Life amid an Ebola outbreak: Combating mistrust—and saving lives

New technology, treatment and education aid the fight in the Democratic Republic of Congo against the deadly disease.Sunday, May 26, 2019

By Rachel Jones
Photographs By Nichole Sobecki
Kavugho Mukoni Romelie, 16, is treated for Ebola at the Alliance for International Medical Action centre in Beni.

From childhood, Mulyanza Huguette was strong and lithe and loved to run long distances near her home in Butembo, in the North Kivu region of the Democratic Republic of Congo (DRC). She also loved working with children, so when she enrolled in Butembo’s Assumption College, she studied early childhood education.

Huguette graduated from college in July 2018—and a month later, the World Health Organization officially declared that North Kivu was experiencing an outbreak of Ebola. So Huguette’s dream shifted: She went to work for UNICEF to educate communities about Ebola—how the viral hemorrhagic fever spreads, how early treatment can arrest it, and how delaying treatment can be fatal.

Kavugho Mukoni Romelie, 16, is treated for Ebola at the The Alliance for International Medical Action (ALIMA) center in Beni. Treatment takes place inside Biosecure Emergency Care Units, known as “cubes”, a recent advancement in technology to treat the virus. The rooms are made of clear, flexible plastic with sleeves, gloves and bodysuits built into the walls, allowing nurses to safely perform about 80 percent of the care an Ebola patient needs without having to put on hot, cumbersome gowns, hoods, rubber aprons, boots and goggles.
A health worker carries Kakule Kavendivwa, 14, to a waiting ambulance in Beni. The day before Kakule's sisters had taken him to a nearby health center, but fled when the team encouraged them to go to a treatment center. The health center alerted the World Health Organization who found the family. After several hours of talking with community outreach workers, they allowed an ambulance to take him for treatment.

In this central African nation of some 81 million, Huguette’s just one of many caught between the promise of new anti-Ebola measures and the barriers to their success: fear and ignorance of the disease, mistrust of foreign-run medical relief efforts, and general unrest fed by armed militias, poverty, and despair.

The continent experienced the largest Ebola epidemic in history from 2014 to 2016, when more than 11,000 people died in several West African nations. By mid-2018 when the virus emerged in the DRC, medical specialists had learned more about it, and had new therapies to try. Educators like Huguette could offer hope: If people sought treatment early, they could recover.

But optimism can be hard to sustain in the DRC, a country that has known conflict and instability for decades—and has suffered through 10 Ebola outbreaks in 40 years. Ebola victims’ families have attacked health workers who attempt to take victims’ corpses for safe disposal. Infectious disease has been hard to corral with so many Congolese on the move, traumatised and displaced by some 50 armed militia groups operating in the DRC. Those groups are bent on disrupting the activities of medical aid workers, outsiders who they suspect have either imported Ebola as a weapon, or who are somehow making money from it. Mistrust has kept many ill Congolese from getting help, with predictable results: By the end of 2018, the DRC Ebola outbreak was the second-largest on record.

During 2018 year-end holidays with her extended family, Huguette felt exhausted. She was helping cook and prepare for New Year’s festivities when what she calls “le très terrible mal de tête’’—the truly terrible headache—began pounding like a hammer inside her head. It lasted for four days. Then came the fever, 102.2F. That's when her family—including uncles and aunts who are doctors and nurses—rushed her to a Butembo hospital.

Huguette was told she had malaria, and received the customary quinine treatment for five days. Only when a doctor from the World Health Organization visited, and asked for a sample of Huguette’s blood, was the correct diagnosis made: Ebola.

Ebola survivor Aisha Ramzani Djadi, 17, holds up clothing she had gathered to prepare for her first child in Beni. When she first became ill, Aisha was pregnant. She lost the baby during her treatment. "I'd like to have more children in the future,” she said. Aisha now works at the Ebola Treatment Center in Beni.

She doesn’t know how she contracted it; she’s never cleaned a dead body or participated in funeral rites. But she’s been to funerals—many funerals. She’s sat next to people who have handled the bodies of their loved ones. She’s held their hands, and hugged them.

A young girl died soon after reaching the hospital and was tested for Ebola post-mortem. All patients who die in Kyondo receive a safe and dignified burial no matter the cause of death. Safely burying people is critical to containing the outbreak. The body of a person who died of Ebola is highly infectious and, if not properly handled during burial, can contaminate others.

How she got Ebola isn’t important, Huguette says, but this fact is: She was cured quickly because she was diagnosed early, before the bloody diarrhea and vomiting and the violent abdominal cramps. After a week of treatment at the Itav Ebola treatment centre in Butembo, she was healthy enough to go home. In her survival, Huguette sees the power of medical science advancing, no matter the obstacles in its way.

On the day that I spoke to Huguette for this story, armed men attacked the Butembo treatment centre where she had been a patient. The men killed a police officer trying to protect the facility and wounded several health workers. Less than a month before that, a Medicins Sans Frontieres (MSF) treatment centre in the nearby town of Katwa had been torched on February 26, killing one health worker, injuring another, and causing the global medical NGO to suspend services.

Outside medical personnel have brought a potentially game-changing tool to this Ebola outbreak: A vaccine developed by Canadian scientists, and tested in the West African outbreak in 2015. By mid-April, more than 100,000 vaccinations had been administered to people in close contact with Ebola patients—such as relatives and health care workers—and a WHO report said the vaccine appeared to be highly effective in reducing Ebola deaths.

A view across Butembo from the site of an attacked Médecins Sans Frontières (MSF) Ebola treatment centre. Aid workers have faced mistrust in some areas as they seek to contain the Ebola outbreak, which has become the most severe in Congo’s history. The Butembo treatment center was attacked in March 2019, the second such attack, following the Katwa centre which was set on fire in February by unknown attackers, forcing staff to evacuate patients.

Such promising news, though welcome, hasn’t stopped the beleaguered citizens of North Kivu from questioning the arrival of all of the white United Nations trucks and foreign medical organisations.

In Butembo, which has more than a million people, nearly 90 percent are members of the Nande, an ethnic group that’s traditionally skeptical of outsiders. The city also has its share of community-based armed groups, who use propaganda as well as force to influence in the chaotic, impoverished areas where they live. Some are known to spread disinformation about the Ebola treatment centers and the aid groups that support them, such as MSF and the International Medical Corps. Ultimately, medical “outsiders” are condemned for things they must do—enforcing quarantine for Ebola patients, imposing burial policies that flout local customs—and accused of things they often didn’t do.

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Over a cup of Nescafe in the improbably named Hotel Versailles in Butembo, a young man named Joffa offered his theory about why Ebola treatment centers were being hit with violence. “When my uncle got sick, and they thought it was Ebola, armed men showed up at his house,” Joffa explained in his halting English. “They tore up everything, before they took him away. They took things, we don’t even know all the things they took. They use (Ebola) as an excuse to do whatever they want.”

In the DRC, “What you have is a group of people who are moving a lot, many to escape the trauma they have experienced from armed militia groups,” says Dr. Michel Yao, an emergency operations program manager for the World Health Organization. “Secondly, you have people who are not open to foreigners because they have really no experience with them, and they have never experienced anything like Ebola.” Although medical relief agencies “learned many lessons from the West African outbreak,” Yao says, “the particular context of [the DRC outbreak] makes it enormously challenging.”

About 90 minutes from Butembo, in the city of Beni, the mood is different.

A mix of ethnic groups have historically lived peacefully together in the area around Beni, which is near the DRC’s border with Uganda. In fall 2018 when a second wave of the Ebola outbreak emerged centered in Beni, medical workers met resistance, says the WHO’s Yao: “It was people refusing the safe burial practices. It killed many people from the same family, and from that family it spread out.” To help overcome the resistance, the WHO and partners recruited local residents to be trained as community outreach volunteers and medical assistants. That helped lessen the mistrust and allowed medical staff to get slightly ahead of the viral spread.

One of the barriers to containing Ebola has been poor security in North Kivu. Here United Nations troops do a night patrol around the city of Butembo, currently the epicenter of the epidemic.
Armed guards patrol Munzambayi, an area near Beni, to combat violence against Ebola treatment centres.

At the entrance of L’hopital General de Reference de Beni, the people I see queued up seemed calm and resigned to the disinfectant drill: washing their hands with chlorinated water and having the soles of their feet sprayed with the same. Many were there to report to work—scrubbing boots, gloves, and other medical equipment, or cooking meals—or to visit patients in a series of Biosecure Emergency Care Units for Outbreaks (acronym: CUBE), used by The Alliance for International Medical Action. These are plastic isolation units designed for the treatment of patients suffering from highly infectious diseases with serious potential for outbreaks. If you saw the John Travolta movie “The Boy in The Plastic Bubble,” imagine that in multiples.

Anthony Bonhommeau, who works for the non-governmental organization (NGO) that developed the CUBEs, says the idea was shaped by experiences in past outbreaks. “One of our teams started to think about how we had isolated the patients,” he says: in quarantine units where it can be difficult for medical personnel to reach patients for care and monitoring, and where patients and loved ones may barely glimpse each other.

Friends and family of police officer Tabu Amuli Emmanuel grieve during his burial in Kitatumba Cemetery in Butembo.

The ideal treatment setting would allow individual attention to Ebola patients and interaction with them, any time it was necessary, that was safe yet more personal. Collaborative research among groups like the Red Cross, the International Medical Corps, MSF, academic institutions, and technology companies resulted in the development of the CUBEs, Bonhommeau says. “We can monitor patients 24 hours a day, and they can talk to you at any time, and we can monitor them with biomedical tools through the use of the gloves and the barriers that reach inside the cubes.”

Ebola survivor Mulyanza Vithya Huguette, 24, shares her testimony with a group of women to lessen the stigma that surrounds the virus.
Health workers check the temperature of everyone who enters the Vayana clinic outside of Kyondo, DRC. Monitoring people's temperature at hospitals, checkpoints and border crossing is one of the tools to effectively break chains of transmission and control Ebola outbreaks.
A World Health Organisation worker administers the Ebola vaccine at a converted children's hospital in the Kalemire area of Butembo. A family had contracted Ebola so they are vaccinating others from the same community but the surviving family members have refused to be vaccinated themselves.

Once CUBE-dwelling Ebola patients have completed the critical phase of treatment and gained strength, they receive psychological counseling. Then they can come out and interact with other recovering patients in a garden area outside the plastic units where they’re visible to their families from a distance. When family members are able to see the patient, not only through the CUBEs but moving about outside of them, it eliminates some of the fear, gossip and rumors about what’s going on inside of Ebola treatment centers, health officials say.

Kavugho Mukoni Romelie, 16, is treated for Ebola at the ALIMA centre in Beni. A friend and Ebola survivor, Adam Kabungulu Elisha, 21, visits Romelie who speaks to him across the fence.

Mulyanza Huguette knows that many people in the DRC don’t like or trust the foreigners setting up tents and carrying their relatives off for care. But Huguette is working to change that, in part by telling her own story. Instead of panicking when she was diagnosed, her family, friends and boyfriend realised there was nothing to fear if she got early treatment, she says. And her story has a decidedly happy ending. If she’d contracted Ebola even a few years ago, her family might have been planning her funeral. But instead, today she’s planning a future which she hopes will include an NGO career, a husband—and five children.

Rachel Jones wrote a story on maternal mortality for the January 2019 issue of National Geographic Magazine. Nichole Sobecki is a photographer based in Nairobi, Kenya. This is her fourth story for National Geographic.
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