Dou­ble dan­ger: Ebola in a war zone

Mil­i­tants launch at­tacks daily in north­east Congo, im­per­il­ing health work­ers who are bat­tling the virus


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 the WHO’s es­ti­mate, the out­break will go on for at least six more 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 Ebo­laaf­fected ar­eas, health work­ers need armed po­lice or U.N. es­corts, said Michel Yao, the 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 over 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 teams’ 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-Maicon­trolled 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.”


A health worker waits to han­dle a new un­con­firmed case of Ebola at a newly built treat­ment cen­ter in Bu­nia, Congo, that is sup­ported by Doc­tors With­out Bor­ders. The virus has been spreading across North Kivu prov­ince since Au­gust, in­fect­ing al­most 500 peo­ple and killing more than 270. It is now the sec­ond-big­gest out­break ever.

ABOVE: Fam­ily mem­bers mourn near a blood­stain left af­ter a woman was killed in an al­leged mil­i­tant at­tack last month in Beni. BE­LOW: Con­golese mil­i­tary per­son­nel stand guard in Beni af­ter the at­tack.

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