The Democratic Republic of the Congo’s conflict-ridden eastern province of Kivu is in the midst of an Ebola outbreak which has been described as the ‘perfect storm’ by the World Health Organisation (WHO). It’s the first known Ebola epidemic in a war zone and already it’s the second deadliest in history with ongoing attacks on Ebola clinics worsening the situation. Recently, sites at Katwa and Butembo have suffered repeated attacks threatening humanitarian organizations to withdraw from the zone. The Centre for Disease Control and Prevention (CDC) director Robert Redfield said, “This is a complicated response,” mistrust is common in isolated parts of the Congo, distrust of outsiders and armed conflict halt progress in the area. Redfield said “This late in the outbreak, and half of the cases are presenting dead… This tells you that the community is not helping us. We need the community to become a key component of the public health Ebola response.”

WHO spokesman Tarik Jašarević wrote that “the recent attacks on Ebola treatment centres in Katwa and Butembo indicate a major deterioration of security in the region.” Attacks heighten the severity of the situation; more people are becoming sick he added. The International Rescue Committee, a not-for-profit aid organization stated, “we denounce the recent acts of violence in the Butembo region, which has led to the decision to suspend our work in the area.” Multiple organizations have ceased aid in the war zone entirely. Despite continuous attacks, some Ebola clinic’s continue to run; Redfield on his last trip to the Congo visited a site hours after it was attacked and reported, “There were bullet holes in the windows,” two nurses were injured and one police officer was killed. “But it didn’t stop these workers from wanting to do their jobs.”

The region has been embroiled in violence since 2004 being tied to many factors, including the recent controversial presidential elections. Political disorganization and the break down of society hinders any large-scale efforts to quell the outbreak although the Congolese government’s decision to consolidate coordination for the Ebola response within Kivu’s capital city, Goma, brings hope about containing the threat.

The outbreaks complexity and growing public frustration are draining aid program resources. Dr Stacey Mearns, Ebola Response Program director for the International Rescue Committee believes that regional violence complicates any form of progress, “A lot of attention and resources have come in for Ebola, but there’s been little focus on the underlying insecurity and displacement that the population are seeing as well.” Within the region dozens of armed groups scramble for the few resources available, the attacks against humanitarian agencies resemble the people’s increased desperation. Posing as a significant threat towards the response, medical units set up to protect them are being burnt down, “These are not attacks by the community, these are attacks on the community,” said the Director-General for WHO. In response to ongoing security issues, healthcare workers are being accompanied by military personnel.

It’s clear that conflict is the root to Ebola’s severity within the region, United Nations Security Council stressed the importance of a ceasefire to better fight the outbreak. The breakdown of communities and increased hostility towards aid workers make efforts battling the outbreak futile. Mearns stated, “The insecurity that we see with the ongoing attacks by rebel groups and ongoing violence basically means we have periods where movement of essential response workers has to stop… We have to constantly adapt our approaches, because one day, we can’t get to this area or we have to evacuate the team… It just makes everything a lot more complex than it needs to be in what is already a complex situation.”

Clinics within zones of infection have become hotspots for disease transmission. Shortage of equipment, lack of sanitation and little to no training only sink the situation further into chaos. Dr Cimanuka Germain of International Medical Corps has been working with local workers to improve infection control although he states many private clinics often resist the help. Germain’s work training nurses in the epicentre of the zone seem to be in vain, with surprise visits finding them treating patients without gloves. Germain states, “To change someone’s behaviour is not [a matter of] one day or two days – you need time.” Health practices have been improving with a policy of watchdogging although desired results take up to two months. Laurent Sabardm health coordinator for the International Committee of the Red Cross noted the frustration changing people’s behaviour, “We have to continually follow up,” he stated. A steady line of supplies is required with the surrounding conflict taking place; convoys are raided and contact with some sites are cut off for weeks. Often by the time you return, staff are out of practice.

An ongoing call for resources is needed. Furthermore, well-trained experts are few in numbers hindering any progress in isolated areas. Mearns reported that her team of 130 people cannot cover the outbreak zone, “You need more resources and partners on the ground to be able to manage such a dispersed response.” Breakdown of infrastructure, poor communication networks and a lack of high-level diplomatic activism are to blame. Confirmed cases of Ebola in urban centres multiplies the outbreaks potential reach which has only started to gain international attention.

Combatting the outbreak so far from the epicentre damages true progress. The Centre for Disease Control has deployed over 100 highly trained experts within major urban centres, the security situation halts work in rural areas. “We need in the field, right now, well-trained experts that have deep experience in responding to Ebola and the community resistance that often occurs during such outbreaks,” said Jennifer Nuzzo, scholar for Josh Hopkins Center for Health Security. “The U.S. government, specifically the Centre for Disease Control, is unmatched in having this experience. We need to figure out a way to enable them to safely go into the field to meaningly participate in the response.”

Redfield argues that to maintain community engagement, workers must be hailing from the outbreak zones. “Each of these communities are different. Each of these communities speak multiple different languages… And we’re trying to gain community trust. So if I go in and speak English or even one of the DRC languages of the [capital] area, I’m an outsider. We realize that in order to train the people that give us the best shot of gaining the trust of the community we needed to move those training activities to the region.”

Experts agree upon a swift campaign identifying and isolating all cases, luckily the availability of experimental vaccines and new treatment options are containing the outbreak. Dr Anthony Fauci from the U.S. National Institute of Allergy and Infectious Diseases said, “The good news is that we have a tool we didn’t have in the West African outbreak. The sobering news is that we’re not able to implement it as extensively as we want to because we don’t have access to all the contacts, because new cases are coming in that we can’t trace to any known case.” Since the outbreak began in August last year,  there has almost been 1,000 cases with 621 confirmed deaths reports WHO. Additionally, 96,000 people have been vaccinated and as of 21st March, 44 million border screenings have helped slow the spread of Ebola. Over U.S. $74 million dollars has been donated to combat the outbreak with organizations requesting up to U.S. $150 million dollars for the complete elimination of Ebola within Kivu.

WHO’s Regional Director spoke out “As we mourn the lives lost, we must also recognize that thousands of people have been protected from this terrifying disease… The communities affected by this outbreak are already traumatized by conflict with their fear of violence is now compounded by fear of Ebola. Community engagement takes time. There are no quick fixes. But we are learning and adapting to the evolving context every day.” Its people are trapped within a vicious cycle, where conflict, disease and isolation brewed the perfect storm, improving living standards is an arduous process though experts hope Ebola will be eradicated by 2020.