Editor's note: This post has been republished with updates to reflect the latest count of new cases of Ebola in Congo.
This week the ongoing Ebola outbreak in Democratic Republic of the Congo took a worrisome turn: The number of people reported sick each week has started to rise precipitously.
Compared to mid-February, when the tally of new cases had been brought down to as low as 24 per week, the figures for this most recent week are on track to double — bringing the total number of infected over the last eight months to nearly 1,000.
World Health Officials say the shift is largely the result of an upsurge in recent weeks of direct, and often deadly, attacks against the health workers trying to respond to the outbreak.
But the pileup of incidents can obscure a crucial feature of the trend that makes it hard to address: The attacks actually fall into two very different categories which call for very different solutions.
The first category consists of coordinated assaults by organized groups such as criminal gangs or the dozens of rebel militia that have long clashed with the government.
The second category of attacks are spontaneous eruptions of rage by members of the community who mistrust responders when, for example, they show up to take suspected Ebola patients in for testing and treatment.
To counter the attacks by organized groups, the government has been bringing in military, police and U.N. peacekeepers to provide protection for health workers. But there's growing concern that that very approach is sowing further mistrust and fueling additional resistance among ordinary people.
The widespread mistrust isn't just an issue because of the violence it sets off. It's the reason significant portions of the population still refuse to get vaccinated against Ebola. It's also why anywhere from a third to half of deaths from Ebola are taking place in the community. That's a sign that people aren't willing to bring a sick family member forward for treatment – and also a potential source of spiraling transmission, since Ebola patients are at their most infectious around death.
Indeed all parties involved in the response – including WHO and the government – now say that convincing the population to overcome its mistrust is the key to ending the nearly eight-month long outbreak — which has already infected nearly 1,000 people.
"We have to win over the hearts and minds and trust of the community," says Dr. Robert Redfield, director of the U.S. Centers for Disease Control and Prevention. He said that was his main takeaway from a fact-finding trip he made to the outbreak zone this month.
But how do you win hearts and minds while also countering assaults by armed groups?
Redfield got a taste of the complexity when he stopped at an Ebola treatment center in the outbreak zone that had been attacked by gunmen in February. According to the government the attackers had come from a local militia. Congo's government had quickly re-opened the center. But hours before Redfield was due to arrive, the center, in a city called Butembo, was attacked again.
"It was a foggy morning," says Redfield. "And this group came in through the fog."
Redfield says the government told him these particular attackers were members of a city gang that wanted to extort money from the center. They shot a policeman dead and hacked at two nurses with machetes before Congolese military chased them off.
When Redfield met with the staff, he says, they were visibly shaken. "They were courageous. They're committed to doing their work," he says. But they also made a point of telling the Minister of Health Dr. Oly Ilunga Kalenga – who was accompanying Redfield – that "the thing they were concerned about was their safety."
The incident suggests a slippery slope by which Ebola treatment centers can become effectively militarized. This particular center was originally run by the aid group Doctors Without Borders and did not use armed guards — in keeping with the group's longstanding policy. But after the first attack, Doctors Without Borders suspended its work there, citing the security risk to its staff.
According to Redfield, once the government took over, it deployed both a police guard around the front of the center and a military guard near the back. And that was before this latest attack that has had staff clamoring for even more security.
A similar dynamic has been affecting burials of suspected Ebola victims. Normally they are handled by the Congolese Red Cross. But Dr. Jacques Katshitshi, who oversees the teams, says after the recent attacks it's become too dangerous to work in a lot of communities without an armed escort. Like Doctors Without Borders, the Red Cross insists on maintaining strict neutrality. "Never! Never! For the Red Cross we can't use an escort," says Katshitshi.
So he says the result is that, at least for now, about 70 percent of burials in the epicenter are being done by government teams with armed guards.
Katshitshi says he's sympathetic to their logic. Still he notes, "militarizing the response is not a good way to operate. Using armed forces is the last option."
After years of civil war many people view the government with suspicion. It doesn't help that the epicenter of the outbreak is a stronghold for the government's opposition. And that last winter the government used the Ebola outbreak as a justification for barring people there from voting in national elections.
As a result, many people have concluded that Ebola is a scam cooked up by the government and aid groups to raise money and control the population. And that impression is likely to be strengthened when a bunch of strangers in hazmat suits escorted by armed guards from the government show up to bury their relatives.
To get a sense of how deep-seated that mistrust can be consider the latest attack on Ebola responders – just last Thursday. According to the government, a resident of a community called Biena had just died of an illness that health workers suspected was Ebola. When they tried to take a blood sample from the body, the relatives and others in the community became enraged. They then ransacked a "transit" facility where people suspected of having Ebola are housed temporarily while they wait for test results. In the ensuing melee, police shot and killed a bystander.
Several aid groups are hoping to surmount the mistrust by enlisting more people in the community to take a direct role in the Ebola response.
For instance, a Senegal-based medical aid group called ALIMA is rethinking how it runs the transit centers for suspected Ebola patients.
Nicolas Mouly is an emergency coordinator for the group. He says the current setup has been for ALIMA to operate one large transit center serving a wide area. It's not surprising that people resist coming in.
"It's far from them. They don't really know what happens inside," says Mouly.
So now ALIMA wants to open smaller transit centers in many communities – "where the population knows the staff, knows the area and would be more willing to go for treatments."
ALIMA is currently setting up a pilot version, with more to follow if it works well.
This hyper-local approach is also now being emphasized by the Red Cross's Katshitshi. He has scaled up an effort to train teams within as many neighborhoods as possible to do the burials themselves. That way it will no longer be strangers burying a loved one, he points out. It will be people the family knows and trusts. So far he says he's got about ten teams up and running, though it will take many more to cover the vast area of the outbreak zone.
The challenge with this approach says Katshitshi: "Going slowly. It needs many, many dialogues with the community before they accept the approach. We cannot, just because we are in an emergency situation, go quickly."
In fact, the experience in a city called Beni, suggests "it takes around three to four months to build community trust," says Jean-Philippe Marcoux, DRC country director for the aid group Mercy Corps. Last fall Beni was the epicenter of the outbreak – with both the highest number of cases and repeated instances of violent resistance to responders. But a concerted campaign to reach out to both local chiefs and youth leaders ultimately turned around public opinion. Today the caseload has been brought down to practically zero – even as a new flare-up started in the current epicenter around Butembo.
The time-consuming nature of community engagement is why Mercy Corps has begun a massive community education campaign around Ebola in the major city of Goma, which is about 200 miles from the outbreak epicenter and has not yet seen infections.
If the current situation has taught the world anything, says Marcoux, it's that "we must put much more emphasis on community engagement – and especially in areas that are not yet affected. So when and if they become affected we don't face the same challenges."