GOMA, Democratic Republic of Congo — The Democratic Republic of Congo's deadliest ever Ebola outbreak has shown signs of slowing in recent weeks, but militia attacks, anti-UN protests, and chronic community distrust are undermining the 16-month effort to end the epidemic.
Simultaneous attacks on two Ebola health centres in the towns of Biakato and Mangina last month left four response workers dead, underlining the challenges responders still face building acceptance among communities in Congo's restive eastern provinces.
Médecins Sans Frontières (MSF) announced last week that it was withdrawing staff from Biakato following fresh attacks by a group reportedly armed with sticks and machetes. The medical charity was managing an Ebola Treatment Centre in the town.
Relief efforts have also been suspended amid attacks blamed on the Allied Democratic Forces (ADF) militia and escalating protests by residents who say UN peacekeepers and government forces stationed in the region are failing to protect them.
The violence and civil unrest has forced aid groups to evacuate staff and many fear it could lead to a spike in cases - just as responders were getting a grip on the disease that has killed more than 2,200 people and infected over 3,000.
The challenges come as the Congolese government and responders formulate plans for getting to zero Ebola cases by the end of December, while discussions are also underway on post-Ebola programming.
Aid groups say key aspects of the response - from community acceptance, to getting patients into treatment centres quickly and tracing the contacts of those infected - need improving before zero cases can be reached.
An Ebola survivor has fallen ill again with the disease, Congolese health authorities announced Sunday. This undermines the received wisdom that survivors are immune and will add further concerns to containment efforts - as does the possibility of the virus living on in the semen of male survivors and the breast milk of women - a challenge reported by The New Humanitarian last month.
This briefing looks at the progress made, the challenges remaining, and the next steps for aid groups in a post-Ebola Congo.
What's the current situation?
Transmission had decreased significantly in recent weeks, with zero cases reported on several days in November.
A second experimental vaccine developed by the US pharmaceutical company Johnson & Johnson was also introduced last month to boost the number of people inoculated.
But militia violence, attacks on Ebola responders, and protests are threatening the progress made. NGOs have had to temporarily suspend their operations in recent weeks, while the World Health Organisation (WHO) has evacuated non-essential staff working in Beni, where the insecurity is centred.
As of yet there has been no indication of the feared spike in new cases, but the suspension of response activities "often results" in cases increasing, according to the WHO.
Contact between Ebola responders, local health facilities, and communities - who provide those responders with data on suspected cases - has dropped significantly in recent weeks, according to the WHO. Operations at the main laboratory used to diagnose Ebola patients in Beni have also been affected.
In addition to the violence against Ebola responders, a military base in Beni was set on fire last month during protests against the UN peacekeeping mission in Congo, known as MONUSCO.
The protests follow the launch of large-scale military operations by the Congolese army against the ADF - an Islamist rebel group formed in 1995 in opposition to Ugandan President Yoweri Museveni.
The army said it has captured several ADF bases in recent weeks, but the Kivu Security Tracker, which maps violence in eastern Congo, said more than 100 civilians have been killed in some of the worst attacks in Beni in years. At least 16 people were decapitated in a single attack late last week.
The attacks have sparked tensions between residents and the UN peacekeeping mission, which has hundreds of troops stationed in Beni and more than 16,000 overall in Congo.
"People are demanding the UN leave because they are doing nothing and civilians are being killed near their bases," said Stewart Muhindo, a civil society representative with LUCHA, a local activist group.
What are the other challenges?
A concerted effort to gain community acceptance in Beni and nearby Butembo in August and September was successful in creating a sharp decline in cases, said David Gressly, the UN's emergency Ebola response coordinator.
"We're better off today than a few months ago, but we're not fully there yet," Gressly told The New Humanitarian.
Several areas in the outbreak zone remain shut off to responders, who still face distrust from residents suspicious of the influx of money and - in some cases - the presence of heavy-handed military forces alongside the responders.
"Access remains the biggest challenge - part of that is security, and part of that is community trust," said Margaret Ann Harris, WHO spokesperson in Congo. "People are still deeply suspicious of the Ebola response in some places, and believe that responders are there for another reason."
Delays in getting patients into treatment centres are also causing problems, according to MSF, which said Ebola cases are confirmed an average of five days after the onset of symptoms.
That's "a time in which they are infectious to others and miss out on the benefits of receiving early treatment" the medical charity said.
And there are concerns that contact tracing - identifying people who have encountered an infected person - isn't being done properly, with an estimated 66 percent of contacts in the last three months not being followed up, according to MSF.
This is posing problems for responders who rely on a strategy known as "ring vaccination" - where everybody who has had direct contact with a sick person is vaccinated along with direct contacts of those contacts.
Some health workers are also concerned that the recent decrease in cases is being misinterpreted as a signal that people can be less vigilant about prevention measures.
Earlier this year, while visiting some of the Ebola-affected areas, Congolese President Felix Tshisekedi announced that he hoped the outbreak would be over by the end of the year. "After that, we've seen a loosening in people's use of (the) infection prevention control process," said Pierre Vernière, project coordinator for MSF in Beni.
Charlene Mgononbi, a nurse with Congo's ministry of health at the Ebola treatment centre in Butembo, said a taxi driver told him last month that he didn't have to wash his hands anymore because Ebola was no longer a problem.
"When I hear that, I stop and make sure people understand that there's still a risk of contamination," Mgononbi told TNH.
As cases dwindle, the government and aid groups are starting to think about post-Ebola programming, particularly for survivors who often face stigma and challenges reintegrating into communities.
Many survivors face guilt from society and also within their own families, said Yvonne Duagani Masika, a psychologist with UNICEF. The more cured people there are, the more there will be a demand for senior psychologists, Masika said.
But Congo's psychosocial commission - which works with Ebola survivors and their families - lacks resources and trained staff. There are currently 115 employees - only 15 of whom are trained psychologists - supporting 779 Ebola orphans and survivors in Beni, according to Justin Kakule Kasai, president of the commission.
The commission needs at least 50 more trained psychologists in major cities in North Kivu province alone to adequately cover the area, Kasai added. Within Congo, the outbreak has been restricted to North Kivu, and the neighbouring provinces of Ituri and South Kivu.
Benoit Munsch, country director for CARE International, said aid groups will need to address the negative effects Ebola has had on people's livelihoods - particularly women who sell goods at markets.
"During the outbreak, the number of people frequenting markets and the exchange of goods between territories reduced significantly," Munsch said.
Post-Ebola will also mean putting the spotlight back on all the other needs Congo is facing - from conflicts in Ituri and South Kivu provinces to a measles epidemic that has now killed more than 5,000 people.
"For the past year, the Ebola outbreak in eastern DRC has overshadowed the complex and long-lasting humanitarian crisis in the country," said Whitney Elmer, country director for Mercy Corps in Congo, citing a commonly held grievance in the region.
After Ebola, Harris of the WHO said the organisation will look to support Congo's wider healthcare system, using the resources and expertise built up over the course of the 16-month epidemic.
"What we have brought in are large teams of health experts whose expertise can be applied to other things," Harris said, mentioning measles and cholera, among other health issues.
"There is so much work to do, and the people that have come in from Ebola have the ability to do it."
With additional reporting from Philip Kleinfeld in Goma and Vittoria Elliott in New York.