Peace Operations at the Intersection of Health Emergencies and Violent Conflict: Lessons from the 2018–2020 DRC Ebola Crisis

II. The Makings of the Public Health System and the Root Causes of Conflict in the DRC

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Dirk Druet
Rethinking the Humanitarian Health Response to Violent Conflict

The origins of contemporary health governance in the Congo lie in the strategies adopted under the colonial rule of Belgian King Leopold II (1835–1908) for the exploitation of human beings for labor. This section traces the evolution of the public health system at key points in the DRC’s history and assesses the relationship between the system—and the massive international humanitarian assistance that enveloped it—to the conflict in the eastern DRC at the time of the onset of the 2018 Ebola outbreak. It describes how the extractive motives of the country’s early health system reproduced themselves in the first decades of the Congolese state and how this had the effect of empowering more localized, if not necessarily more effective or just, forms of service delivery. Following the country’s descent into the logic of violence that is dominant today, the historical roots of public health in the Congo offer critical insights into how power and knowledge in health are perceived and understood in different segments of the population.


a. The Colonial Origins of an Extractive Congolese Public Health System

With the arrival of colonial rule in the Congo came new diseases and new vectors of transmission. As local Congolese people were pressed into service by the Europeans—as long-haul porters, steamboat crew, or rubber pickers—previously isolated communities came into much more frequent contact with one another. Accelerated by malnutrition, wounds, and exhaustion among enslaved workers, new diseases spread rapidly, especially smallpox and “sleeping sickness” (trypanosomiasis). Five hundred thousand Congolese people were estimated to have died of sleeping sickness by 1901, shortly before rule of the Congo passed from Leopold to the government of Belgium in 1908.8

Under Leopold, the state initially provided few public services beyond the maintenance of public order, leaving the health and education systems almost entirely to missionaries.9 When the Belgian government took control of the country, it made greater efforts to develop medical services, which resulted in a gradual fall in mortality rates.10 Social historian Maryinez Lyons argues that the initiative was motivated primarily by a desire to counter international perceptions of colonial Congo as a bastion of cruelty while still maintaining the labor force.11 In a 2021 historical analysis of the Congolese health system and its implications for the Ebola crisis, the Congo Research Group argues that, “under the Belgian colonial system, biomedical healthcare was not a right or a public good; instead, it was provided and mandated to keep workers on rubber plantations in working condition, to increase Congolese women’s fertility and child-bearing for the prosperity of these plantations, and to minimize the effects of infectious disease (including syphilis) on the Belgian colonists running plantations.”12

As Lyons describes, the Belgian administration’s response to sleeping sickness from 1900 to 1940 changed social and political dynamics in the Congo, thus helping to shape the future of the state. The colonial authorities’ approach to combatting the disease was based on the (partly correct) theory that its spread was made possible by the movement of people. Building on the recommendations of a study by the London and Liverpool Schools of Tropical Medicine, in 1905 the authorities established a system of “cordons sanitaire” knows as “lazarets” or compulsory isolation camps. Canoes were taken from villages to prevent riverine travel, which also eliminated fishing. People found to be infected were forbidden to travel, sent to the lazarets, and given atoxyl injections that often appeared to make patients worse. People were regularly caged or chained if they tried to escape. By the 1930s, the sleeping sickness campaign formed the core of the colonial health program, examining approximately three million people annually and maintaining quarantine zones across the country. The system depended on a principle of “incessant surveillance” that encouraged all Europeans in the territory to regularly “palpate” Congolese people under their authority for early signs of the disease and dispatch them to medical services for further examination and potential isolation.13

As the sleeping sickness program expanded, individual health services provided by missionary orders were increasingly brought under the program, creating a nascent national health care system. While the lazarets became less cruel over time, the authorities continued to balance public health concerns against priorities for economic productivity.14 This balance shifted with the outbreak of World War I, when demand for rubber and other natural resources motivated an intensification of forced labor practices. Public health concerns were also invoked during this period to justify forced population movements, wherein small villages were collectivized into larger, more easily administered population centers in closer proximity to points of economic production.15

These practices help explain why the Congolese people were markedly hostile to the colonial public health system. Many associated the presence of Europeans with the outbreak of disease in a given locale, leading to the conclusion that colonists were undertaking “a kind of biological warfare.”16 Isolation was seen as a death sentence, and rumors that autopsies carried out by the Europeans involved cannibalism were widespread. Many Congolese thus strongly resisted surveillance, isolation, and treatment measures. Resistance to population relocations was so strong that the policy was abandoned in 1931.



  • 8Adam Hochschild, King Leopold’s Ghost: A Story of Greed, Terror, and Heroism in Colonial Africa (Boston: Houghton Mifflin, 1998), 230. Sleeping sickness is caused by a parasite first spread by the bite of the tsetse fly, which is concentrated at lower altitudes and near bodies of water and river systems. Once contracted by humans, it is highly contagious and causes fever, swelling of the lymph glands, a craving for meat, and sensitivity to cold, followed by the lethargy that gives the sickness its name.
  • 9Robert Benedetto, Presbyterian Reformers in Central Africa: A Documentary Account of the American Presbyterian Congo Mission and the Human Rights Struggle in the Congo, 1890–1918 (Leiden: E.J. Brill, 1996), 38.
  • 10Martin Ewans, European Atrocity, African Catastrophe: Leopold II, the Congo Free State and Its Aftermath (London: Routledge Curzon, 2002), 241.
  • 11Maryinez Lyons, The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940 (Cambridge: Cambridge University Press, 1992), 3.
  • 12Congo Research Group, Ebola in the DRC: The Perverse Effects of a Parallel Health System (New York: New York University Center on International Cooperation, September 2020), 8.
  • 13Lyons, The Colonial Disease, 68–132.
  • 14Ibid., 137.
  • 15Hochschild, King Leopold’s Ghost, 278.
  • 16Lyons, The Colonial Disease, 216.

b. Centralizing and Hollowing Out the Postcolonial Health System

By the time of Congo’s independence in June 1960, Belgium claimed that its health system, despite numerous injustices, was the best in Africa.17 This assessment was based on the number of available hospital beds and the success of the sleeping sickness program, which had established a large medical infrastructure that extended across the vast country and had benefited from a wave of Belgian investment in infrastructure after World War II.18

The Congo’s first prime minister, Patrice Lumumba, struggled against entrenched interests in the resource extraction industries, leaving elements of the colonial labor and population management systems in place. The coup that installed Joseph-Désiré Mobutu (later known as Mobuto Sese Seko) as prime minister in November 1965 ushered in a new era of repression and mismanagement in the Congo—renamed Zaire by Mobutu—that would last over three decades. Public health, like other government services under Mobutu’s reign, was heavily centralized and quickly hollowed out. “Support of schools and hospitals dwindled to almost nothing. . . . For years, garbage piled up in heaps, uncollected.”19 An initial wave of foreign investment and international loans was largely used to enrich Mobutu and his patronage circle. By 1990 the government was spending 2.1 percent of the national budget on health and education combined, down from 17.2 percent in 1972.20 As national debt rose, the gross domestic product shrank and inflation skyrocketed. In this context, “Most hospitals were closed, with private sources of health care available to only 50 percent of the population. In those hospitals which did operate . . . the practice of ‘impounding the ill’ in order to guarantee payment for services was common. The [Forces Armée Zaïroises] regularly ‘patrolled’ the hospitals to ensure that those indebted could not escape.”21

As the national health care system was hollowed out and international assistance petered out amid corruption concerns, smaller administrative divisions benefited from the lack of centralized interference, especially in the east, where local and international nonstate actors began to play a significant role in providing health services. Beginning in the 1970s, small universities, churches, and international nongovernmental organizations (NGOs) began providing a patchwork of piecemeal services. As the Zairian state abandoned the health system in the 1980s, many formerly public hospitals and clinics were forced to begin charging fees. “Following the withdrawal of the federal government from active management of health in the 1980s and 1990s,” J.M. Janzen writes, “the decentralized regional health zone became the effective framework for both public health services and the coordination of health care institutions.”22

In 1997, a rebellion backed by Zaire’s neighbors brought Laurent-Désiré Kabila to power during the First Congo War. Spending on the health care system under Kabila was less than 1 percent of the national budget. Many of the county’s five hundred health zones dissipated as wars broke out, personnel fled, and buildings were destroyed. “Yet,” Janzen insists, “the survival of the Congolese health zones is a remarkable story.” By 2000, half of the clinics in the country were funded by faith-based organizations, and by 2012, the WHO estimated that nonstate actors accounted for over 99 percent of public health and health care services in the country.23

In sum, at the time of the First Congo War and the DRC’s entry into its contemporary cycle of conflict, the country’s national public health system had been both centralized and hollowed out. From its origins as little more than a tool for the management of forced labor, it became another symbol of the predatory state and a source of mistrust and suspicion. At the same time, the failure of the central system increased the importance of local systems of health services delivery and peoples’ reliance on health mechanisms that were partially or wholly separate from the central Congolese state. This trend would have significant implications for local acceptance of national health programming during future public health emergencies, including the 2018–2020 Ebola crisis.


  • 17Ibid., 223.
  • 18Jeanne M. Haskin, The Tragic State of the Congo: From Decolonization to Dictatorship (New York: Algora, 2007).
  • 19Hochschild, King Leopold’s Ghost, 303.
  • 20William Reno, “Sovereignty and Personal Rule in Zaire,” African Studies Quarterly 1 (3) (1997): 43.
  • 21Haskin, The Tragic State of the Congo, 69.
  • 22J. M. Janzen, Health in a Fragile State: Science, Sorcery, and Spirit in the Lower Congo (Madison: University of Wisconsin Press, 2019), 119.
  • 23Ibid.