexpected idea is now part of the World Bank’s financing plan to support the global response to Ebola. But why would giving people short-term jobs help fight an epidemic? Indeed, employment-based safety nets, such as labor-intensive public works, can seem like an incomplete technocratic fix to what has been referred to as the most complex health crisis in history. Yet, such programs could help address a critical obstacle that has so far undermined all attempts to stop the disease from spreading: the massive lack of trust between communities and the government.

National authorities, humanitarian organizations, and international institutions like the WHO all agree that effective community engagement is essential to curtailing the epidemic. A cursory look at current statistics and explanatory trends shows why. According to an update from the Congolese Ministry of Health, nearly 2,600 Ebola cases have been registered across eastern Congo, with more than 1,700 people losing their lives. The complex reasons for this crisis are well documented. North Kivu and Ituri, where the epidemic is raging, are among the most fragile and conflict-affected provinces of the DR Congo. Tens of armed groups operate at large, including attacks against Ebola responders. Ongoing clashes between self-defense groups (Mai Mai militias) and security forces, as well as interethnic violence, have displaced 300,000 people in June alone. Apart from Ebola, overlapping measles and cholera epidemics have overpowered an already weakened health system. Meanwhile, pockets of community resistance in Ebola hotspots have led to 200 recorded violent incidents against health workers. Most people still refuse to seek help in Ebola Treatment Centers due to misinformation about root causes of the disease, and the supposedly occult intentions of responders—an estimated 68 percent of deaths happen in private homes. It is, therefore, no wonder that all actors are asking public health responders to put communities front and center in the Ebola response. “We need to listen with the ferocity with which we want to be heard,” says an emergency medical manager for Médecins Sans Frontières (MSF) in a recent media report. This, after all, was the major lesson of the 2014 Ebola epidemic in West Africa.

Listening to community voices is a good start, but for outreach efforts to be effective, consultations with local leaders should translate into tangible improvements in people’s lives. In this regard, efforts to strengthen social safety nets such as providing short-term employment for community members to execute public works in Ebola-affected areas could be a powerful economic add-on to public health and stabilization strategies. Labor-intensive public works could boost local economies and address long-standing infrastructure needs that limit first responders’ access to patients and at-risk communities. Moreover, by offering equitable employment opportunities to all community members, cash-for-work interventions could allow Ebola sensitization efforts to target a larger number of people who otherwise would be inaccessible.

To see how this approach could work, consider the city of Butembo, a major commercial center of North Kivu with trade connections extending into Rwanda and Uganda. It is also a major site of violence against Ebola responders, including the burning down of Ebola Treatment Centers and killing of a Cameroonian epidemiologist working for WHO by armed militias in April. Media coverage describes Butembo as “neglected, with potholed dirt roads, open sewers, crumbling infrastructure and its perfect storm of overlapping issues that conspire to hamper the Ebola response.” Another article describes how local unions representing 10,000 taxi-moto operators—the lifeblood of business coursing through the city’s arteries—are resistant to helping the government’s response efforts and are forcefully denouncing the lack of redistributive impact of the multihundred-million-dollar Ebola response: “You’ll find no state infrastructure out here, not even the Congolese flag.” This statement is consistent with nationwide trends underscored in a 2018 World Bank country diagnostic: Only four of the DR Congo’s 26 provincial capitals can be reached by road from Kinshasa, and less than 5 percent of the 58,000-kilometer national road network is paved. In terms of logistics performance, only Somalia has fared worse. The question therefore arises: What if the state came back and offered poor and vulnerable groups in Ebola-affected communities short-term employment to rebuild roads, drain standing waters, or maintain public areas? Could quick results and tangible benefits for the communities help the Ebola response efforts? The Social Fund of DR Congo, a public entity supporting poverty reduction programs, is actually piloting this approach in Butembo with 2,000+ local workers. Could this work?

For its part, the policy and academic literature is ambivalent about the role of employment programs in increasing social cohesion and peacebuilding. A 2016 joint declaration by the United Nations, International Labor Organization, and World Bank identified two main challenges related to this topic: the lack of a unified analytical framework, and a need to strengthen the empirical evidence on the relationship between employment and peacebuilding. An accompanying review of the literature covering more than 400 employment programs in fragile states (including cash-for-work interventions), underscores that while theories of change are well-defined, supporting empirical evidence is either weak or missing. A recent impact evaluation of labor-intensive public works in fragile states found that they produce short-run economic welfare gains, boosting incomes and in some cases, translating into higher expenditure and savings. However, the same review underscored that these programs did not lower crime and violence levels, nor did they improve civic engagement.

Even so, the situation in eastern Congo is unique: a public health emergency of international concern in the middle of a conflict zone marked by weak governance, community violence, and forced displacement. Conclusions drawn from prior evaluations may thus be an insufficient guide to what we could expect from a community-driven safety net program. Instead, initial lessons from other contexts marked not only by fragility, but also by active conflict (in the Central African Republic and Yemen), indicate that labor-intensive public works are worth exploring. They could address social infrastructure needs that affect all local community members and offer a much-needed short-term injection of cash in the local economy. But through a wider community appeal that goes beyond public health concerns, they could also attract influential socio-economic groups (like taxi-moto operators) that have so far resisted Ebola response efforts, but have been positively involved in previous epidemics.

Ultimately, an emergency social safety net program in Ebola-affected areas that benefits communities equitably would help counter the narrative that occult interests in the “Ebola business” dictate the response. Beyond a short-term impact, public works programs could lay the foundation for a sustainable post-Ebola development path. This strategy goes hand-in-hand with public health efforts and complements new approaches to security provision. To go back to the original question—yes, public works can help fight Ebola, both as an immediate safety net for the affected population, as well as an approach to planning for a new social contract between the state and its citizens.