By Stephanie Nolen
A few months ago, Mireille Efonge fell ill, suffering from a fever and distressing blisters on her groin. She became so weak that neighbors transported her to a health center made of plastic sheeting in Pakadjuma, a dense and impoverished area in Kinshasa, the capital of Congo.
At the health center, a nurse summoned an ambulance to take her to a hospital. Shortly after, lesions began appearing on her head and elsewhere, each one a painful, throbbing bump.
Eventually, she received a diagnosis: Mpox. “I’d never encountered it before,” Efonge remarked.
This incident took place in August, during a period when mpox — a virus closely related to smallpox — was still largely unknown in Kinshasa, which houses 17 million residents.
Researchers now reflect on that time with a sense of longing, as it may have been feasible then to contain the mpox virus and avert a calamity.
However, they believe that opportunity has likely passed.
The identification of a new, rapidly spreading variant of the virus in a remote mining town in eastern Congo prompted the World Health Organization to declare mpox a global public health emergency in August. The virus’s spread has only intensified since then.
The virus has established itself in overcrowded camps housing millions of displaced Congolese, who live in makeshift shelter with inadequate access to water. Moreover, it has infiltrated the cities of Congo, including its sprawling, crowded capital.
Efforts to manage mpox in Kinshasa, including isolating patients and vaccinating their contacts, have been inconsistent and poorly organized, unable to keep pace with the virus’s rapid spread and mutations.
Bureaucratic hurdles have hampered Congo’s response to this emergency; many involved in the situation privately express frustration that leaders are embroiled in disputes over access to an influx of international funding. Efforts are further complicated by the country’s immense size, inadequate infrastructure, and a healthcare system that struggles with poorly compensated workers.
A much-publicized vaccination initiative is proceeding very slowly. Hundreds of thousands of doses remain in freezers, gathering dust. Half of the cases involve children, yet not a single one has been vaccinated.
Only a small percentage of mpox cases are confirmed through laboratory testing. The tracing of contacts of infected individuals is minimal. The situation is particularly alarming in Kinshasa, where two variants of the virus are now spreading among a particularly at-risk population.
Historically, mpox has primarily affected rural areas in Congo, resulting in sporadic small outbreaks predominantly impacting children in isolated communities deep in the forests of the central and western regions.
This health crisis began a year ago when scientists identified a novel strain of the mpox virus that appeared to be spreading through heterosexual intercourse in a mining town in the far east. They named it Clade Ib, distinguishing it from the variant known and studied in Congo since 1970, Clade Ia.
Since then, Clade Ib has expanded into six additional African nations and has been detected in travelers in the U.S., Canada, Thailand, Sweden, and several other countries.
In Congo, this has contributed to a surge in mpox cases, reaching a record-high 53,000 this year, more than tripling from the previous year’s total. Approximately 1,250 individuals have died from the virus this year.
In Kinshasa, Clade Ib, believed to be more transmissible, has established its presence in Pakadjuma, where many women earn a living by engaging in sex work for clients from across the city.
The virus’s proliferation in the narrow alleys of Pakadjuma has elicited a much weaker response compared to mpox outbreaks elsewhere in Congo. However, it presents a serious danger not only to local residents but also to the broader population and even globally.
Pakadjuma, located just six miles from the sleek offices of the National Institute for Public Health, is shielded by tall walls erected to protect a railway. Those walls conceal open sewage ditches, scrap-metal shanties, and children playing barefoot in muddy streets.
Cases of the endemic strain first emerged in the neighborhood last year. Many locals frequently travel to Équateur province in the northeast, where the virus has been prevalent. Now, the new variant has made its way to Pakadjuma as well.
“Analysis of the genomes shows that Pakadjuma is a hot spot; you can observe both clades circulating here,” stated Dr. Placide Mbala, head of the epidemiology division at Congo’s National Institute of Biomedical Research and director of its pathogen genomics lab.
The community resembles a congested, unintentional scientific experiment.
“We can speculate that this might lead to a virus capable of more sustained transmission between humans,” Mbala remarked, also noting that it’s inevitable that someone will eventually get infected with both strains.
These individuals will be like Efonge, who supports her children by engaging in sex work. She and her neighbors are among the most disadvantaged in the country, lacking access to adequate medical care. “If the virus takes hold in this community, it will be challenging to eradicate,” Mbala emphasized.
Vaccination initiatives against mpox in Pakadjuma began in early December, four months after the United States had extended an initial donation of 50,000 vaccines to Congo. Vaccinators held two of the planned ten days of immunizations; as of Friday, they had only managed to provide vaccinations to a few hundred sex workers and health personnel.
Over 385,000 donated mpox vaccines have been received by Congo, with at least 700,000 more waiting to be shipped. Yet, as of last week, only 53,000 shots had been administered.
“Are we satisfied? Not in the least,” declared Dr. Ngashi Ngongo, overseeing the mpox response for the Africa Centres for Disease Control and Prevention, which coordinates vaccine distribution across the continent. He added that Congo must utilize the supplies it currently has before additional doses can be allocated.
Six months into the epidemic in Kinshasa, the mpox response center in Pakadjuma is offering merely two services for those who suspect they may be infected. A nurse can take a sample from their lesions for testing or arrange ambulance transport for severely ill patients to one of two treatment facilities.
At Vijana hospital, patients are crammed into small rooms, five or six at a time, within a modest two-story brick building. Infection control measures are inadequate, with masks, gloves, and gowns changed inconsistently. One doctor contracted the virus from a patient and spent weeks hospitalized, requiring supplemental oxygen.
One morning, a woman arrived at the Pakadjuma center for testing. She moved carefully, with a distinctive gait common in the area — her thighs held apart to avoid contact of any skin in her groin. As she reclined in the testing tent, nurse Bébé Bola swabbed her vulvar lesions; the woman let out a piercing, high-pitched scream.
Bola urged the woman to seek hospitalization, but she refused to leave her community — a common response Bola encounters daily.
“This is their home, where their family can visit them — if they go somewhere else, they will be isolated,” she explained. Patients fear judgment and stigma as residents of Pakadjuma, leading them to decline hospital transport.
“We cannot compel them,” Bola said. “If we could keep individuals here, we might manage the outbreak — but for now, we allow them to leave, and the disease continues to spread.”
Typically, sex workers in Pakadjuma serve about five clients in a single night, with music pulsating from speakers and colorful lights illuminating bustling houses. However, business has declined as news of the virus has circulated.
An increasing number of patients are children infected by their mothers (the virus can be transmitted through touch and shared bedding).
Ongoing bureaucratic disputes continue to delay the first shipment of 50,000 doses of LC16, a Japanese-made vaccine, the only vaccine approved for children against this virus. Japan had offered Congo 3 million doses of the vaccine in August, with delivery expected in the coming weeks.
Protecting children will require more than just the vaccines: Unlike the vaccines for adults, LC16 must be administered with a special two-pronged needle that penetrates the outer layer of skin. Japan is providing an initial supply of these needles, but Congo’s healthcare workers need training to use them properly; this method hasn’t been employed in decades.
The vaccine is provided in a 250-dose vial that must be discarded six hours after opening; Congo’s vaccination initiatives have not demonstrated the capacity to deliver the doses within that time limit.
