'To protect ourselves, we live in anonymity.'
Local responders are at the forefront of efforts to contain the latest Ebola outbreak in the Democratic Republic of Congo. But with this reality comes greater risks - from the virus itself, but also from attacks by armed groups and distrustful local communities.
Doctors and vaccination teams have been targeted. Families of health workers have been harassed. A hygienist was beaten to death by fellow villagers who turned against him. This week, two response teams were also attacked by a group of boys who lost a friend to Ebola in Beni, a town in the outbreak's epicentre.
Since January, response teams or Ebola centres have been attacked more than 174 times, with the majority of incidents against local responders in their own communities, according to Jessica Illunga, a Congolese Ministry of Health spokeswoman.
For one local responder working for the international non-governmental organisation Mercy Corps, the risk of catching the disease and facing physical threats has been a daily concern.
"To protect ourselves, we live in anonymity," said the responder, who spoke to The New Humanitarian over email and on condition of anonymity for fear of security threats. "All family members know that (they) should not talk about what 'dad' is doing."
Rumours that the virus isn't real, or that it is being used against people, have fanned tensions. There has also been anger over the fact that some people have benefited financially while the region as a whole has remained poor.
All but 100 of the Ministry of Health's approximately 1,500 Ebola personnel are from the outbreak area and working as doctors, nurses, de-contaminators, and drivers. More than half of the World Health Organisation's 630 Ebola response staff are also categorised as "local", meaning they are from somewhere in Congo.
Another local responder from Mercy Corps who provides wash kits to households, schools, and other places in the outbreak zone said that threats sometimes stand in the way of getting the job done.
"One day I went to a house, and the people in the community threatened my life if I carried on with my work," said the responder, who also spoke on condition of anonymity and via email.
While international organisations are generally required by donors to have stringent financial risk management policies, the same requirements aren't necessarily applied to local staff's security, according to Abby Stoddard, a humanitarian policy analyst and a partner at the Humanitarian Outcomes consultancy.
"They don't get additional security at home; their transportation is less secure because they're taking the local bus, for instance," Stoddard said. "And, in high-risk areas where a local worker's status is well known in the community, that exposes them to greater risk."
For many, it's a risk they are willing to take.
"The need for work is huge here," Trish Newport, who works with Médecins Sans Frontières on Ebola, said of the response in North Kivu province. "There are people who would be willing to have a job and put themselves at risk."
Stopping Ebola's spread
The complex set of challenges that allowed for the disease to spread quickly since August has led to several strategy shifts in the response.
Vaccination doses are being split so that more people can be vaccinated. Contact 'rings' around potential cases have been extended. And a special UN envoy - David Gressly - has been appointed to help strengthen the response and security for Ebola responders, the majority of whom are local.
More than 1,530 people have been killed by the virus in the outbreak so far. The Ministry of Health says 30,516 frontline workers have been vaccinated. However, that hasn't spared them: 123 health workers have been diagnosed with Ebola and 39 have died - all local responders. It is not clear how many of those who contracted the disease received inoculations, and some did but not in time.
Although the latest outbreak is smaller than the one in West Africa that killed more than 11,300 people between 2013 and 2016, it is located in an active conflict zone with dozens of armed groups jostling for control in North Kivu and Ituri provinces. The area also sits close to major transport and trade routes to Rwanda, South Sudan, and Uganda, which had its first reported cases in June.
Response operations have been suspended several times because of violence - delays that have made it difficult to contain the disease.
In February, two clinics operated by MSF were attacked by unknown assailants, prompting the organisation to pull out of Katwa and Butembo - two towns in the Ebola outbreak zone. The organisation feared not only for the safety of its foreign workers, but also for local staff and patients.
Adding to the volatility of the situation has been distrust of the government and foreigners, coupled with anger that the area's wider humanitarian and economic needs have been overlooked.
Those sentiments were likely at play on 28 May in Vusahiro village when Ebola hygienist Kambale Sambili was beaten to death by fellow villagers. He was the fifth person to be killed since the April death of Dr. Richard Valery Mouzoko Kiboung, a Cameroonian epidemiologist working for the WHO.
Putting locals at the centre of the response hasn't always been standard practice. In the outbreaks that followed the discovery of the virus in 1976, containment responses were often led by officials in countries far away from the outbreak.
In recent years, however, criticism has grown over what has been referred to as the international community's parachute approach to aid - an approach that has sometimes sidelined the voices and skills of local actors. As a result, local organisations are increasingly being given greater funding and support.
At a press conference in Geneva last month, Michael Ryan, the WHO's executive director for health emergencies, described transferring capacity to local workers who then have to go and sleep in their own houses at night as a "double-edged sword".
"When everyone says, 'well all we need do is transfer capacity to local workers and then everything will be ok'. Well it's obviously not ok. There are real issues to be dealt with in terms of not only transferring skills but also transferring risk. We have to risk manage so that those workers get the best possible protection."
More risk, fewer protections
Most international and national non-governmental organisations say the best protection for local responders is building trust within communities.
Locals have generally shouldered much of the risk and responsibilities during Ebola outbreaks simply because of geography.
There are numerous definitions of what makes a 'local' responder. For WHO, local means Congolese. For other organisations, it might mean being from the outbreak's epicentre or being from a specific community or neighbourhood.
Vaccinations, burying the dead, and de-contaminations are all carried out by local actors, according to Stephanie Tam with Mercy Corps.
Local responders who speak the language and understand specific communities are most effective in combating the disease, but they also face greater resistance and risks.
"There's almost this blind trust given to local actors that they can manage the risk because they're local," said Véronique Barbelet, a senior research fellow with the Humanitarian Policy Group at the Overseas Development Initiative (ODI) who has studied local attitudes towards humanitarian aid in Congo.
In practice, local actors often have less say than their international counterparts about the policy and strategy informing the response plan, said Stoddard.
The jobs are often paid less than those of international staff, whose food, housing, and transport are also covered. Though local responders receive hazard pay on top of their salaries, many local responders have complained that they have received their hazard pay late or not at all. Ilunga, the Ministry of Health spokeswoman, said a non-computerised system had led to delays in verifying payments.
But even with the delays, in areas like North Kivu where jobs are scarce, a local salary may be the kind of money someone can't refuse. According to Ryan, nearly 90 percent of WHO's local staff agreed to renew their contracts after they expired in April.
About 3,000 UN peacekeepers have been allocated to provide security for the Ebola response, but this too can complicate operations.
"Any movement towards more confrontational ways of engaging with people undermines that critical effort to build trust," said Jeremey England, chief of the delegation at the International Committee of the Red Cross in Congo.
In a phone interview with TNH on Wednesday, Gressly said that instead of accompanying teams into the field, peacekeeping operations focus more on "area security", where patrol teams will go out in advance of an Ebola team or in a particular area to provide security more generally.
"They're not necessarily point security for responders, but they can be available to respond quickly," he said.
And while international staff may be evacuated if they face security risks, organisations see evacuating local staff as too great an expense, according to Stoddard.
Local staff are evacuated or relocated if they face serious threats, Illunga of the Ministry of Health told TNH, but she could not give any numbers.
Despite the risks, the feeling among some local responders is that they must be committed to containing the disease and helping their communities.
"As a humanitarian and son of this country, it is a fundamental duty to contribute toward helping my own brothers," said the Mercy Corps responder, who said he lives in anonymity to protect himself and his family. "I have chosen to be an emergency responder and to relieve suffering."