“Ebola is like water. If you don’t build a perfect dam, even a small hole can lead to a flood of new cases,” said Marie Roseline Belizaire, the World Health Organization’s deputy manager for the response.
Health officials are confident the outbreak is not spiraling out of control but are worried the holes in that dam are opening up faster than they can plug them. Along the four international borders near the outbreak zone, hundreds of thousands of people move unimpeded from country to country each day, using countless footpaths that save them the hassle of immigration authorities and, now, health checkpoints.
Although the WHO has repeatedly declined to declare a global health emergency, the countries surrounding Congo are scrambling to find a way to contain the virus.
Health workers fear the looming possibility that Ebola could spread to the Congolese city of Goma, a provincial capital of more than 1 million where as many as 70,000 people cross the border with Rwanda each day.
“Given how connected Goma is, one case there could lead to hundreds of infections there and elsewhere in just a few days,” said Jean Felix Kinani, the WHO’s team leader for preparedness and readiness in the city. “We are already investigating every death in the city, swabbing every body. We are putting up a wall around Goma, with vaccines, mass communications, surveillance teams, and chlorination and temperature checks at all entry points.”
Unlike past Ebola outbreaks in Congo, which occurred mostly in remote regions, this one more closely resembles the devastating Ebola epidemic in West Africa that killed more than 11,000 across three closely linked countries between 2014 and 2016. Belizaire said she sends urgent messages each week to colleagues in bordering countries, warning of a possible carrier of the virus headed their way.
Last week, for the first time, confirmed cases of the virus were found to have crossed from Congo to Uganda, before being quickly contained. Thousands of health workers are being vaccinated at Congo’s borders with Uganda, Rwanda and South Sudan, and soon will be in Burundi, too. Contacts of confirmed cases have traveled as far as Dubai and China before they have been tracked down.
As the outbreak continues to grow, authorities are resetting their response to take into account the challenges that “the most complex environment imaginable for an Ebola outbreak” poses, said David Gressly, the United Nations’ recently appointed emergency response coordinator.
People in the area cross borders regularly, in part because the lines are so arbitrary — quite literally boundaries drawn in the dirt by colonial powers that resulted in families, ethnic communities and economically interlocked regions becoming different countries.
That the virus has been contained to a relatively small area within Congo’s North Kivu and Ituri provinces is a testament to the extensive amount of work that has been done. More than 65 million impromptu health checkups have been conducted at checkpoints scattered across this densely populated region since the outbreak began in August.
Still, more than 2,000 people have been infected during the outbreak, two-thirds of whom have died. Even in the best-case scenario put forth by WHO officials, the outbreak has at least three months left before it can be extinguished — the duration of entire previous outbreaks in Congo.
Some health officials outside the WHO and Congo’s Health Ministry, which are leading the response, see the scaling-up underway as welcome, if late.
The U.S. Centers for Disease Control and Prevention has activated its own emergency operations center for the outbreak, but the American presence on the ground is extremely limited, as CDC workers are barred from deploying to the zone of active infection for extended periods, partly because of security concerns stemming from ongoing clashes there.
U.S. officials have stressed that the response needs a reset. They say the indicators show the outbreak moving in the wrong direction, pointing to the high number of new cases that weren’t known contacts or weren’t being monitored; the persistence of infections occurring in health-care settings, including the cases of more than 115 health workers; and the fact that nearly half of recent recorded Ebola deaths occurred in communities rather than at health facilities.
In an interview at Goma’s airport before he made his ninth trip to the outbreak zone, WHO Director General Tedros Adhanom Ghebreyesus acknowledged that the response needed “constant resetting.” But he said that he felt that health workers were doing almost all they could, and that the biggest obstacle to success was the region’s fraught political dynamics.
“This Ebola should have been finished many months ago. So what is failing? It is the political environment. Ebola cannot be seen in isolation from politics,” he said.
Last week, Tedros met with ruling party and opposition leaders in Congo’s capital, Kinshasa, but neither Congo’s president nor high-profile politicians in North Kivu have yet taken a prominent role in encouraging locals to cooperate with health workers.
Festering mistrust has hampered the response, prolonging the outbreak, and even provoked lethal attacks against health workers. The violent pushback stems, in part, from a conflict that has plagued North Kivu for more than 25 years. From the mid-1990s to the mid-2000s, the region suffered through vicious ethnic violence, sparked by the genocide in neighboring Rwanda, and people in the area are wary of outsiders.
“At the start, people believed this was a new strategy to exterminate them. The virus, to them, was like a new kind of bomb,” said Edouard Valumbira, the president of a local committee to support the Ebola response outside the sprawling city of Butembo, which for many months witnessed the most rapid spreading of the virus.
“Communities in North Kivu are engaged in self-preservation against each other — that is why Ebola is seen firstly as a weapon,” he said.
Valumbira has been attacked because of his work three times, and his house was partly burned down by a mob that accused him of betraying the Nande people, Butembo’s majority group. He says that his community’s concerns are understandable and that suspicions have only risen as the outbreak stretches on.
“All these groups have been here for 10 months spending huge amounts of money and the disease is still here. That makes people confused what their purpose is. They don’t think Ebola is a weapon anymore,” he said. “They now see it as a business.”
When the outbreak began, foreigners were rare in Butembo, and $60 a month was considered a high salary in town, Valumbira said. Now the WHO will pay $10 a day for janitorial work. People are leaving other essential jobs, including as teachers and police officers, for lucrative temporary jobs with the response.
Money is pouring in from all sides. The WHO, UNICEF and the Health Ministry are renting 650 vehicles from locals at a cost of $1.8 million a month, which one driver, who spoke on the condition of anonymity because he feared losing his job, said is double the old market rate.
“The local economy has been undone in less than a year. Butembo is now a place with big inequalities and rivalries,” said Valumbira. “Some people who don’t like it say, ‘If the foreigners spent all that money on medicine, this whole thing would have been finished a long time ago.’ ”
Gressly, the U.N.’s new head of response, said that he intends to initiate a “real dialogue” with communities but that the web of financial entanglements was a difficult dilemma. The WHO says it needs $54 million more to stop the outbreak, but more important than the money, Gressly said, is stopping interruptions to the response effort.
After the motorcyclists barged their way through the checkpoint, the health workers there — who work for the U.N.’s International Organization for Migration — said part of the reason perfect monitoring of movement is so difficult is that they fear reprisals from the community. Last month, an argument at an Ebola victim’s funeral devolved into a shootout, and the checkpoint was torn down in retribution.
On a recent day, young men in the back of a truck shouted “Hapana Ebola!” — “No Ebola!” — at a reporter about 100 yards from the checkpoint.
“Rumors, conspiracies, arguments, jealousy, real grievances — it is all here,” said Eric Kilambu, who oversees the checkpoint. “That’s why I don’t wear my WHO vest anymore. I need to blend in for my safety.”
Lena H. Sun in Washington contributed to this report.