Africa: Ebola Outbreak - a Crisis of History, Not Misinformation

SAN Francisco, United States, Kinshasa, Democratic Republic of the Congo — Even with a pause in the violence, communities will still need to be heard - and to be convinced that responders mean them well.

Every global health textbook starts with colonialism. International health and extraction went hand in hand for centuries. Disease prevention in the colonies had one main aim: Keep the subjugated population healthy enough to allow resource extraction.

Last month, when an angry crowd in Mongbwalu - the epicentre of the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC) - burned down an Ebola treatment tent, the international response was to engage in more risk communication, education, and correction of misinformation.

The embedded assumption is that people in affected parts of the DRC are resisting response efforts because they lack an understanding of Ebola and the danger it presents.

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While communities subscribe to clearly false rumours that Ebola is a hoax or being spread by government and international responders, the reasons such misinformation appears plausible - a history of exploitation, insecurity, and neglect - are undeniably real.

Overcoming distrust and getting communities to buy in to efforts to control this outbreak require not just fact-checking misinformation about Ebola, but reckoning with communities' rational, historically grounded basis for that distrust.

The Bundibugyo Ebola outbreak declared on 15 May is already the third largest Ebola outbreak on record with more than 800 cases and nearly 200 deaths. The virus, for which there is no approved vaccine or specific treatment, continues to spread through a region with a milieu of state, rebel, and other armed actors campaigning for control of the affected areas

Already designated a public health emergency of international concern (PHEIC) by the World Health Organization (WHO), early projections suggest the outbreak could approach the scale of the 2013-2016 West African Ebola epidemic, which resulted in over 28,000 infections and 11,300 deaths.

The community is the wrong problem

Commentators across the spectrum have rightfully zeroed in on community distrust as a central obstacle. We have seen how challenging this can be to address. During the COVID-19 pandemic, one of us anchored the response when the Navajo Nation in the United States faced a catastrophic surge in cases in the Spring of 2020.

Many blamed the community, due to its high rate of diabetes, obesity, and lack of running water. These factors were true, but what was overlooked was the history underneath them: broken treaties, chronic underfunding of the Indian Health Service, and more than a century of federal neglect that made the land and its people more vulnerable before the virus arrived.

Distrust of outside authorities in that community was not irrational - it was well earned.

We can't stop Congo's Ebola outbreak until communities lead the response

Mistrust is handicapping the response. To mobilise the local community, trust must be built fast.

During the West African Ebola epidemic, two of us helped build and guide the response in Guinea, one of the three most affected countries. Community distrust was a major challenge that enabled transmission to persist, with families hiding the sick, secretly burying the deceased at night, and deliberately omitting names when asked about exposed contacts.

This distrust of response measures - or even of the veracity of Ebola itself - was based on the decades of misrule communities had faced. They often perceived international agencies as complicit with that regime, yet absent when their children were faced with malaria and other routine conditions.

In order to navigate these challenges, we had to diplomatically engage opposition politicians to throw their support behind the government's response, and even dispatched anthropologists to sit in communities and to listen.

Safe and dignified burial protocols were redesigned with community input, not imposed against community resistance. Ultimately, enough people from enough communities who may have still doubted that Ebola was real bought in because their fears, concerns, and lived experience were acknowledged and respected.

The result was not simply an outcome of better communication and messaging, but one of - even imperfectly and incompletely - bearing witness.

Aid agencies complicit

The same logic applies in eastern DRC, in starker form, because the distrust there rests not on one grievance but on layers of them. For decades, communities in the region have suffered displacement and violence, yet with little in the way of help when their children suffer from malaria and diarrhoea or their families struggle to earn enough for food.

For communities who then watched outsiders arrive to address a single disease while ignoring all the rest, the message was clear: Your body is a problem to be managed, not a person to be cared for.

That neglect sits inside a region defined by active conflict and insecurity, where the state is itself an object of suspicion, and where generations of mining and mineral smuggling have taught people that the outside world's interest in their land is, first and last, in what can be taken from it.

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The institutions leading the response carry their own record. During the 2018-2020 North Kivu and Ituri outbreak, an independent panel documented sexual exploitation and abuse in the Ebola response, including cases involving WHO personnel and collaborators.

And the most recent chapter is the starkest. Many of the same governments expecting local communities in eastern DRC to trust responders have spent the past year withdrawing the aid that sustained basic care and, in some instances, replacing it with deals that trade medicine for minerals.

The rumour that the outbreak is a hoax to draw in foreign money and attention is factually wrong. But the suspicion underneath it - that interventions serve interests other than those of the population, and that the attention will leave when the cases do - is historically grounded. Correcting misinformation while leaving the grievance beneath it untouched is not enough to overcome distrust.

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Corrupt practices may have made the response to the first Ebola outbreak in an active conflict zone even harder than it had to be.

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There is no template

So how can this be overcome? There is no template. The political and social contours of each setting need to be examined, and strategies tailored accordingly. This is a central part of the work that must be taken on now with potentially varied approaches deployed.

First and foremost, in the absence of a pause in fighting, it will be difficult to even engage communities much less pursue any response measures. Brokering a truce at least until transmission can be contained is challenging given the array of actors and mining interests in the area, with multiple governments implicated.

Neutral diplomatic pathways may be needed, including regional mechanisms such as the International Conference on the Great Lakes Region (ICGLR), a Great Lakes intergovernmental forum that has played a role in regional ceasefire-monitoring efforts.

Even with a pause in the violence, communities will still need to be heard - and to be convinced that responders mean them well. No one can honestly promise that much will change for the region once the cases are gone. The distrust has always understood that. Earning back trust in spite of it is the immediate work.

But if the deeper patterns that make distrust rational are left intact - the episodic arrival of emergency responders, the chronic absence of basic care, and the long extraction of wealth from communities treated as sites of risk rather than subjects of obligation - the next outbreak will be met by the same alienation.

Not because communities failed to understand the message, but because the history beneath the message remained unchanged.