Mireille Efonge got sick a few months ago, with a fever and painful blisters on her groin. She became too weak to move, so neighbors carried her to a health center with walls of plastic sheeting in Pakadjuma, a crowded, poor community in Kinshasa, the capital of the Democratic Republic of Congo.
There, a nurse called an ambulance to take her to a hospital. Soon lesions broke out on her head and the rest of her body, each one a hard nub of throbbing pain.
Finally she was given a diagnosis: mpox. “I’d never heard of it,” Ms. Efonge said.
This was back in August, when the mpox virus — closely related to smallpox — was still almost unknown in Kinshasa, a city of 17 million people.
Some researchers now recall that time almost wistfully, because it might still have been possible back then to fence in the mpox virus, to fend off disaster.
That window has probably closed, they say.
The detection of a new, fast-spreading strain of the virus in a remote mining town in eastern Congo led the World Health Organization to declare mpox a global public health emergency in August. Since then, its spread has only accelerated.
The virus is taking hold in crowded camps home to millions of displaced Congolese, who live crammed into rough shelters with limited access to water. And it has reached Congo’s cities, including its enormous, congested capital.
Belated efforts to control mpox in Kinshasa — by isolating patients and vaccinating their contacts — have been halting and haphazard, far outpaced by the speed of the virus’s spread and change.
Congo’s response to the emergency has been choked by bureaucracy; clinicians and others involved say privately that their leaders are locked in fights over access to an influx of international funds. The effort has been complicated by the country’s vast size and feeble infrastructure, and by the weakness of its health care system, whose workers are poorly and rarely paid.
A much-hyped vaccination campaign is unfolding at a glacial pace. Hundreds of thousands of vaccines sit in freezers, unused. Half of those infected are children, but not a single child has been vaccinated.
Only a fraction of mpox cases are confirmed with laboratory analysis. Few contacts of sick people are traced. And nowhere is the effort less effective than in Kinshasa, where two strains of the virus are now mingling within a particularly vulnerable population.
Mpox has historically been a rural disease in Congo, causing sporadic small outbreaks, mostly infecting children in isolated communities in the thick forest in the center and west of the country.
The current health crisis began a year ago, when researchers identified a mysterious new strain of the mpox virus that seemed to be spreading through heterosexual sex in a mining town in the far east of the country. They named it Clade Ib to distinguish it from the version that had been known and studied in Congo since 1970, Clade Ia.
Since then, Clade Ib has spread to six more African countries and turned up in travelers in the United States, Canada, Thailand, Sweden and other nations.
In Congo, it has helped drive mpox cases to a record high of 53,000 this year, more than triple the number in 2023. About 1,250 people have died of the virus this year.
In Kinshasa, Clade Ib, which is thought to be more contagious, has taken root in Pakadjuma, where many women make a living by selling sex to customers from all over the city.
The virus’s spread in Pakadjuma’s narrow alleyways has drawn a response far less robust than that for mpox outbreaks in other parts of Congo. Yet it poses a significant threat: to the people who live there, to the rest of the country and to the world beyond.
Pakadjuma, just six miles from the gleaming offices of the National Institute for Public Health, sits behind high walls built to shield a railway line. The walls hide away ditches of open sewage, scrap-metal shanties and children playing barefoot in muddy lanes.
Cases of the endemic strain were reported in the neighborhood for the first time last year. Many residents come and go from Équateur province to the northeast, where the virus has long circulated. And now the new strain is in Pakadjuma, too.
“When we analyze the genomes, we can see that Pakadjuma is a hot spot: It’s where you see both clades circulating,” said Dr. Placide Mbala, who heads the epidemiology division of Congo’s National Institute of Biomedical Research and runs its pathogen genomics laboratory.
The community is a crowded, unplanned science experiment.
“We don’t know, but I can speculate and say this can lead to a virus capable of more sustained human-to-human transmission,” Dr. Mbala said. He added that it’s a “matter of time” until a patient ends up infected with both strains.
And those patients will be people like Ms. Efonge, who supports her children by selling sex. She and her neighbors are among the most marginalized in the country, with the least access to medical care. “If the virus seeds in this population it would be difficult to get rid of it,” Dr. Mbala said.
Vaccination against mpox finally began in Pakadjuma in early December, four months after the United States offered Congo a first donation of 50,000 vaccines. Vaccinators conducted two of a planned 10 days of immunizations; as of Friday, they had offered the shots to only a few hundred sex workers and health workers.
More than 385,000 donated mpox vaccines have arrived in Congo and at least 700,000 more are awaiting shipment. But the country had administered just 53,000 shots as of last week.
“Are we satisfied? Not at all,” said Dr. Ngashi Ngongo, who oversees the mpox response for the Africa Centres for Disease Control and Prevention, which is coordinating vaccine distribution throughout the continent. Congo will need to use the shots it has before the country can be allotted more doses, he said.
Six months into the epidemic in Kinshasa, the mpox response center in Pakadjuma offers just two services to people who think they may have the virus. A nurse can swab their lesions, and send the sample away for testing, or call an ambulance to take the very ill to one of two treatment centers.
At Vijana hospital, patients are crammed five or six to a room in a small two-story brick building. Infection control practices are imperfect, with masks, gloves and gowns changed haphazardly. A doctor caught the virus from a patient and spent weeks hospitalized, needing supplemental oxygen.
On a recent morning, a woman came to the Pakadjuma center for testing. She moved slowly with a distinctive walk that’s familiar in the neighborhood — her thighs held wide apart to try to keep any of the skin in her groin from touching. When she lay down in the tent, a nurse, Bébé Bola, dabbed at lesions on her vulva with a testing swab; the woman let out a ragged, high-pitched scream.
Ms. Bola tried to convince the woman to go to the hospital, but she was unwilling to leave the community — a response Ms. Bola encounters every day.
“This is their village, where their family can come — somewhere else, they will be alone,” she said. Patients fear they will face judgment and scorn as residents of Pakadjuma. So they refuse the hospital transport.
“We can’t force them,” Ms. Bola said. “If we could keep people here we might control the epidemic — but for now, we let them leave and the disease circulates.”
Sex workers in Pakadjuma normally see about five customers in a typical night, when music thumps out of speakers with heavy bass. Colored lights guide the way to busy houses. But business has fallen off as word has spread about the virus.
Kyiazine Lwanga, who was infected in October and spent a week in the hospital, said the clinic workers told her to stop the sex work.
“But I have no other way to make money, so I kept working,” she said. With the decline in customers, she’s selling her possessions to survive, including her only chair.
There is little or no contact tracing for infected people in Pakadjuma. “People move around, they go out, to try to make a living,” said Dr. Dieudonné Mwamba, the director of the National Institute of Public Health. “They could be away from home for three or four days. And you can’t do contact tracing by phone, the way you would in the U.S.”
Increasingly, the patients are children infected by their mothers (the virus can spread through touch and shared blankets.)
Bureaucratic wrangling continues to stall a first shipment of 50,000 doses of a Japanese-made vaccine called LC16, the only immunization for this virus approved for use in children. Japan offered Congo 3 million doses of the vaccine in August. It may arrive some time in the next few weeks.
Getting children protected will take more than the vaccines: Unlike the shot used for adults, LC16 must be delivered with a special two-pronged needle that punctures the top layer of the skin. Japan is donating an initial supply of the needles, but Congo’s health workers must be trained in using them; this method has not been used in decades.
The vaccine comes in a 250-dose vial that must be discarded six hours after opening; Congo’s vaccination programs have not shown the ability to administer the doses in that time frame.
Dr. Christian Ngandu, the director of Congo’s national disease surveillance and preparedness organization, said Pakadjuma is his chief preoccupation. “Many resources have been deployed here in the capital to try to snuff out the epidemic,” he said.
But, Dr. Ngandu said, the outbreak — even the emergence of the new clade — might have been avoided if Congo had support in 2022, when a different strain of mpox caused a global pandemic, with the virus spreading chiefly among men who have sex with men and reaching 120 countries. (That outbreak was controlled by swift response and deployment of vaccines in other countries.) Or, he added, in the 40 years before that, when mpox circulated in the country and few, beyond a handful of researchers, paid any attention.
“In 2022, they said it was over, but D.R.C. still had cases and the virus did not hesitate to spread,” he said. “I’m happy the world is now looking at the African countries to say, ‘How can we resolve the problem?’ But it should have happened much sooner.”
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