Congo especially stands to benefit. The country has experienced ten Ebola outbreaks since 1976, and its health authorities are adept at identifying and isolating infected individuals, tracing and monitoring exposure networks, and controlling the spread of the virus. But as the current outbreak in the eastern province of North Kivu has shown, no amount of medical preparedness can overcome the difficulties of fighting an outbreak under conditions of insecurity.
Over the last 12 months, more than 2,000 Ebola patients have died in eastern Congo, a region that has been racked by episodic instability for the last two decades. This Ebola outbreak is the second deadliest ever, eclipsed only by the one that claimed more than 11,000 lives in West Africa between 2014 and 2016. And the virus keeps on spreading: health workers confirm an average of 81 new cases each week, according to the World Health Organization.
Congo’s Health Ministry and the World Health Organization have led the international response to the outbreak, and their measures have proven increasingly effective. But the new drug therapies alone can’t stop this or any future epidemic. Eradicating Ebola in Congo will require building public trust among Congolese and working with community organizations in order to reach vulnerable populations and overcome governance issues.
A DAUNTING GROUND ZERO
North Kivu sits on the far eastern edge of Congo, along the borders with Uganda and Rwanda. The region was the epicenter of two major wars that drew in many of Congo’s neighbors in the late 1990s and the early years of 2000. A 2002 peace settlement officially ended those conflicts but failed to account for local disputes over land and citizenship rights in the region, so Kivu remains fraught with violence. According to researchers at New York University, roughly 130 armed groups are currently active in North and South Kivu Provinces alone. The number and nature of these groups constantly change, but they are part of the insecurity that has continued since the wars began in 1996.
A militant group called the Allied Democratic Forces (ADF) poses an especially big problem for Ebola responders. Active in the Beni territory of North Kivu, which is the hardest hit by the outbreak, the ADF terrorizes civilians through murder and looting. Along with other armed groups such as the Mai Mai Mazembe—a coalition of militias in the region—the ADF has helped make Beni one of the most violent places in Congo, the site of an estimated 31 percent of all civilian killings in the region.
The violence has severely constrained the Ebola response. To contain an epidemic, health workers must be able to move quickly to identify infections, isolate patients in safe medical facilities, and trace the patients’ contacts. Responders also need to move equipment, medication, and vaccines into affected areas. All of these tasks are complicated by armed groups, which maintain roadblocks to collect bribes, attack medical facilities to loot medicines and other supplies, and kidnap people traveling through the areas they control.
At the same time, insecurity has hastened the spread of the disease. According to the Internal Displacement Monitoring Centre, a Geneva-based group that tracks people who flee their homes but stay in their country, more than three million Congolese are currently displaced as a result of conflict, and 1.8 million were newly displaced in 2018 alone. Another 850,000 Congolese are refugees in other African countries, according to the United Nations. All this movement raises the risk of Ebola transmission and increases the difficulty health officials encounter in determining who may have come into contact with the virus. Should someone infected with Ebola be among those fleeing across borders to refugee camps, or to family and friends in distant cities, health authorities would have a very difficult time finding them before they exposed others to the disease. And because the symptoms take up to three weeks to present, someone unknowingly infected with the virus could easily travel, become ill, and infect others. Just such a scenario unfolded in July, when a pastor who had conducted healing services in Butembo—a city with many Ebola cases—took a bus to Goma, then fell ill with the disease. Authorities have monitored his fellow bus passengers to prevent further spread of the disease.
If today’s medical responders succeed in North Kivu, they will have improved on the government’s long record of failure—a history that makes health workers’ jobs all the harder. For nearly a quarter century, the Congolese government has failed to deliver basic public services in the region. Most ordinary citizens have come to expect little besides corruption, inefficiency, and violence from public officials, so they don’t trust anything the government says, including about Ebola. As a result, Congolese don’t take symptomatic family members to health centers, hide ill people in their homes to avoid detection, and undertake traditional burial rituals without informing state authorities. All of these activities expose caregivers to infection themselves, causing the number of cases to skyrocket.
Congolese are equally distrustful of international actors, including aid agencies, nongovernmental organizations (NGOs), and the United Nations. Congolese concerns about what foreign aid workers are up to are easily dismissed as conspiracy-mongering (fallacious rumors include the claim that patients are being injected with the disease). But such suspicion rises from long experience of foreigners saying one thing and doing another. The Belgians looted Congo’s natural resources under the guise of a “civilizing mission.” The CIA supported (if not actually carried out) the assassination of the country’s first post-independence prime minister.
And Rwanda and Uganda have both repeatedly invaded in support of rebel movements, while the world’s largest UN peacekeeping mission has done little to actually bring peace. Given that history, one can hardly blame the Congolese for being wary of outsiders.
Consider, then, the unusual safety precautions taken by Ebola responders. Dozens of sick people enter hospitals, where foreigners keep patients out of view of families and friends, and few ever return. Families are told these people have died, but their bodies are never produced. Everything that happens is a mystery, so rumors fill the void. That groups of angry, frightened civilians have attacked Ebola treatment centers is hardly surprising under the circumstances.
TOWARD A REAL CURE
Despite all the obstacles and misunderstanding, there are promising signs that this epidemic can be brought under control. The new Ebola vaccine has prevented most health workers from contracting the disease from their patients. And although the Congolese government is weak, its Ebola response and vaccination programs are not. In Congo and in neighboring countries, extensive vaccination programs run by the state and NGO partners have been underway since the outbreak began. While isolated cases have made it to Goma and across the border to Uganda, health workers quickly contained them, and there have been no major outbreaks beyond northern North Kivu.
The very weakness of the Congolese state supplies another reason for hope. Because the government has been so dysfunctional for so long, Protestant and Catholic churches run much of the country’s public health system and manage most public hospitals and clinics. Under this system, church-run health facilities are part of the public health system, for which NGOs help supply funding and implement programs.
Church health authorities are at the forefront of the Ebola vaccination, prevention, and treatment efforts. Their role matters because churches were among the few social institutions to survive the state’s collapse: while the government, economy, army, and just about everything else ceased to function as instruments of public good, the religious institutions survived. Almost every Congolese is a member of a church or mosque, to which congregants look for leadership and information.
To make the most of these robust religious networks, and of the high levels of trust Congolese place in them, Ebola responders should work more closely with religious leaders, especially to spread information about early Ebola symptoms and effective treatment. Ebola responders should provide regular briefings to pastors and imams and encourage them to incorporate Ebola information into weekly services. Responders should also work with religious leaders to develop alternative rituals that allow families to properly commemorate their loved ones while preventing Ebola from spreading.
Churches are not the only bastions of the public’s trust. Responders should enlist the help of Congolese civil society organizations and local NGOs such as Goma’s HOLD-DRC to disseminate information, answer questions, and assuage fears. These and other reputable community-based organizations enjoy high levels of trust. Their representatives speak local languages and can communicate lifesaving information in culturally sensitive ways.
Local NGOs can even help Ebola responders contain the disease among migrants fleeing violence. Responders currently run health-monitoring posts along major roads and in refugee camps. These are necessary but not sufficient. Local NGOs can help find potentially infected people in urban areas that host large numbers of unregistered, displaced Congolese. Donors should finance and train leaders in these urban centers to reach out to displaced people, in the languages the migrants speak.
During the 2014–16 Ebola outbreak in West Africa, too, trust was of the essence. One simple innovation—the use of transparent isolation tent walls that allow family members to see and visit with infected family members—helped to dispel rumors and calm fears. Health workers in Congo should make the most of the lessons their colleagues learned from the last epidemic.
The trajectory in eastern Congo is positive, but the outcome will not depend only on the hope the new drugs provide. Working closely with religious institutions and community organizations, coming up with innovative solutions, and building trust within the population will ultimately allow responders to defeat the Ebola virus in eastern Congo. But given the daunting challenge responders face—an extremely insecure environment, population movements, and high levels of mistrust—it will be an uphill battle.
This article was originally published on ForeignAffairs.com.
