Beni/Kasindi/Mpondwe — The current outbreak of Ebola in the Democratic Republic of Congo is the second deadliest in history, killing more than 400 people and infecting hundreds more. Its location in both an active conflict zone and a busy border region has created what one of those leading the response describes as a "perfect storm" of risk for central Africa.
Since the outbreak erupted in August, a massive response effort has built up around the epicentres in eastern North Kivu and Ituri provinces. It now involves hundreds of Congolese officials and World Health Organization staff, as well as hundreds of local and international aid and health workers. But a lesser-known parallel effort is also underway - within Congo but also in neighbouring countries - to ensure that a regional epidemic like the one that claimed more than 11,000 lives in West Africa in 2013-2016 isn't repeated.
Weeks of IRIN reporting, including trips to assess efforts in border areas, revealed some intensive monitoring and tight collaboration, especially between Congo and Uganda, but also a realisation from health officials of the extreme difficulty of policing thousands of kilometres of porous frontier in a busy trading area prone to spiralling violence.
Officials at Kasindi do body temperature checks as a first test for symptoms of Ebola.
At the Kasindi border between eastern Congo and Uganda, a line of people waits to make the crossing. Before they get their documents checked, they stand - forehead first - in front of a hygiene official in a surgical mask who screens them with an infrared thermo-gun. Those found to have higher-than-normal body temperatures are tested further for Ebola-like symptoms.
This screening station - just a simple wood and tarp gazebo, some plastic outdoor furniture, and a makeshift water tank for hand-washing - represents the front line of the cross-border system trying to prevent the deadly Ebola virus from spreading from one country to the next. More than a dozen similar stations are now dotted along the Congo-Uganda border, health ministers from both countries told IRIN. Across the border in Uganda, 22 of the highest risk areas have implemented additional monitoring measures to try and ensure Ebola stays out.
Between 20,000 and 30,000 back-and-forth crossings - most by informal traders or people with cultural and family links - take place between the two countries each day, according to Congolese border officials. These large human flows have become a major challenge for those involved in the Ebola response.
"People are crossing borders all the time," Peter Salama, the WHO's deputy director-general for emergency preparedness and response, told IRIN. "The challenge really is just the sheer volume of people. It requires a real level of cross-country collaboration to be able to ensure that a case on one side of the border is adequately traced on the other side of the border."
Fears of a cross-border epidemic aren't restricted to Uganda, which is closest to the current outbreak. They also stretch to Rwanda, Burundi, and South Sudan.
Up to 60,000 people cross between Rwanda and Congo daily, according to the Red Cross; while Congo's ministry of health said more than 24,000 people cross between Congo and Burundi each month, and another 3,000 each month between Congo and South Sudan.
Travel within Congo is also a concern - Ebola has already spread from an initial epicentre near Beni to more densely populated areas, such as the major trading hub of Butembo, home to more than one million people.
"The context for this outbreak is a perfect storm," said Salama. "There's the combination of great insecurity that has been going on for decades - now increasing in severity and frequency - a highly mobile and also very dense population in urban areas, proximity to international borders, major logistical challenges, and of course the fact that all of this is occurring in an election period."
Together with the WHO and health NGOs, the governments of neighbouring countries say they have strengthened cross-border collaboration to keep the outbreak from spreading. The health ministers of Congo and Uganda told IRIN in December that they are working closely together to screen travellers and track potential cases. Salama said more than 18 million people have already been screened across various points of entry.
But it is no easy feat.
The Kasindi crossing into Uganda lies 82 kilometres east of Beni. It's the third busiest point of entry between Congo and any neighbouring country after the port of Matadi (with Angola) and the town of Kasumbalesa (with Zambia). It has become even busier in recent months, as stricter entry and exit measures have been imposed at nearby irregular crossing points in an attempt to keep Ebola contained.
The border region around Kasindi is also home to the Nande and the Konzo - communities who live between the two countries (the former in Congo, the latter in Uganda) but share the same ethnicity.
"[People] have family members on both sides of the border. Over the years, they have crossed the border unofficially," explained Eddy Kasenda, head of Congo's border hygiene services. "But with response teams currently stationed at the places formerly used for irregular border crossings, there is a big influx at [Kasindi's] port of entry and exit."
Kasenda said teams are now stationed at both formal and informal crossings to control local migration and help execute the six pillars of Ebola response, which include surveillance, contact tracing, and community engagement.
A few people remain sceptical, some saying the response is nothing more than a business opportunity for international organisations, but Kitsa Musayi from Beni said almost everyone in his neighbourhood is now serious about complying with the Ebola response measures.
Standing in line at the Kasindi border while his two friends disinfected their hands at the water tank, Musayi added: "when some of those resisting the response activities started to die from Ebola" is when people began to cooperate.
Oly Ilunga Kalenga, Congo's health minister, said the exchange of information between Congolese and Ugandan response teams was a big factor in the success, up until now, in preventing Ebola's spread to Uganda. "We collaborate intensively, especially in sharing information on alerts. The disease control general directorates of both countries are in constant contact to facilitate the collaboration," he said.
With more than 20,000 crossings between DRC and Uganda each day, monitoring everyone has become a major challenge.
Ugandan health minister Jane Ruth Aceng said she viewed all of Uganda's border districts with Congo as being at high risk.
"There is a lot of information and training for health workers in high-risk districts," she said. "Three thousand health workers have already been vaccinated in Uganda as part of Uganda's preparations to face the epidemic. Teams from the Congolese health ministry came to Uganda to train Ugandan health personnel to administer the vaccine against the Ebola virus.
"We are not waiting for the first confirmed case to launch the response. We are in the midst of deploying experimental treatments."
Rwanda and Burundi, although further away from the outbreak, are also on high alert. Several Congolese towns are located close to the border with Rwanda, including the capital of North Kivu province, Goma - a city of more than one million people that has an international airport. Burundi, meanwhile, shares more than 10 entry and exit points along Congo's border.
Both countries say they are conducting screenings at border crossings and building up the capacity of their response and healthcare infrastructure in case the outbreak spreads. Last month the UN Central Emergency Response Fund allocated $10 million to strengthen Ebola preparedness in neighbouring countries. Rwanda's ministry of health, in collaboration with the WHO, also conducted Ebola simulation exercises in two border districts earlier this month.
Perhaps the main neighbour of concern is South Sudan, which has three principal border crossings with DRC. Years of war have decimated South Sudan's economy; it has no properly functioning healthcare service; and a lack of roads and infrastructure in some parts of the country - not to mention ongoing conflict - could seriously impede response and containment efforts if Ebola were to spread there.
The worst-case scenario would be if "insecurity in DRC itself becomes so profound that it really limits entirely our ability to control this outbreak," Salama said. This would have major implications for all neighbouring countries, especially South Sudan, which "will be one of the more difficult scenarios."
Like Uganda, South Sudan also started Ebola vaccinations for frontline health workers in December.
"The government willingness is there," said Salama. "But the issue with South Sudan is that after decades of conflict, and ongoing conflict, the primary healthcare system - which is really the first line of defense for surveillance, labs, community health work, for all of our detection and response - is really very rudimentary."
There are also major accessibility issues. "Outside of urban centres it's extremely difficult even to access areas, either because of a lack of paved roads, or because of insecurity," Salama said. "That poses a huge challenge and it's really why it's so important that if anyone is symptomatic with symptoms that could be consistent with Ebola, they are able to identify that at the points of entry with South Sudan. Because if they cross, it will be much, much more difficult outside of the urban areas to pick out the first confirmed case in that country."
So far, no confirmed cases of Ebola have been found outside DRC. But the WHO says alerts have been investigated in South Sudan, Uganda, Rwanda, and in one traveller returning from Burundi to Sweden.
Inside Congo, cases have been confirmed in 17 different health zones. To try and stem the flow of potentially infected people, officials have set up checkpoints along the road between towns in eastern DRC, health ministry spokeswoman Jessica Ilunga said.
Butembo, which saw its first case of Ebola in November, is one of the bigger concerns. Large numbers of people travel in and out of the city daily from all across the region, many of them traders buying and selling produce and supplies before moving on to other towns where they do the same.
"Because there are relatively good road connections in these parts of the country, the population and the traders are very mobile," Ilunga said. "We set up health control stations on the main roads being used by the population, including those leading to Uganda and bigger Congolese cities like Bunia, Kisangani, and Goma."
Congo's health ministry, NGOs, and the WHO have been tackling the outbreak for nearly six months.
At some stations, she added, officials even check people's identities to make sure their names are not on the lists of contacts health teams are tracing for possible exposure to Ebola.
Travelling on the Beni-Kasindi road, IRIN met Jean-Jacques Mali, who trades between Butembo and Uganda's capital, Kampala. He said many of those initially resistant to the extra preventative measures have now changed their minds.
"Those who were most resistant have now started word-of-mouth communication within their communities, warning them about the risks of refusing the vaccine, for example," Mali said. "Some have even helped people with Ebola-like symptoms to visit hospitals."
The key to tackling this outbreak is "not just [to] have community engagement, but also having the community driving the response," Salama said, explaining that trying to access a highly mobile population in dense urban areas in a region where there are ongoing armed attacks means some affected populations may not be reachable.
"In some of the most insecure areas, we have trained community health workers and given them cell phones so they are the ones who are following up on a daily basis, to see if the contact is becoming symptomatic and calling that information back into the central emergency operation centre," he said, adding that response teams have been able to reach 16-20 percent more people who would otherwise have been inaccessible.
Ilunga, the Congolese health ministry spokeswoman, expressed relief that Ebola hasn't reached neighbouring countries or other big Congolese cities like Bunia, Goma, and Kisangani. But her relief was tinged with caution and acceptance of the scale of the challenge that still lies ahead.
"We know that it can still happen," she said. "As long as there are sick people and contacts who are travelling, there is still risk for the outbreak to spread. As long as the outbreak continues, we are still on high alert."
Additional reporting by Africa Editor Sumayya Ismail