In his published letter, Peace is a better focus than Ebola in the Democratic Republic of the Congo (DRC), ^{Reference Brett-Major1} David M. Brett-Major provides a vital reminder of the tragic undercurrent of violence and political instability dominating African regions currently impacted by the second worst Ebola outbreak in modern history. He characterizes health-centric activities as a “common mistake” to remedy the “vicious cycle” of endemic violence and disease outbreaks in the DRC and surrounding areas. ^{Reference Brett-Major1} What is truly needed is a “concerted peace and development process, with health as a voice in a chorus – not alone.” ^{Reference Brett-Major1}

Brett-Major’s message is salient but also disconnected from the reality that persons impacted by Ebola presently in the DRC (and surrounding areas) cannot wait for lasting peace to be established. Ebola mortality rates in the DRC approach 65% of known cases. ^{Reference Soucheray2} Nearly 1200 persons have perished already in the current outbreak. ^{Reference Goldstein3} Actual death counts may be substantially higher as some community members refuse to cooperate with public health responders. ^{Reference Goldstein3} Tens of thousands more persons are at immediate risk of infection, despite an available vaccine. Health care workers deployed to the region via public and private entities gamble their own safety and lives to control the epidemic. ^{Reference Goldstein3}

As Gostin et al. ^{Reference Gostin, Kavanaugh and Cameron4} and Nuzzo and Inglesby ^{Reference Nuzzo and Inglesby5} suggest in their respective Ebola commentaries, every available, efficacious public health intervention should be undertaken to stymie morbidity and mortality. Primary public health tools like surveillance, reporting, epidemiologic investigations, contact tracing, vaccine administration, quarantine, isolation, and safe handling of human remains are designed to reign in deadly, infectious conditions like Ebola for which treatments are elusive and cures non-existent.

Real-time execution of these powers is complicated by multiple factors. Lawful support may entail emergency authorizations. Gostin et al. have directly challenged the World Health Organization (WHO) to declare a public health emergency of international concern. ^{Reference Gostin, Kavanaugh and Cameron4} Against the backdrop of rising case counts, accurately predicted months ago, it is unfathomable that the WHO Emergency Committee took until July 17, 2019, to issue a declaration while resources were drained, misperceptions among affected communities surfaced, and violence targeting health care workers and victims proliferated. ^{Reference Goldstein3}

From the onset of the epidemic, efforts to curtail the spread of Ebola have been thwarted by violence and community resistance in the DRC. ^{Reference Goldstein3} Treatment facilities have been torched. Doctors and other health care workers have been threatened, assaulted, and murdered. ^{Reference Goldstein3} Morticians are unable to complete proper burials for having to flee from community attacks. Omnipresent law enforcement aligned with public health actors only heightens community resistance and distrust. Political instability underscored by regional volatility directly impinges public health interventions. Brett-Major is right to argue for stability but wrong to insinuate that public health actors and policy-makers seeking immediate interventions are oblivious to the greater need for peace.

Public health scholars and actors have consistently urged transnational cooperation and multi-sector coordination to address the larger humanitarian crisis underlying the epidemic. Gostin et al. ^{Reference Gostin, Kavanaugh and Cameron4} and Nuzzo and Inglesby ^{Reference Nuzzo and Inglesby5} acknowledge the importance of addressing the DRC’s humanitarian crisis through international engagement and collaboration to enhance security for front-line health workers. WHO officials are concerned that Ebola will continue to spread because of unremitting violence in the DRC. Mike Ryan, Director of WHO’s emergency programs, equates quelling violence with curtailing the spread of Ebola. ^{Reference Goldstein3} On October 18, 2018, the WHO Emergency Committee emphasized multi-sector coordination to address regional instability. ⁶ On May 8, 2019, WHO security forces repelled the attack of over 50 armed militia near health care staff accommodations in Butembo. ⁷

The United Nations (UN) resound similar views. Intercommunal violence and community resistance present enormous obstacles to effectuating public health response activities. ⁸ On March 18, 2019, the UN advocated for concentrated engagement among health actors to address these barriers. ⁹ Lelia Zerrougi, head of the UN Stabilization Mission (MONUSCO), said it “was sparing no efforts to protect civilians from the violence.” MONUSCO sent additional personnel in late March to provide security assistance in areas of active conflict after recent attacks. ¹⁰ On March 29, the UN Security Council authorized the deployment of over 16 200 additional military personnel in the DRC. ¹⁰

The US Centers for Disease Control and Prevention (CDC) links suppression of ongoing regional violence with efficaciously controlling the epidemic. ¹¹ Escalating security risks led the CDC to withdraw its own personnel from the region in October 2018. In concert with the US Department of Health and Human Services (HHS), the CDC is collaborating with the DRC’s Ministry of Health, border countries, and other international players to coordinate robust responses. ^{Reference Azar12} On November 7, 2018, HHS Secretary Alex Azar acknowledged, “Whether health threats are naturally occurring, accidental, deliberate, or, as in the case of the DRC, complicated by armed conflict, we must face up to these challenges and work together to overcome them.” ^{Reference Azar12}

Achieving peace across the DRC and other impacted countries is clearly the end game. Absent greater stability, notes Brett-Major, Ebola and other infectious conditions may only continue to emerge and spread. This synergy between epidemics and volatility is not lost on public health actors. Front-line responders in the DRC are performing essential public health services in the shadow of enormous risks. Their primary mission is about saving lives now from a scourge tied to an infectious condition and fueled by disharmony across regions. Focusing on assuring the health of immediately impacted individuals in environments wrought with political strife and violence is not a “mistake”; rather, it is the essence of public health preparedness and response.