Epidemic response performance in contested territory: a comparative analysis of Ituri and North Kivu during the 2026 Bundibugyo virus disease outbreak

In the eastern part of the Democratic Republic of the Congo, a landscape scarred by decades of conflict, a new health crisis is unfolding. This is not just a story of a virus spreading through a population, but of how that spread is shaped by who controls the land. The region is home to two provinces, Ituri and North Kivu, which have been the epicenters of multiple deadly outbreaks in recent years. The virus at the heart of this current story is the Bundibugyo virus, a rare and dangerous cousin of the more famous Ebola virus. When this virus infects a person, it causes a severe illness that can lead to death, and stopping it requires a massive, coordinated effort to find sick people, track everyone they have touched, and provide care. However, in this part of the world, the ability to mount that effort depends heavily on the local reality. In some areas, the national government runs the hospitals and coordinates the response. In others, armed groups have taken over the territory, setting up their own rules and administrations. The question researchers are asking is simple but profound: does the difference in who holds the power on the ground change how well the health teams can save lives?

A team of researchers from major global health organizations, including the World Health Organization and the Africa Centres for Disease Control and Prevention, set out to answer this by looking at the data from the 2026 outbreak. They focused on two neighboring provinces that were hit hard by the virus but were governed in very different ways. In Ituri, the national government still held administrative control, even though the area was insecure and plagued by fighting. In North Kivu, the situation was different; since early 2025, a coalition of armed groups had captured the capital city and surrounding areas, establishing a parallel administration that operated independently of the national health authorities. The researchers wanted to see if this split in governance created a split in the health outcomes. They gathered every piece of public data available on the number of people who got sick, how many died, and how well the teams were able to track down and monitor people who had been exposed to the virus. They compared these numbers between the two provinces and also looked back at a massive Ebola outbreak that had struck the same two provinces between 2018 and 2020, using that past event as a historical mirror to understand the current situation.

The numbers told a stark story. By early August 2026, the outbreak in Ituri had confirmed over 3,600 cases, with a death rate of about 43 percent. In North Kivu, the situation appeared far more dire. While there were fewer total cases reported—around 470—the death rate was significantly higher, at 67 percent. This means that in the territory controlled by the armed coalition, nearly two out of every three people who were confirmed to have the virus died, compared to less than half in the government-controlled province. The researchers also looked at how well the teams were following up with people who had been in contact with the sick. In North Kivu, the teams managed to check in on about 75 percent of the contacts they identified, a number that fell short of the safety threshold needed to stop the virus from spreading. In contrast, the government-controlled areas performed slightly better, though still not perfect. The gap in death rates was so large that it was statistically impossible to be a random fluke; the data showed a clear, measurable difference between the two regions.

However, the researchers were careful not to jump to a single conclusion. They knew that just because two things happen at the same time does not mean one caused the other. It is possible that the higher death rate in North Kivu was not solely because of the armed control, but because the outbreak there was in an earlier, more chaotic phase where only the sickest patients were being found and counted. If the health teams could not reach the milder cases because of fighting or roadblocks, the official numbers would only show the severe deaths, making the death rate look artificially high. The study tested this idea by comparing the current numbers to the 2018–2020 outbreak. They found that the death rate in North Kivu this time was almost exactly the same as it had been in that previous crisis, suggesting that the high death toll might be a feature of the geography and the nature of the conflict there, rather than a new failure of the current response. Meanwhile, the death rate in Ituri was surprisingly low compared to the past, which might mean that the government-controlled teams were doing a better job of finding and treating the milder cases that usually go unrecorded.

The study concludes that while the difference in governance is strongly linked to the difference in health outcomes, it has not been proven to be the sole cause. The data suggests that the lack of access to the territory controlled by the armed groups is a major factor, likely delaying care and making it harder to track the virus. But the researchers emphasize that this is a hypothesis that needs more proof. They argue that the current way of looking at the data, which treats the whole province as one block, is not enough to see exactly what is happening on the ground. To truly understand the problem, they say, health teams and donors need to stop treating all conflict zones as the same. They need to recognize that a province where the government still functions is operationally different from one where an armed group runs the show. This means that funding and negotiation strategies should be tailored to these specific realities. Instead of just throwing money at the problem, responders need to negotiate access specifically for the contested areas and build trust with the local powers that be, just as they did with community leaders in the past. The paper serves as a call to action, urging the global health community to treat contested territory not just as a dangerous place, but as a distinct operational challenge that requires a unique and carefully designed approach to save lives.