A medical worker prepares to treat Ebola patients in Beni, Congo, on Sept. 6. (Fiston Mahamba/Reuters)

This week, the World Health Organization (WHO) held off on declaring the latest Ebola outbreak a public health emergency of international concern — a designation that would have initiated a greater international response. This may make it far more difficult to stop the spread of this particularly deadly strain.

Ebola has flared up in Congo many times before, but never quite in these circumstances. The outbreak’s location near the eastern city of Beni, in a volatile borderland — and amid the presence of a shadowy rebel group — means that it will take more than medical expertise to prevent a much wider epidemic. In recent weeks, militants attacked Red Cross workers, and other aid groups had to suspend activities in the face of mass killings by rebels.

This latest Ebola outbreak was first reported in August. Health officials have registered 220 cases, nearly two-thirds of them proving fatal. The affected border region covers much of eastern Congo and part of western Uganda. Three factors make responding to this Ebola outbreak enormously challenging:

1. There is little trust in the government

It is not uncommon in central African border regions to find an uneasy relationship between the government and citizens. In eastern Congo this is certainly the case, as the central government in Kinshasa has long practiced a policy of neglect toward a region it tends to regard as merely peripheral.

Delivery of state services like health care and infrastructure development have been minimal. And while the government claims to provide security in the form of the national army, much of the population remains fearful of the Congolese military, which outside observers have identified as one of the country’s main abusers of human rights. As a result, citizens in the eastern part of the country have historically had to rely on themselves, while also contending with a central government that is either absent or ineffective.

These feelings of distrust carry over to the national and international response to the Ebola outbreak — led by the Congo’s Ministry of Health and supported by the WHO and other international organizations. Since the outbreak began, local citizens have often been uncooperative and even resistant to outside assistance.

Here are some examples. There have been instances of people “actively fleeing” health workers, hiding symptoms of the virus and failing to abide by safe burial practices. In September, responders came under attack when citizens threw stones at a Red Cross vehicle transporting a deceased Ebola patient.

2. The ADF and other rebels make the region unsettled

Further compounding the difficulties responders face is the extreme insecurity that characterizes the region. Approximately 120 rebel groups operate in Congo’s eastern provinces. One in particular, the Allied Democratic Forces (ADF), inhabits the Ebola-affected zone.

Border regions are often attractive environments for rebel groups. The proximity to a border can provide a group with cross-border sanctuary and an easy exit route — as well as opportunities to engage in lucrative and illicit cross-border trade. And distrust and/or resistance toward the government on the part of the local population can give the rebellion a degree of civilian support.

Furthermore, a rebel group can have an upper hand in fighting given its familiarity with the terrain and the government’s lack thereof. And missing or weak road infrastructure can make it difficult for government forces to maneuver in the area. A rebel group can then find itself with ample space from which to mobilize, organize and implement its agenda.

My research on insurgency in central African borderlands demonstrates that this has undoubtedly been the case with the ADF, a group many analysts refer to as a “foreign” and “Islamist” group. The ADF’s pull, however, makes more sense in a local context. This is a local insurgency that manipulates and preys upon citizens’ grievances toward the government. It has successfully tapped into regionalized trade networks of various natural resources, including timber and gold. And it has survived numerous military assaults from the Congolese army, Ugandan army and U.N. peacekeepers.

The ADF’s existence for over two decades proves how embedded it has become in the borderland. As the area in and around the city of Beni is largely ADF territory, the group is well situated to wreak havoc on Ebola response efforts.

Most recently, the ADF was blamed for an attack on Beni in which 21 people were killed. Following the attack, Beni’s civil society leaders declared a period of mourning, and most Ebola response activities were halted. Not only was it difficult during this time to reach infected patients, but organizations such as the International Rescue Committee decided to suspend activities altogether out of concern for their staff’s safety.

It is not clear — nor likely — that the ADF is behind each and every massacre or attack in the region. What is clear, however, is that the likelihood of violence continuing is high — and this acts as a deterrent to Ebola responders.

3. Ebola can easily traverse eastern Congo’s many cross-border networks

The population of eastern Congo is highly networked with neighboring countries, particularly Uganda and Rwanda. A significant proportion of the region’s economy involves cross-border trade. And the ongoing insecurity means people are continually fleeing to safety across the border to western Uganda. With such a mobile population, there is great risk of Ebola spreading beyond Congo.

Indeed, despite the WHO refraining from labeling the epidemic an international emergency, the organization has stressed its potential regional ramifications. While screening efforts and other preparedness activities are being undertaken by Congo’s neighbors, the WHO has stated that “neighbouring countries should accelerate preparedness and surveillance, and request partners to increase their support.”

Ultimately any one of these three factors — lack of state legitimacy, rebel violence and cross-border migration — would make containing Ebola’s spread difficult. With all three factors in play, Ebola continues to be a serious concern for the region and beyond.

Lindsay Scorgie-Porter is assistant professor of political science at Huron University College in London, Canada, and author of a forthcoming book on borderlands and rebellion in Congo and Uganda. Follow her on Twitter @LindsayScorgie.