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Translated from French
WORLD HEALTH ORGANIZATION
EMERGENCIES AND HUMANITARIAN ACTION
DEMOCRATIC REPUBLIC OF THE CONGO
GOMA OFFICE, E-DRC
,
END OF MISSION REPORT
Dr Anne Ancia
Emergency coordinator
Goma, E-DRC
15 February – 30 April 2002
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World Health Organization
End of mission report
Submitted by: A. Ancia, EHA
Programme classification/EHA
Visit to: Goma
Inclusive travel dates
Co-travellers: none
14 February to 14 April 2002
Purpose/objective of travel: To support the WHO EPI-Polio coordinating office in
Goma, with coordination of public health in emergencies, following the Nyiragongo
volcanic eruption of 17 January 2002.
Brief summary: The eruption of the Nyiragongo volcano, on 17 January 2002,
caused considerable damage to the town of Goma, in the east of the Democratic
Republic of the Congo. A total of 450 000 people fled, before rapidly returning to find
that 14 000 houses, some 13 % of the town, had been submerged in lava or looted.
The victims were accommodated by their families or took refuge in makeshift camps.
Despite this situation, the immediate public health impact was minimal; an estimated
70 deaths were recorded as a result of the eruption, subsequent looting and the
explosion of a petrol station. The incidence of conjunctivitis and of respiratory
infections also increased. Immediate and effective reaction from the humanitarian
community in Goma to the already existing complex emergency situation averted a
catastrophe. Now that the initial phase of the emergency is over, the humanitarian
community is attempting to restore living conditions to their pre-eruption state.
Sectoral committees are working on this, and WHO is involved in coordinating the
health committee. However, Goma is still under threat from abnormal geological and
volcanic activity, which is difficult to predict. Surveillance of these phenomena is
being boosted, and a contingency plan has been drawn up. WHO is the coordinating
agency for emergency preparedness and response in the health sector, in close
collaboration with the overall plan. WHO also has a role to play in assessing and
forestalling hazards resulting from the volcanic eruption, which was begun by
Professor Baxter in March 2002. Lastly, this experience has demonstrated the need
for, and ability of, WHO to coordinate emergency preparedness and response in the
whole of the eastern RDC, which has been in the grip of a complex emergency for
years. All national and international partners, as well as the donors, with whom we
have discussed this, fully approve of this idea.
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Recommendations/Actions to be taken
1) Follow-up of the coordinating work of the health committee in Goma and active
participation in drawing up the contingency plan for response to the threat of a
volcanic eruption.
2) Monitoring activities to assess and forestall the risks from the geological and
volcanic activities, unique to the Kivu region.
3) Finalization of training on emergency preparedness and response for health
workers in the region under threat.
4) Extension of WHO’s public health activities in Goma, with the opening of a
permanent emergency preparedness and response post in eastern DRC.
1. Background
Following the volcanic eruption of Mount Nyiragongo, on 17 January 2002, the
WHO/EHA Office, in collaboration with the WHO Offices in the Democratic
Republic of the Congo (DRC) and Rwanda, conducted a health assessment in Goma
and Gisenyi.
One of the principal findings of this assessment was the need for the presence of a
WHO-EHA Consultant in eastern DRC able to work jointly with the Epi-Polio
Coordination Team already established in Goma. I accepted the post on 27 January
2002 and arrived in Goma on 19 February 2002, after a briefing in Kinshasa.
2. Terms of reference
1. To represent WHO in health-sector coordination functions in support of local
health authorities, in collaboration with UN agencies, representatives of NGOs
and donors. To act as health sector coordinator.
2. To identify priority health- and nutrition-related issues among the affected
population and ensure that these are properly addressed in an integrated primary
health care approach that preserves and strengthens the existing health system.
3. To ensure immediate life-saving actions through outbreak response and nutritional
interventions.
4. To ensure control of preventable ill health particularly communicable and
vaccine-preventable diseases.
5. To ensure that risks to the environment are recognized and properly managed.
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6. To ensure good quality access to basic preventive and curative care including
essential drugs and vaccinations for all, with special focus on vulnerable groups:
the elderly, very young children, pregnant women, the disabled and the
chronically ill.
7. To ensure that Humanitarian Health Assistance is in line with international
standards and local priorities.
8. To contribute to advocacy efforts for secure humanitarian access, neutrality and
protection of health workers, services and health structures as integral parts of
health promotion.
3. Humanitarian Situation
The Nyiragongo eruption on 17 January 2002 caused

A massive exodus of the 450 000 inhabitants of Goma, followed by their rapid
return in the days following the eruption.

The destruction of 12 000 houses and shops in the commercial heart of the city,
and to the looting of many others.

The destruction of three health centres and a 100-bed hospital

A significant increase in the number of homeless people, the majority of whom
sought refuge in makeshift public buildings or with shelter families already
overburdened and stressed by earlier events.

Splitting in two of the city by the lava streams, creating communication and
transport problems.

Collapse of the main public services.
Many local and international NGOs, United Nations agencies, donors and
representatives of civil society were already on the spot in Goma on account of the
complex emergency in DRC. Their presence made it possible rapidly to organize
humanitarian assistance for the population, thus averting the expected catastrophe.
The humanitarian agencies met at sub-committee level to deal with the different
problems caused by the volcanic eruption. The following committees were set up:

the health committee, coordinated by WHO and Asrames;

the education committee, coordinated by UNICEF;
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
the water and sanitation committee, coordinated by OXFAM;

the child protection committee, coordinated by Save the Children;

the shelter and reinsertion committee, coordinated by CONCERN;

the food committee, coordinated by WFP;

the non-food items committee, coordinated by UNICEF.
The objectives of the humanitarian actions were:
1. To prevent any further catastrophes, such as the outbreak of an epidemic or a
deterioration in security;
2. To restore as quickly as possible the pre-emergency situation.
The main actions carried out to achieve this were:
1. The repair of the road network with the assistance of the German Agro Action
NGO;
2. The organization, from the very first week, of chlorination points for the water
drawn along Lake Kivu, by the AMI-KIVU NGO, the provision of water supplies by
tanker lorries and tanks installed by the IRC and OXFAM NGOs. These actions
resolved the problem of water distribution by Regideso, whose network was heavily
damaged by the eruption. Most of the network has now been repaired, thanks to the
help of ICRC.
3. Organization, by WHO, UNICEF and MSF-B, of a measles vaccination campaign
in Goma and Kirotshe health districts;
4. Repair of part of the electricity network, either from Goma and Bukavu in the west
or from Gisenyi, in the east, by SNEL (National Electricity Company);
5. Free provision of public services, including health services;
6. Free distribution of food by WFP and its distribution partners, first of all to the
entire population of Goma and subsequently solely to victims of the catastrophe;
7. Organization by UNICEF of reception sites for the displaced population, at which
food and non-food items (tarpaulins, soap, kitchen utensils and blankets) were
distributed; provision of sanitation for the sites, installation of water supply,
construction of latrines and showers by MSF and OXFAM.
8. Organization of family reunion by ICRC and Save the Children;
9. Implementation of a contingency plan for the possible evacuation of Goma, in the
likelihood of a further volcanic eruption or earthquake.
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These emergency measures were mainly undertaken during the first phase of the
emergency, which lasted until 1 March 2002. The next, transition phase, involved:
1. The return to charges for part of the cost of public services;
2. Staggered and focused distribution of food, and distribution of non-food items only
to displaced persons returning from Gisenyi or Bukavu;
3. Distribution and construction of temporary shelters on individual plots;
4. Cutback in the number of tanker lorries used to distribute water and of lakeside
chlorination points;
5. Reopening of schools, despite a number of strikes by teachers on account of nonpayment of salaries;
Overview of the situation at present

A total of 10 000 families are still being relocated, 2500 of them are at the Esco
site, 15 km west of the town, and 1000 at the Itig site near the airport. The others
are with host families. In Rwanda there are still 2500 families in reception sites,
although they are gradually returning to Goma. Most of the families will be
entitled to the temporary shelters provided by the SRC, Atlas, BRC, CONCERN
and LWF NGOs, although no decision has yet been taken on where they will be
definitively housed.

The electricity supply network to the eastern part of Goma has not yet been
repaired. This part of the town is currently supplied by the Rwandan network, but
SNEL says that it has no funds either to pay the Rwandan bill or to repair the
damaged network.

Most of the Regideso water supply network has now been repaired, although some
minor repairs are still required. The work should be completed by mid-May.

Food will be distributed to the victims until 30 June 2002, and a food-for-work
programme has been set up to help revive the town's economy. However, Save
the Children, which in March 2002 carried out a social and economic survey in
Goma, has drawn attention to an economic recession in the aftermath of the
eruption, and has recommended preventive measures such as cash for work, food
for work and housing aid.

The persistence of magmatic, tectonic and volcanic activity in Goma has led to the
reinforcement of:
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1. Monitoring of the Nyiragongo and Nyamulagira volcanoes;
2. Monitoring of developments associated with rifting in the regions; tracking the
faults and ascertaining whether the towns of Goma and Bukavu are sinking below the
level of Lake Kivu.
3. Monitoring gaseous emissions at the sites known as “mazuku” and in the faults.
4. Studies into the consequences of the presence of methane and carbon dioxide
pockets in the depths of Lake Kivu.
The contingency plan drawn up to deal with this threat has not yet been finalized. In
Goma, two groups have informed and educated the population and organized civil
defence. Now that this work is more or less complete, it has to be shared with Sud
Kivu and Rwanda for final acceptance. This task, which was supported by OCHA,
was carried out in partnership with the local authorities.
Lastly, the inter-Congolese dialogue, which is under way on 19 April 2002, also raises
political and security issues that call for continued attention, on account of its
potential humanitarian and health effects in Goma and in the whole of eastern DRC.
4. The health situation
1. Morbidity and mortality
 The volcanic eruption killed approximately 70 people. Some of them died in
villages on the side of Nyiragongo, where children and the bedridden were unable
to escape in time. In Goma, one family suffocated after having taken refuge in the
basement of a house. Some people also died during the looting. However, most
deaths were caused by the explosion of a fuel reservoir which survivors were
trying to drain.
 Seven cases of burns to the feet and thighs were reported; these occurred when
people tried to cross the lava flow in the first few days after the eruption, and after
the first rainfall, as a result of hot lava heating the water vapour.
 two women lost consciousness near the fissure running through the 8th Cepak
Church in Goma: this was probably due to carbon dioxide emissions. Three
weeks later, when we took gas readings at the spot with Professor Baxter, we
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could find no traces. However, this does not mean that there were no emissions
earlier.
 An increase was reported in the number of cases of conjunctivitis in the two days
following the eruption. However, the situation became stable the following week.
Upper and lower respiratory tract infections also increased significantly in the
wake of the eruption, and are now the second reason for consultation in Goma
health centres, ahead of diarrhoea. There was little change in the incidence of
diarrhoea after the eruption, thanks to the rapid measures adopted by the water and
sanitation committee.
 However, the cutback in large-scale distribution of water in the western part of the
town, as part of the return to normal, led to an increase in reported cases of
gastroenteritis. Last week, epidemiological week 14, six out of seven stool
samples were found to be infested with Ogawa-type cholera vibrios. The Carmel
cholera treatment centre, which covers the area concerned, has been opened and
supplied with Ringer lactate, ORS and chlorine. Community health workers and
the local radio station have been mobilized to promote preventive measures and to
broadcast messages. All the patients reported that they had failed to chlorinate
water taken from Lake Kivu. The number of chlorination points maintained by
Ami-Kivu was immediately increased. Regideso and ICRC were also requested to
complete repairs to the district water supply system as a matter of urgency. No
cases of cholera were reported in the other parts of the town, although active
surveillance is being maintained, and we hope to be able to prevent any outbreak
of cases in the centres for displaced persons.
 The WHO Office in Kinshasa also sent a mental health expert, Professor Mavinga,
to assess the impact of the volcanic eruption on the mental health of Goma's
population.
2. The health system
 The lava flow carried off three health centres and a 100-bed hospital (CBK
Virunga). All these facilities are now being rebuilt (MDM-B, Merlin, DOCS).
 After the eruption, these centres stopped operating for only four days. They
resumed work, providing services free of charge and with the support of the
following NGOs: Asrames, Merlin, MDM-F and SCF-UK, who provided primary
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health care assistance; NPA, Malteser and Médecins en catastrophe, who
provided hospital support; OXFAM and Goal, who helped with health education;
World Vision and SCF-UK, who provided nutritional assistance, and MSF-E, who
helped with epidemic prevention.
 Epidemiological surveillance activities were carried out daily rather than weekly,
and diseases specific to a post-eruption phase were added to those usually
included in the surveillance.
 From 6 to 11 February, UNICEF, WHO and MSF-B organized a measles
vaccination campaign in Goma and Kirotshe health districts. The level of
vaccination coverage attained was 64.6 % in Goma and 101 % in Kirotshe.
 Free care, which was provided until 1 March 2002, led to a sharp increase in
attendance at all Goma's health centres. On average, the number of consultations
increased ten-fold in comparison with the pre-eruption period. After the
introduction of a patient's contribution of CF 50 on 1 March, the number of
consultations was divided by four. On 15 April 2002, the patient's contribution
was increased to CF 120, half the fee charged before the eruption. Changes in the
number of consultations subsequent to this charge increase were not available
before my departure, but they should be followed up. I personally believe that
these changes came too rapidly in the wake of the crisis, before the local
population had fully recovered from the natural catastrophe; as the SCF-UK study
shows, this is a town, which is in the throes of economic recession. It should be
noted, however, that the disaster victims housed in the makeshift camps still have
access to free primary health care.
 A survey on the economic and financial resources of the Goma population in
relation to their access to health care was carried out in 488 families in the first
week of April 2002. Results were not yet available when I left, but they should be
taken into account in any decisions to raise the patient’s contribution to the costs
of health care. To be continued…
 It should be said that collaboration between all health partners and health
authorities was excellent. The Goma province health office was very actively
involved in the emergency response, although we regret the lack of involvement
on the part of the Goma health area central office, which was conspicuous by its
absence from health committee meetings or activities during the crisis period. The
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collaborative spirit which reigned between the different health partners and
between different committees and local authorities was a key factor in the
effective response to this emergency. Similarly, the fact that NGOs and UN
agencies were already on the scene at Goma in connection with its long-standing
problems was also a key factor for the rapid organization of the crisis response
following the eruption.
5. Achievements
1. Coordination of the health sector for emergency response activities in Goma
On my arrival, the health committee had already begun its activities and Dr Palaku,
head physician of the WHO EPI-Polio regional unit at Nord Kivu, was in charge of
coordination with Asrames and the physician inspector for the province, Dr
Mutombo. I took over from Dr Paluku at these weekly meetings. If the cholera
situation in the west of Goma stabilizes, and provided access to health centres from
the perspective of the city’s health situation is acceptable (despite the increased
patient’s contribution), this committee should consider meeting twice monthly.
However, the problems mentioned above should be closely monitored so as to ensure
an appropriate response to the cholera threat in Goma and health coverage, which
meets the real needs of Goma's population.
The WHO also represents the health committee at the weekly general coordination
meetings.
2. Representation of the health sector in drawing up a contingency plan for Goma
WHO took an active role in drawing up a contingency plan. The Goma team
examined the pre- and peri-critical phase in particular detail, while the Rwanda team
worked on post-critical analysis. In Goma, two subgroups were formed: educationinformation and civil defence. WHO was principally involved with the latter sector.
Should a catastrophe occur, the role of WHO would be to ensure the early evacuation
of hospitalized and disabled patients to hospitals in Masisi and Ruhengueri, as well as
to organize medical treatment for the homeless in the Mushaki camps, with referrals
to the Matanda health centre. These health facilities and the sites for displaced persons
have been assessed and their directors informed.
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3. Participation in assessing the vulnerability of the people of Goma following the
eruption of Nyiragongo and in view of persisting geo-volcanic activities, in
collaboration with Prof. Baxter
In the wake of the Nyiragongo eruption, WHO emphasized the need to conduct a risk
assessment at Goma. A four-person WHO team was to have accompanied Prof.
Baxter, but for safety reasons only Prof. Baxter was able to reach Goma. There we
worked together on:

Reconstructing the history of the 17 January eruption, the evacuation of
Goma, and the first stage of the humanitarian response, in order to analyse the
negative and positive features in the way the population and humanitarian
community had reacted when confronted with the crisis, and to draw lessons
for the future.

Analysing those physico-chemical factors which could have an impact on the
health of the inhabitants of Goma: gas emissions, water composition, air
quality, possible toxic fumes from the volcanic ash emitted by Nyiragongo and
Nyamulaguira, as well monitoring fissures and seismographic data in
collaboration with local vulcanologists.

Making plans for a conference organized by the WHO EPI-Polio Coordination
Office in Goma to present the initial results of assessment, to provide exact
information and to reassure the population.
The final report to this assessment ought to have been submitted by Prof. Baxter in the
weeks following. It is not yet available since some analytical results have been
delayed.
4. Monitoring assistance and response to epidemics in eastern DRC
By means of its integrated epidemiological monitoring programme, WHO regularly
receives updates on epidemics breaking out in the provinces. This is an important
asset for an emergency preparedness and response programme. During my stay in
Goma, I endeavoured to follow the multiple epidemics in eastern DRC by sending
feedback to the provincial epidemiologists (MEP) and district epidemiologists
(MED), by giving information to appropriate persons likely to be involved in
treatment, and by trying to provide a technically correct response. This is however a
long-term job which requires a permanent presence in eastern DRC in order for it to
be truly effective.
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5. Technical assistance to operational partners
Several protocols and technical files on the management of specific diseases (monkey
pox, haemorrhagic fevers such as Marburg fever) were also provided to medical
partners working in at-risk regions. The “minimum package of activity” strategy, as
defined at the Nairobi meeting in September 2001, was sent to new field partners and
provided the basis for discussion on how to initiate new medical programmes with
local and international partners. Nevertheless, this approach has little impact if carried
out solely on a temporary basis.
6. Preparation of WHO training on emergency preparedness and response
In response to the threat of a new eruption or other seismic event at Goma, the EHA
offices in Brazzaville, Nairobi and Goma have drawn up a training proposal and
curriculum on emergency preparedness and response. This proposal is currently in
Brazzaville, and is due to be presented to the WHO representatives in DRC and
Rwanda for acceptance and application. Initially directed at members of WHO, MoH
and some NGOs in the regions concerned by the geological and volcanic threat, this
training programme could be distributed to other provinces of DRC. Once accepted
by the representatives, the contents will need to be expanded in detail, which could
take a few weeks yet. It would be advantageous if Dr Quitz, who works in the EHA
department in Kinshasa, could monitor and contribute to the finalization of this
training programme in collaboration with Nairobi and Brazzaville.
7. Definition of actions and basic research in order to continue and extend the EHA
position in 2002
It took me very little time to realize how essential a WHO permanent presence is for
emergency coordination in eastern DRC. It could rapidly have a significant and
positive effect on the quality of the humanitarian response in the health sector. It is on
the lips of all partners, whether the department of health, civil societies, local or
international NGOs, United Nations agencies or donors. During my mission, I had the
opportunity to meet representatives of ECHO, OFDA, DEC London and OCHA New
York. They were all satisfied with the WHO response to the emergency in the posteruption period, but would like to see this post permanently manned. Mr Gil Collard
of ECHO and Mrs Miriam Lutz of OFDA stated that they would be in a position to
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meet costs incurred by WHO in providing emergency coordination in the health sector
in DRC. A brief proposal for urgent financing was submitted to Mrs Lutz of OFDA,
in response to her express request, but will need to be reviewed personally by the
Representative, who was absent during this exchange. I believe the EPI-Polio
Coordination Team in Goma also felt relieved to have me on hand during this difficult
situation and would be equally delighted to welcome a permanent WHO-EHA
member to the office. The terms of reference for this post should be almost identical
to those consigned to me on my departure, and are set out in annex.
6. Problems and limitations

The absence of funds and basic material in the WHO Office in Goma was the
major problem of this mission. Not only did this problem handicap the
advancement of field activities, but it also gave rise to vitally significant lost
time. The absence of funds and certain equipment sometimes led to the
adoption of measures that did not meet safety standards, although the city of
Goma is currently in security phase 4. This is regrettable. Lastly, these factors
do not always encourage staff to work.

The limited time of my mission was undoubtedly a hindrance to undertaking
activities which I deemed essential for mounting an effective health sector
response to the crisis which is currently affecting eastern DRC. Since I was
unsure whether I would be replaced or would have to work permanently in an
open post, I preferred not to embark upon certain activities rather than do so
and then find myself, in the event of my departure, obliged to abandon them
without follow-up.

The delay in receiving Prof. Baxter’s report and the results of field analyses
has hindered me from 1. ensuring their distribution and 2. applying any
preventive and/or corrective measures, which the expected results might have
entailed.

The departures of Drs Schouten (EHA Nairobi) and Chellouche (EHA AFRO)
on other missions slowed down progress in drawing up the training curriculum
on emergency preparedness and response, even though we had planned this
training for the first week of May 2002 in Goma. I left the mission without
having been able to ascertain what the WHO Representatives in DRC and
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Rwanda thought of this proposal and without having been able to finalize its
contents.

It is, lastly, a pity that I did not have the opportunity to transfer my mission
duties personally to Dr R. Quitz. Dr R. Quitz is currently in Geneva, and has
not had prior occasion to visit eastern DRC. I hope that this end-of-mission
report will partially make up for this problem.
7. Conclusions
Despite the drawbacks cited above, my mission to Goma proved to be, on balance,
positive. WHO actions have had an impact on improving the conditions of life and
health of the population of Goma after the eruption, and have provided hard
knowledge that will help to protect this population should another catastrophe occur.
This mission has also demonstrated to partners in the field that WHO has a real
commitment and ability to invest in the response to health crises affecting eastern
DRC. In addition, the WHO team in Goma, undergoing complete office
reorganization after the eruption and very little time before the NIDs, found
themselves relieved of follow-up and management of health problems linked to the
eruption of the volcano. Personally, this mission has taught me a great deal about the
follow-up and health response, which should be provided in a volcanic eruption, in
particular in a complex emergency situation. I hope I shall be able to avail myself of
this experience in the future. Lastly, I would like most especially to thank the WHO
team in Goma for its welcome, its openness, and its daily assistance in my work.
Although this team has had its difficult moments when the WHO office was destroyed
by the lava stream from Nyiragongo, the devotion of each and every one is admirable
and ought to be widely broadcast. I would also like to thank Kinshasa, Brazzaville,
Nairobi and Geneva for the support provided during these two-and-a-half months and
for the confidence displayed throughout this mission.
8. Recommendations
1. Follow-up of the coordination of the health committee in Goma and participation
in contingency plan finalization in response to the geological and volcanic threat.
These activities can be readily accomplished by members of the WHO coordination
bureau or regional unit at Goma.
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With regard to the health committee, it is important to monitor changes in the
numbers of cases of cholera-like diarrhoea and ensure that they are managed
correctly. Similarly, it is crucial to monitor changes in the consultation rates in the
health centres of Goma and the impact of the new health care charges on the health of
the population. WHO has a duty to provide a clear and objective opinion on this item
in the committee.
The contingency plan is practically finalized; all that remains is an exchange of
proposals with Sud Kivu and Rwanda in the final summary. The participation of
WHO is essential in view of its presence in Rwanda and Sud Kivu, but also because it
is the only medical organization to have helped to the draw up this plan: its public
health aspect is a core element.
2. Follow-up of risk assessment and prevention related to the unique geological and
volcanic activities in the Kivu region.
The recommendations expressed in Prof. Baxter’s report, pending the results of
analysis, should be monitored and applied if they are accepted by the WHO
Representative in DRC. Many people in Goma are awaiting this report and the
analytical results, and steps ought to be taken to ensure its wide and rapid distribution
once it has been cleared by WHO Kinshasa.
3. Finalization of training on emergency preparedness and response for health
workers in the region under threat.
The work accomplished to date consists of drawing up the training proposal and its
general contents. It remains the task of the regional office to discuss its methods with
the WHO representatives in DRC and Rwanda, and for a third party (Dr Quitz?) to
finalize the breakdown of the contents. I shall be available to provide this person with
any additional information or assistance as needed.
4. Extension of WHO public health activities in Goma, with opening of a
permanent post for emergency preparedness and response in eastern DRC.
This item is particularly close to my heart since I believe that WHO has the occasion
and ability to provide key assistance to the humanitarian community’s response in the
health sector to the complex and long-standing crisis experienced by eastern DRC.
Such assistance would require the permanent presence of an emergency public health
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coordinator. Financing could be met by donors (OFDA, ECHO) present in Goma,
who placed their confidence in the response mounted by WHO after the volcanic
eruption of Nyiragongo on 17 January 2002. For the record, the terms of reference for
this post are set out in the annex.