NAIROBI, Kenya – The medical anthropologist was in the shower when she heard the first pops of gunfire. Initially, she thought it might be the action movie she’d left playing on high volume. Then the wall shook.
The violence in eastern Congo, which has stymied the international response to a growing Ebola outbreak in the region, had arrived at the guesthouse used by many of those working to prevent the disease’s spread.
Terrified, Julienne Anoko dropped to the floor and crawled into the corridor outside her room. She and five others from U.N. agencies, Congo’s health ministry and the World Health Organization, which she works for, hid in another bathroom for three hours until a U.N. peacekeeping force arrived and gave the all-clear.
“It was like a horror film,” Anoko said of the Nov. 16 attack in the city of Beni, the epicenter of the outbreak.
Attacks by armed groups happen on a daily basis across Congo’s North Kivu province, where the Ebola virus has been spreading since August, infecting almost 500 people and killing more than 270. It is now the second-biggest outbreak ever, after the vast epidemic that swept through Guinea, Sierra Leone and Liberia between 2014 and 2016.
The constant insecurity in North Kivu has proved an enormous obstacle, thwarting attempts to the contain the virus. By WHO’s estimate, the outbreak will go on for at least another six months.
“The fear we feel, and that the community feels, makes our job 10 times harder,” said Abdourahmane Diallo, a Guinean doctor who coordinates the administration of an experimental Ebola vaccine. He was at a different compound in Beni that was attacked the same day as Anoko’s.
“We know that violence is a constant risk. But that’s why I was ready to go to work the very next day,” Diallo said. “We simply cannot stop our response if we hope to overcome this outbreak.”
This is the first Ebola outbreak during which health workers have had to regularly don bulletproof helmets and vests. To reach at least 20 percent of Ebola-affected areas, health workers need armed police or U.N. escorts, said Michel Yao, WHO’s response coordinator in Beni.
The U.S. government withdrew its only personnel in the region in late August and has no plans to redeploy them. The WHO has 300 specialists from around the world in North Kivu. Those on the ground describe a chaotic effort to either negotiate with or simply avoid the region’s various militias.
“It turns into a cat-and-mouse game – we are the mouse trying to evade the armed groups,” said Anoko, who is from Cameroon. But Anoko, whose job entails conducting extensive interviews with locals, cautioned against the assumption that health workers are being targeted for their work. “There’s been decades of war, it cannot be so simply understood,” she said.
A quarter-century of vicious conflict, triggered by spillover from the Rwandan genocide in 1994, has been accompanied by deprivations of food, medicine and shelter that have shattered North Kivu’s society. Amid the widespread trauma and desperation, foreign companies have continued to extract the region’s extensive mineral wealth, often paying protection money to armed groups, stoking the conflict. The U.N. peacekeeping mission – established in 1999 and now the most expensive in the world – has been the target of violent protests due to its perceived ineffectiveness. Suspicion of outsiders is common and rooted in history.
To protect themselves, many communities have taken up arms. The resulting militias, which vary greatly in size, are collectively known as Mai-Mai. Other groups, such as the Allied Democratic Forces (ADF), a Ugandan-origin extremist group infamous for its child soldiers, routinely skirmish with Congolese government forces and attack anyone they perceive to be collaborating with them. The brunt of their vengeance falls on civilians.
An effective Ebola response relies on persuading people in the affected area to cooperate with health workers, but the distrust sown by years of conflict makes that much more difficult. Yao, the WHO coordinator in Beni, said not a week goes by in which his teams are not attacked by skeptical locals.
“Even yesterday, one of our investigations team’s car was destroyed and a team member’s house was burned,” said Yao, who is Ivorian Canadian.
Generating trust is the task of medical anthropologists like Anoko, as well as local politicians and traditional leaders. On top of the conflict, they are contending with Ebola’s newness in North Kivu. Though this is Congo’s 10th Ebola outbreak, there has never been one in this region, and knowledge of the virus is low.
Marie Roseline Belizaire, a Haitian doctor managing the WHO’s response in Butembo, a city of 1.3 million south of Beni where the disease is also spreading, has tried to infuse money into the local economy as a way of buying trust. Recently, for instance, she purchased 30 motorbikes for her team locally, even though she had clearance to have them imported.
But Belizaire also takes a more hands-on approach. Ebola is being transmitted in worryingly large numbers in Mai-Mai-controlled suburbs of Butembo. She spends days negotiating with the militias for access.
“New Mai-Mai groups keep calling us and making their demands; it’s like a new one every day,” she said. “But they are very hostile to outsiders coming in. In some cases, we’ve agreed to have them send community members to us so we can train them instead of the other way around.”
While many Mai-Mai groups are open to such arrangements, the ADF won’t engage. Local workers have taken to calling an ADF-controlled area between the towns of Mbau, Eringite and Kamango “le triangle de la mort” – the triangle of death. That’s where many are worried Ebola transmission is happening out of sight of the responders.
Congo’s health minister, Oly Ilunga Kalenga, said in an interview that he deeply appreciated the international community’s help and that with the help of Congolese health workers, “thousands of cases and deaths have been avoided so far.”
But with every attack comes a pause in the health workers’ response, and with each pause a jump in the number of cases.
“We can’t abandon these people in North Kivu,” Anoko said. “They have suffered so much. We have great sympathy for them.”