Archippe Kamuha knows the signs of Ebola well: diarrhoea, bleeding, persistent fever. But if the 25-year-old developed such symptoms, she would not contact specialist health workers.
“I know that if I go [to a treatment centre], I’ll die. All my friends who go there don’t come home, they die,” said Kamuha, whose home town, Butembo, in north-eastern Democratic Republic of the Congo, is at the centre of the country’s escalating Ebola outbreak.
Since the epidemic began last August, 1,340 confirmed and probable cases of Ebola have been recorded, more than 250 cases since the beginning of April, and 874 people have died – among them are Kamuha’s teenage cousin and a friend’s daughter.
Agencies blame the recent surge in transmission on a continued lack of trust in communities and violent attacks on treatment centres in February and March, which forced health workers to wind down some services.
On Friday, violence erupted when an armed group stormed a hospital in Butembo, reportedly ordered foreigners to go home and accused them of bringing Ebola to DRC. Dr Richard Valery Mouzoko Kiboung, an epidemiologist from Cameroon who was working for the World Health Organization, was killed during the attack. Hours later, a group armed with machetes tried to burn down an Ebola treatment centre in neighbouring Katwa.
The latest attacks are likely to aggravate the epidemic, as insecurity prevents agencies from treating new cases. “It’s going from bad to worse right now,” said Jean-Philippe Marcoux, Mercy Corps’ country director for DRC. “This is symptomatic of the deficiencies of the response – in terms of community engagement and communication.”
April has already seen a higher number of cases reported than any other month since the outbreak began.
Health experts have warned repeatedly that the disease is not under control and that agencies face unprecedented challenges. Transmission is occurring in highly populated areas where health systems are weak and more than 100 armed groups operate.
A government decision in December to suspend voting in the presidential election in Ebola-affected areas also led to the response being politicised, increasing the distrust in an already traumatised region. Rumours – such as that Ebola doesn’t exist, or that it’s used as a money-making scheme – are common.
“Health workers want to make a lot of money, they don’t want the virus to end,” said Aimee Lwanzo, a 27-year-old shopkeeper from Butembo. “I don’t trust the [Ebola response], they want to protect the money, not the life of Congolese. It’s a trade for some, and a loss for others.”
A failure to encourage patients to go quickly to Ebola treatment centres is also a major reason for the stubbornly high rate of cases. Despite efforts to make protective equipment appear less intimidating, such centres are still associated with deadly disease, a perception exacerbated by the use of police escorts by some health teams.
Among the victims of Ebola announced last week was a nurse from Katwa, who had declined an experimental vaccination offered to health workers. She developed signs of the disease after coming into contact with an Ebola patient, according to the Ministry of Health. She hid at home, where she was cared for by her colleagues, and went to a health facility in Butembo only after her condition deteriorated. She later died there.
The longer a patient waits before getting proper treatment, the less likely it is they will survive.
“People seek healthcare in lots of different places – there are Ministry of Health centres, private clinics, traditional healers,” said Natalie Roberts, emergency operations manager for Médecins sans Frontières (MSF). Not all providers collaborate with the response or refer patients for specialist care.
Agencies are trying to integrate specialist Ebola care into existing general government facilities, said Roberts, in an effort to better meet community needs.
Transmission rates between patients in general health centres are alarming, according to MSF, and one of the biggest risk factors associated with the disease.
A report by WHO’s Africa regional office, released last week, said workers were tracing 534 people who had contact with a medical doctor who died of Ebola in Beni earlier in April.
An experimental vaccine, made by Merck and thought to be highly effective, is being offered to frontline workers as well as known contacts of Ebola patients, and in turn, their contacts. However, health workers warn that there are also delays in reaching contacts. Around one in 10 people offered the vaccine either decline the offer or are absent.
It is likely that a second experimental vaccine, developed by Janssen Pharmaceuticals, could be rolled out within the next two months, according to Yap Boum, professor at Mbarara University, Uganda. It’s thought the vaccine will be used as a preventative measure in surrounding areas where the disease has not yet spread, but this will require large numbers of health workers to administer the treatment.
“The human resource is really the key point,” said Boum, who is also regional representative for Epicenter Africa, the research arm of MSF. “Then you have the logistics: how are you going to deploy it? It seems simple, but when you are in DRC and you see the state of the roads and you are in rainy season, it complicates some of those things.
“The vaccine is not the [magic] bullet,” he added. “We may use the second vaccine, but if there is still distrust in the community [the outbreak] will continue.”
Last week, DRC’s president, Felix Tshisekedi, visited Beni, a city affected by Ebola, to implore communities to accept the disease is real and trust health workers. “It is not an imaginary disease,” he said. Traditional leaders also met in Butembo, where they too urged communities to take the threat of Ebola seriously and pressed response teams to better adapt to the needs of communities.
One concern is that communities see large amounts of money flowing into the area exclusively for Ebola. Kate Learmonth, a health coordinator for the International Federation of Red Cross and Red Crescent Societies, said: “[People are saying], ‘We also have cholera and measles …’ There’s a number of other concerns, and so the community is coming back and saying they want to be very much involved [in decision making].”
Dr Oliver Johnson, who worked on the frontline of the Ebola crisis in west Africa and whose book, Getting to Zero, documents a litany of mistakes made during the outbreak, said that improvements have been made in how the World Health Organization responds to crises. But he added that there has been a huge focus on vaccine and diagnostic innovations, and far less on building community trust.
Responses have to be led at local level, and this requires major investment and time, he said. “One part of this has got to be a redoubling of international support for the outbreak from DfID, and the international community more broadly, to enable those trusted people from communities to have those kinds of conversations.
“Right now, how much does the British or American government actually care about lives of people in north-eastern DRC? How much are they seeing this as a security concern?”
In Butembo, Kamuha fears the death count will continue to rise. Last week, the local health officer had announced that nine people had died of the disease. “Even a baby died. It’s shocking.This virus, whose origin I don’t know, will kill our entire city,” she said.