The Democratic Republic of the Congo is facing the second-largest and second-deadliest Ebola outbreak in world history. At least 814 people have been infected with the virus and 488 have been killed since the epidemic began last August, according to the most recent data from the World Health Organization.
That’s bad enough. But there’s a bigger problem: the province at the epicenter of the outbreak, North Kivu, is also an active war zone.
Rigo Fraterne Muhayangabo is a Congolese doctor who has spent years working with the International Medical Corps on Ebola crisis responses. During West Africa’s 2014 Ebola outbreak—which killed more than 11,000 people—Muhayangabo worked as the IMC’s medical coordinator in Guinea and Liberia. He now oversees the organization’s treatment and prevention activities in the eastern DRC.
Muhayangabo spoke with The Daily Beast to explain what it’s like to fight a lethal outbreak—especially when the local community pushes back—and how working in the throes of an active war zone has made that challenge even harder.
The interview has been lightly edited and condensed for clarity.
When you worked the West African outbreak, you weren’t in an active war zone. How does the war change your team’s response?
The big challenge is security. That’s what’s different compared with the West African response—because we’re in an insecure and hostile environment. The insecurity is very acute, and some areas are not even accessible because of militia or armed groups. It becomes very difficult to lead the response in those areas.
It is tough when you understand that people are being killed [daily]. Sometimes the responders have been shot: I remember, like a month ago, one of the doctors who worked on the Ebola response was shot—shot dead.
But there are also lots of concerns in terms of population resistance. Because of course, we understand, the population has misconceptions—and sometimes they’re very difficult to change. It’s not something that can be done in a second; it requires time.
What misconceptions have you seen?
There are quite a lot.
Some people think that Ebola is not real, [that] it was something generated by the government because they didn’t want to hold elections. And unfortunately, when they used it as a reason to postpone elections in Beni and Butembo recently, it made that rumor something that is true, yet not true.
[Editor’s note: The DRC’s recent elections were the first democratic power transfer since the country became independent from Belgium in 1960—but they were mired in controversy. Former president Joseph Kabila, who postponed elections for more than two years to keep his grip on power, banned approximately 1 million voters in the opposition strongholds of Beni and Butembo from heading to the polls, citing the risk of Ebola contamination. The move sparked furious protests and deepened distrust of healthcare workers. During pre-election rioting, many health-care centers were burned and looted.]
Secondly, many people think that Ebola is something that’s generated to make money—because the people that are responding, the people that are giving out resources, are making money. And when they see the level of resources that are being pumped in, the logistic support, the financial resources, the number of people around, they understand that there is money and they think that’s the reason why.
The other is that they think we do burials without the participation of family members because they think we take organs and sell them.
Those kinds of misconceptions have been seriously affecting the response.
These populations have been resisting—some times [they] have been very aggressive—and have not been adhering to the response efforts. In some communities, they strike—they throw stones on every vehicle, every team member passing.
We even had to relocate some of the staff over security concerns because some of the population became very aggressive and started burning all the care facilities.
[Editor’s note: On February 28, Doctors Without Borders suspended treatment activities at the outbreak’s epicenter, following two violent attacks on treatment facilities that occurred in a span of just four days.]
I just came from an area where some of the triage units are being threatened to be looted. Ten were looted [during the pre-election period]—and even now, we see a lot of threats from the communities to burn them—because they see the screening and the triage units and they think it’s a means of perpetrating Ebola in the communities and they react to that.
That, unfortunately, will prolong the length of the outbreak.
Where did you have to withdraw from due to communities burning centers?
We withdrew from Beni and from Butembo because people were attacking all of our structures, and targeting everybody who’s involved in the Ebola response. Sometimes, we had to remove our visibilities—staff had to remove stickers, keep a low profile, and not wear any T-shirts with organization visibility—so that they cannot be recognized as an Ebola responder.
How have you been changing strategies to adapt?
We had originally been using community health workers for all of the contact screenings. They’re trained on the specifics they have to look for in a contact and how to do a screening: taking temperatures twice daily, the questionnaire that they have to administer to contacts. And they were doing this perfectly—but because there are small incentives [for the work], the family members at some point started protesting—they would forbid the community health workers to enter some of the homes, for example.
Now, instead of using community health workers, when there is a patient we look in his family to see if we can identify a focal person who can be trained on how the screening can be done, who can be equipped with all the tools necessary, and who can be screening and reporting.
Have you seen resistance to people being vaccinated, too?
Yes. There’s lots of resistance to everything in this Ebola response—to safe burials, to vaccination, to hand-washing, to screening and monitoring populations—there’s lots of resistance on everything. And some of the vaccination teams have been attacked by the community members, because they didn’t want to be vaccinated and they didn’t understand. They think sometimes that the vaccine will induce Ebola in the vaccinated patient, so we also have resistance to the vaccines.
What does your team need to fight the epidemic that it hasn’t been getting?
For now, the big challenge we have is the supply chain. With the Ebola outbreak, the demand for medical supplies is high—and it’s hard to find a qualified supplying country. We need to do this through international procurement, and sometimes when [international procurement centers] ship supplies internationally to the DRC, it’s very lengthy—it takes 3 to 6 months, which is too much time when it comes to having supplies on the ground.
The U.S. has pulled all of its on-the-ground workers from the epicenter of the outbreak. Has that caused any problems?
Yes. Pulling out the health workers from the epicenter has caused some problems because during [the ongoing conflict], the population movement could not be controlled.
During the looting of the health care facilities, some of the highly suspected contacts—and even patients—had to escape, causing a risk of new contaminations. And all the cases were not investigated. The consequences of that currently is that we are in a high peak.
Now, we are recording more cases. We recorded 11 cases per day, which is a huge number, and that has never happened.
If things stay as they are now, what happens?
A lot of work needs to be done in terms of ensuring security. Because as long as we have insecurity in that area, it’s hard to control the epidemic, and the risk of it spreading is very high.
What kinds of dangerous situations have you seen?
During the pre-electoral period, for example, we had to withdraw all the health workers, and we’re seeing the consequences now.
There are also some health areas that are not accessible. If we have a contact in those areas, there’s no way we can follow them. We don’t follow them. Because otherwise we’d be putting the health workers at risk.
In one of the Ministry of Health facilities we support, a worker was taken hostage, and people did ask for ransom. That’s a facility where we work, where we have our screening and referral unit, where we have our teams.
In the area where we have our Ebola treatment unit, people have been kidnapped on the roads several times. Sometimes they’re population members—but when it happens, it affects the momentum, and it affects everyone.
Who’s been kidnapping people?
We have a lot of armed groups, and sometimes they do the kidnapping for financial reasons, because they need to get some ransom. In that situation, we need to be keen on our movements—[reducing] our travel times, reducing the amount of time we spend in communities—and all of that affects the response, because we don’t spend as much time there as we could spend.
Have there been any particularly difficult moments for you?
The most difficult moment I had was during the pre-election period when we had to pull out all of the staff, because the community was striking. To withdraw our staff from the communities where they were living and secure their transport to the airport was very difficult. Normally we don’t use military or police escorts, but this time we were forced to do so—because there were a lot of concerns, and everybody was protesting.
As country director, having to be in charge of the security of 200 staff, I had sleepless nights trying to ensure that everyone was safe where they are, which meant tracking the movement of everyone on a daily, hourly, minute-by-minute basis.
What would you want people to know?
We have Ebola in an insecure environment. With this outbreak and insecurity, the population in poverty has been increasing every day.
That’s where the international community should do their best to support the DRC and support these efforts that are going on. At least we get rid of the Ebola, we get rid of the insecurity, and we can start thinking about the development of the country.