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Here’s why Ebola has been so hard to contain in Eastern Congo

Levels of citizens’ mistrust shape how they respond to the epidemic.

- June 24, 2019

Public health authorities have recorded more than 2,000 cases in the ongoing Ebola outbreak in eastern Congo. Last week, a 5-year-old boy died of Ebola in neighboring Uganda, signifying the outbreak has spread across the border. The latest update published by the World Health Organization (WHO) suggests the Congolese outbreak is not close to ending — the number of new cases is actually on the rise.

Ebola has spread for nearly a year in Congo. Officials are scrambling to ‘reset’ the response.

This is the second-deadliest Ebola outbreak on record. In the 2014-2016 Ebola epidemic in West Africa, health authorities recorded more than 28,000 cases, and more than 11,000 people died.

Why has the current Congolese outbreak been so challenging for the government and other stakeholders to contain? Most reports focus on insecurity in eastern Congo. Analysts have observed a spike in Ebola cases coinciding with organized attacks by armed groups on response teams.

But insecurity isn’t the only challenge hampering Ebola response. Recently published research drawing on data collected in the two deadliest outbreaks suggests one other major factor hampering response: citizen mistrust of government. Here’s what you need to know.

Why West African governments are struggling in response to Ebola

Ebola in Congo, 2018-2019

Ebola is a viral disease that infects immune system cells. Early symptoms resemble the flu or malaria. Ebola can be gruesome — potentially resulting in internal or external bleeding, organ failure — and often death.

Congolese health officials officially announced the current Ebola outbreak in August 2018. As of June 16, there are 2,168 confirmed and probable Ebola cases, and 1,449 reported deaths.

The U.S. pulled back its Ebola response in Congo. Here’s the story.

The region in which the Ebola outbreak is occurring is small, comprising a few territoires (counties) in the far north of North Kivu and several territoires in Ituri province. However, these are some of the most insecure areas in Congo, where up to 175 armed groups are active.

The government has little meaningful control of its territory, especially outside major cities. Citizens have experienced conflict since the First Congo War began in 1996, and while there are periods of calm from time to time, violence is an unfortunate fact of life for many residents of the outbreak zone.

This makes Congo’s Ebola crisis different from previous outbreaks, dating back to 1976. While the Congolese have effectively contained previous outbreaks, those occurred in other, much more secure regions of the country. Likewise, the 2014 West Africa outbreak occurred in countries that were stable and fully under government control.

Insecurity hampers health-care logistics

Why does this matter? For one thing, insecurity makes delivering medical care and other forms of assistance much more difficult. Armed groups and civilians have attacked health-care workers and facilities responding to the Ebola crisis. The logistics of getting needed supplies to the region, from vaccines to protective equipment, are extremely challenging. And reaching communities that may be affected, but are located in areas controlled by or beyond rebel lines, can be nearly impossible even for the bravest of health professionals.

While the outbreak continues unabated, the WHO declined to declare a public health emergency of international concern (PHEIC), even after cases emerged last week in Uganda.

WHO says Ebola isn’t a global emergency yet. But it’s spreading in Congo — quickly.

One organization supporting the Ebola response in eastern Congo is Doctors Without Borders (known by its French initials — MSF — for Médecins Sans Frontières), a humanitarian organization that provides medical care in emergency situations, including in conflict zones. While MSF’s own staff members have faced violence from armed groups, they also pointed to community mistrust as a serious obstacle to their Ebola response efforts.

What the research says about mistrust and Ebola response

A leading health journal, the Lancet Infectious Diseases, recently published an important research article studying how Congolese citizens are navigating the current Ebola outbreak. Surveying a random sample of 961 adults living in Beni and Butembo — cities in eastern Congo affected by the outbreak — the researchers found evidence of how citizens’ mistrust shapes how they respond to the epidemic.

Less than a third of the study participants trusted that local authorities represent their interests (according to the study, citizen trust is even lower as you move up levels of governance). A quarter of the study participants believed that the Ebola outbreak was not real. Study participants with low institutional trust and belief in misinformation had a decreased likelihood of adopting behaviors that would prevent Ebola infection, including acceptance of Ebola vaccines.

These findings are consistent with research that a team of political scientists including MIT’s Lily Tsai found during the West African Ebola outbreak. In their study conducted during the Ebola outbreak in Monrovia, Liberia, they found that Liberians who distrusted government took fewer precautions against Ebola. Those who distrusted government were also less compliant with Ebola control policies.

The research is consistent with what Ebola responders are reporting

These studies are consistent with MSF concerns that community mistrust keeps health workers from containing the outbreak. Earlier this year, two MSF-run Ebola treatment centers were targets of arson attacks. MSF’s International President Joanne Liu remarked on how so many new Ebola cases involved people who died in the community, not in treatment centers. She said, “That means that we have not reached them, and they have not sought our care.”

‘We don’t know their motivation’: Ebola treatment suspended after attacks on clinics in Congo

It’s not surprising that people in eastern Congo might not trust political leaders in this crisis. Their communities have been subject to conflict and violence for more than 20 years, and people long ago learned that they could not depend on government to protect them. The promises of NGOs and foreign aid workers have likewise often been unreliable over time.

What would begin to build trust in this crisis situation? Research by one of us (Laura Seay) suggests that working closely with local religious organizations is one potential avenue. Churches and mosques were the only institutions to survive the violence in many areas of eastern Congo, and most people have high levels of trust in community-based Catholic, Protestant and Muslim leaders.

Closely coordinating messaging with religious leaders about the symptoms, the need to go to health facilities for treatment, and changes to burial rituals may be the only avenue to build needed trust in the short time required to stem the outbreak.

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