As an outbreak of Ebola ratchets up in the Democratic Republic of Congo's densely forested northwestern province of Équateur, warning signs are growing that corruption problems that dogged the last epidemic, in the conflict-torn east, risk being repeated.
Eight weeks into the latest outbreak - which has infected 67 people and left 31 dead - several senior humanitarian officials involved in the response told The New Humanitarian that government officials have been trying to profit from relief funds, following a precedent set during the previous outbreak, which cost more than 2,200 lives between August 2018 and June 2020.
When hundreds of millions of dollars were pumped into that response it kickstarted a local scramble to profit. Examples of what became known as "Ebola business" included vehicles being rented from elites at sky-high prices, and security services paying millions of dollars for military escorts.
Among the key concerns in the Équateur outbreak is a government list of approved service providers that contains the names of parliamentarians, civil servants, and other connected individuals. As response funds flow into the region - more than $34 million has been budgeted until September - humanitarian organisations say they have been "pressured" to hire people on the list.
Though aid organisations responding to the outbreak told TNH they were recruiting staff according to their own guidelines, the list has created tensions between local officials, angered some residents who feel they are not benefiting from the response, and, according to local doctors and civil society members, "politicised" what should be a medical issue.
"What seems to be happening is... some of the practices from the east moving west that didn't exist in 2018 [during an earlier Équateur outbreak]," a humanitarian official involved in the latest response told TNH, speaking on condition of anonymity due to the sensitivity of the issue.
COVID-19 travel restrictions and border closures, meanwhile, have hindered efforts to bring staff and equipment into the country to fight the current outbreak - the 11th Congo has faced since the virus was first discovered near the country's northern Ebola River in 1976, and the second affecting Équateur since 2018, when 54 people were infected and 33 died between May and July.
There has been no mass vaccination campaign so far in Équateur because of a shortage of vaccines in the country, while poor conditions at some Ebola treatment centres - which fell into disrepair after the 2018 outbreak - have prompted patients to leave before their treatment has been completed.
Cases originally appeared in Mbandaka - the main town of roughly 1.2 million people in Équateur - but have since spread to several hard-to-reach areas, including health zones that were spared from previous outbreaks and are comparatively ill prepared to deal with the present one.
If cases increase, there are concerns the virus may travel up or down the vast Congo River, which passes from Mbandaka to major urban centres including the sprawling capital city, Kinshasa, or spread across the border to neighbouring Congo-Brazzaville or Central African Republic.
"The epidemic is running ahead of us," Robert Ghosn, Ebola operations manager for the International Federation of the Red Cross (IFRC), told TNH earlier this month. "The response overall is not on par with the needs."
'Jobs for the boys'
A perception that Ebola represented a business opportunity for aid agencies and local elites was one of several factors that caused distrust and tensions between communities and responders in the eastern outbreak. Hundreds of attacks on medical workers and treatment centres were recorded over a nearly two-year period.
An investigation by TNH showed how some of those perceptions were grounded in reality: the World Health Organization, which supported the Congolese government during the eastern outbreak, paid millions of dollars in inflated per diems to Congolese security forces, and large sums to civil servants - some of whom were participating in the response - to rent their vehicles.
David McLachlan-Karr, who works as the UN's humanitarian coordinator in Congo, told TNH that various measures have been put in place in Équateur to avoid a "repetition of what has been unfortunately described as 'Ebola business'".
He said aid groups had agreed to a common payment scale for service providers; have discussed local pricing issues with the provincial authorities in Équateur to avoid inflation; and have been encouraged to share facilities and services to reduce costs.
Margaret Harris, a spokeswoman for the WHO, said the health agency has "prioritised" ensuring administrative and financial processes are followed in Équateur, with procurement of service providers overseen by the agency's main country office in Kinshasa and staff able to report mismanagement of funds through a toll-free hotline.
But aid officials that visited the province in recent weeks, and doctors working on the ground, told TNH that officials in the Équateur administration have still attempted to profit from the outbreak through the list of service providers - known as a liste de prestataires - which one official described as an attempt to find "jobs for the boys".
Isidore Ekila, an official at the provincial ministry of health in Mbandaka, compared compiling the list - thought to contain more than 1,000 people, from doctors to psycho-social workers - to "gymnastics", adding that names had been recommended by "political and administrative authorities".
The time it has taken to finalise the list has slowed down the government's own recruitment efforts, according to aid officials who spoke to TNH. It has also stoked community tensions in an area where perceptions of "Ebola business" already run high, according to interviews TNH conducted with more than a dozen residents.
"Many accuse the response of being politicised," said a doctor in Mbandaka who is working in the response but asked not to be named.
Though government officials have tried to pressure humanitarians organisations into recruiting from their list, McLachlan-Karr said the "challenge" has not stopped aid agencies from rolling out the response in affected areas, adding that he had met Congolese officials to explain that the UN has its own rules for procurement and hiring and firing staff.
"Responding to dangerous diseases such as Ebola cannot be an opportunity for cronyism," McLachlan-Karr told TNH.
Harris, meanwhile, said the WHO was aware of the list but had not seen a copy and was committed to following a "transparent" process and "standard operating procedures" for recruiting staff and procuring services.
Dense forests and a river of worry
Though the Congolese government has said it will lift COVID-19-related travel restrictions next month, aid groups said the pandemic has slowed down efforts.
The IFRC's Ghosn said his team spends "25-30 percent of their energy and time" trying to get people and cargo in and out of the country due to restrictions. A flight containing equipment for infection, prevention, and control measures took "weeks" to arrive, he said.
Some agencies participating in the response said they had redeployed staff members and equipment from the east, though cautioned that teams are still needed to do surveillance in the old outbreak zone in case survivors relapse or infect others through their body fluids.
"It is possible that another resurgence could happen in the east," said Michelle Chouinard, who is coordinating Ebola efforts for the Alliance for International Medical Action, or ALIMA, in Congo. "There still needs to be some surveillance and some capacity [there] to act quickly."
Thick rainforests and unpaved roads mean responders are facing even greater logistical challenges than in the east. A helicopter supplied by the UN's food agency, WFP, was recently sent to Mbandaka, but cars and speed boats are still needed.
Treatment centres are up and running but insufficient food supplies have resulted in some patients discharging themselves. And national stocks of an Ebola vaccine that was first rolled out in Équateur in 2018 and then deployed in the east are running thin, with just 7,000 doses available in the country, according to the WHO's Harris, who said more should arrive soon.
Chiara Maria Frisone, a spokeswoman for UNICEF in Congo, said collaborating with local healthcare workers, community members, and traditional and religious leaders - as opposed to an "alienating top-down approach" - has helped responders build trust with residents.
But resistance to relief efforts has been a problem in some parts of the province, with civil society groups and community members who spoke to TNH citing "Ebola business", a lack of confidence in the local authorities, and "safe and dignified" burial procedures as their main grievances.
In one recent incident, a group of young people tried to enter a treatment centre in Mbandaka to remove the body of a patient who had died, while an earlier demonstration against response efforts in the city was met by heavy-handed policing, according to residents.
Aid officials fear that if opposition to the response increases, so will the risk of "militarisation" - a common problem in the east, where long distrusted security services escorted some responders, policed treatment centres, and coerced communities to comply with Ebola care, fuelling yet more resistance.
"We have seen this happening in the past," said Ghosn. "We know how community resistance can lead to coercion... and we are worried about that trend."
Additional reporting from Robert Flummerfelt in Goma, eastern Congo