An Epidemic and a War Doctors Face Two Enemies in Fight Against Ebola

The second-largest outbreak of Ebola in history is ravaging the Democratic Republic of Congo. But as humanitarian organizations and the Congolese government struggle to fight the virus, they find themselves thwarted by the very people they are trying to help.

Sergio Ramazzotti/ DER SPIEGEL

By Fritz Schaap and Sergio Ramazzotti (Photos)


On the last Monday morning in February, three days before the fight against Ebola in eastern Congo turned into an all-out war, Dr. Jean-Christophe Shako stood in the scorching equatorial sun in Katwa, between eucalyptus trees and corn fields, looking down at the smoking ruins of the Doctors Without Borders (MSF) treatment center.

Shako, the director of Ebola operations in Butembo, was dismayed. The expression on his face conveyed a mixture of anger and fatigue. Two deep wrinkles had formed on his brow. He spoke quietly. "People here just don't want to accept that this disease exists," he said. "They think that we're killing them with this vaccine, that our clinics are places of death, that the government wants to eradicate their tribe, the Nande."

In the night, around 30 men had stormed out of the bush and attacked the MSF clinic with machetes and bows and arrows. The patients were evacuated. The attackers left behind leaflets that read, "We have more surprises."

The clinic was about the size of a football pitch. Shako gazed out at the devastation from the night before. Now it was littered with singed wooden skeletons, destroyed generators and a burned-out car. Three days later, Shako received a WhatsApp message saying it was time for him to die.

So Close and Yet So Far

Nobody knew where exactly the attackers had been in the clinic -- or what they touched. Did they come into contact with a highly infectious corpse? Were they now carrying the virus, spreading it to other people?

It was a disaster.

Shako is one of the Democratic Republic of Congo's most respected epidemiologists. He has been fighting the Ebola virus in the province of North Kivu on behalf of the Health Ministry since August 18 as head of operations in Butembo, the current epicenter of the outbreak. Under his leadership, staff from the Health Ministry, the World Health Organization (WHO) and MSF have battled the second-largest Ebola epidemic in history. The only period in which there were more Ebola-related infections and deaths in West Africa was between 2013 and 2016. It is also the largest outbreak ever in Congo, where the virus first transitioned to a human host in 1976.

So far, 980 people are known to have contracted the virus; of those, 610 people have died. Unnecessarily. Because modern medicine has everything it needs to defeat the virus.

Back in 2015, toward the end of the epidemic in West Africa, a new vaccine was used for the first time in humans, with good results. Virologists were very optimistic. The vaccine, they said, would change the way the world saw the virus. In eastern Congo, where it's now being used for the first time on a large scale, it is considered highly effective. So far, 87,390 people have been vaccinated.

The idea is to contain the virus using so-called ring vaccinations. Anyone who may have come into contact with an Ebola patient will be vaccinated. That way, the virus is robbed of potential hosts -- it has nowhere to go; it starves and dies. With the new vaccine, it would have been an easy victory.

If only.

Epidemics Are Not Natural Disasters

Ebola doctors and nurses always wear protective suits and gloves. The Ebola virus is highly contagious. It is transmissible by blood, saliva, urine or the vomit of an infected person. It cannot be transmitted by air. Once the first symptoms appear, a sick person is contagious; more than half of those infected die in agony.

Epidemics, as North Kivu has shown, are not natural disasters. They are products of human error. And there are few parts of the world where human failure is as pronounced as it is in eastern Congo. The "Great African War," which began in 1998 and left well over 3 million people dead, never really ended here -- a conflict between the government and various rebel militias.

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This is the first time that Ebola has broken out in a conflict area of this sort, which is what makes the fight against the epidemic so difficult. The virus has found allies in the region, which has been neglected for decades. The more than 100 militias that slaughter each other over gold and coltan, money and power, and who terrorize the local population and rape women by the thousands in the dangerous hills of North Kivu, have made it hard to eradicate the disease using the vaccine. Ignorance and war have become the virus' partners in crime.

There is also growing concern about the disease spilling over into neighboring Rwanda or Uganda, ferried across the borders by people fleeing violence at home. Vaccination programs for endangered groups were launched months ago in multiple locations.

"Surrender," Shako said, "is not an option." He is one of the most experienced hunters of the Ebola virus. Back in 2014, during the West African outbreak, he was sent to all the most dangerous places. "I'm here as a general commanding his troops," he said.

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Ebola Outbreak: Congo Struggles to Save People From Themselves

Helping People Who Don't Want to Be Helped

From a wooden platform that reeked of gasoline, Shako looked down onto the remains of the warehouse where the vaccine was once stored. It was completely destroyed in the previous night's attack. Small flames still flickered here and there. His biggest enemy was no longer the virus, he said, "it's ignorance." People's thinking here is too corrupted by witchcraft, conspiracy theories and political leaders who instrumentalize the virus for their own personal goals.

Shako hurried out of the clinic alongside Butembo's WHO head and the mayor. People had begun to gather in front of the fences, looking at the destruction with satisfaction. Shako was tired. He's a small, almost delicate man who tends to bend his head slightly forward as he walks and finds it difficult to hide his anger.

He headed back to headquarters to prepare for a meeting with some leaders with the Maji-Maji, the local militias. Maji means water; the warriors douse themselves with "magic" water before battle because they, and many others, believe it makes them invincible.

"I have to protect my people," Shako said.

As he was leaving, MSF workers wearing plastic goggles and rubber boots started decontaminating the buildings at the treatment center. The villagers' anger was growing.

"Leave already!" a woman shouted, grimacing.

"Ebola is a lie!" yelled another.

Gratia Kalungero, a prim young man in a tight-fitting shirt and slim blue trousers, stood in the middle of the circular mob.

Kalungero is one of the people Shako must protect: a so-called "risk communicator" with the World Health Organization who studied psychology. He drives to the villages before the ambulances arrive to pick up the corpses, before the decontamination teams and vaccination teams show up. He also accompanies the teams when they go to the villages. He's there to prevent attacks and to explain to locals that these people in the protective suits are not after their lives, that they're trying to prevent their deaths.

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'This Is a Warning'

Around 50 people surrounded Kalungero, maybe more. Half the village seemed to have gathered in front of the clinic. "You can't attack the clinics," Kalungero explained. "This will only cause the virus to spread further."

"We don't want your Ebola!" a woman screamed.

"You can't hide the sick," Kalungero said. "That's how you get infected."

Behind him lay the clinic's deserted isolation ward. Protective suits hung from hooks in empty rooms. The floor was covered in shards of broken mirror. "They think the government made all this up to prevent them from voting," Kalungero said. In December, people in Beni and Butembo weren't allowed to vote in presidential elections due to the epidemic. This caused the situation to escalate considerably. Conspiracy theories abounded.

According to a Health Ministry estimate, up to 30 percent of people don't believe that Ebola exists. Everything that's happening is the work of the government, they say, carried out with a mysterious poison or witchcraft. Some accept that the virus exists, but think it's being spread by the medical teams in order to earn money. Others believe it's a scam to harvest their organs.

Kalungero walked to his car. He was tired too; he had been working for months, risking his life. He knew how ruthless the militias are. Kalungero's from North Kivu. The 29-year-old has known this war since his childhood.

"The resistance against our teams is growing," he said.

As he walked, a choir of voices rose up behind him. "Lyi mufano," they called: "This is a warning."

'Talk To Everyone'

The next morning, just after 10 a.m., Shako sat in his car. Every morning, he holds an early meeting with all the involved NGOs. But the primary subject at that day's meeting wasn't the three new Ebola cases from the day before, or the 12 cases of resistance against the vaccination teams, or the fact that only a small number of teams were able to leave the hospitals, four of which required military escorts. No, for Shako, the priority was clear: Do not, under any circumstances, allow the virus to get ahead of us.

"If you don't consider the risk of them chopping you to pieces to be too high, get out of your car and do your job. Vaccinate people. Negotiate in every way possible. Talk to the families. Talk to the priests. Talk to everyone."

It's a vicious circle. The greater the resistance, the more the teams must worry about their safety. But the greater the militarization of the operation, the greater the fear and resistance in the villages. Shako is not a fan of the escorts. But he also doesn't want to be responsible for the death of any of his people. "There's a war going on," he said.

The epidemiologist was on his way to Vuhovi. The village and area that surrounds it had been designated a "red zone," a high-risk area. Many people who had been in contact with the last Ebola patients here could not be located and vaccinated.

"If we lose these contacts," Shako said, "the virus spreads and our efforts are pointless." The problem was that there are currently no doctors working in the small health clinic in Vuhovi. It was too dangerous.

Six days prior, a group of militiamen had demanded $1,000 (880 euros) from one of the nurses at the local health center. They had accused him of getting rich off Ebola. When the man was unable to produce the money, the fighters dragged him into the bush and beheaded him.

Shako called a meeting with eight Maji-Maji leaders from the area. "Once I have spoken with them," he said in the car, "the resistance will decrease. They usually want money and some form of participation. In their eyes, the doctors are earning a lot of money now." Shako's voice was hoarse. Like every night, he spoke to his wife on the phone in the capital city Kinshasa, some 1,600 kilometers (994 miles) away. Sometimes he just wants things to be over quickly so that he can go back to visiting the zoo with his kids.

Meeting the Rebels

The convoy made its way through Butembo. The city cuts deep into the bush, extending for kilometers over hills on either side of a wide tarred road. Everything is pastel-colored here, and seems to be decaying. The homes along the main road are often painted with advertisements for beer, soft drinks or mobile phone providers. In contrast to Liberia, Sierra Leone or Guinea during the West African outbreak, there are no banners or posters warning of the disease.

"It wouldn't help," Shako said. "People would tear them down immediately. It just provokes them." He didn't have an escort with him, because the Maji-Maji would attack them immediately.

A short while later, he was sitting in a community center in Vuhovi next to eight militia leaders. One of them wore a hat made of leopard skin like the dictator Mobutu once did. Another wore an orange suit.

Outside, next to a flagpole, the old village policeman bellowed a few notes on a trumpet, always the same ones. The most important thing, Shako had told his people before the meeting, was respect. The Maji-Maji do not like being talked down to. "Then they get violent. Then they kill. Or they'll kidnap us," he said.

Around 60 people gathered in the room, occupying raw wooden benches and plastic chairs. "Why can't you explain to your people how dangerous the disease is? I can't do that. You have the power here. More power than the president. I want you to use that power."

The men nodded.

"Your weapons are useless in this battle. With Ebola, everything will get much worse here," Shako said. Then the militia leaders spoke. One told him that doctors had come around to his village and told the people that Ebola didn't exist. These doctors were jealous of the salaries of the Ebola teams, he claimed, and were looking to get revenge.

Another complained that people without Ebola were being brought to the clinics. The man with the leopard-skin hat said maybe they should just let the people die, then maybe they would believe the disease was real. Everyone laughed.

This went on for a while, until nearly all of them demanded money or jobs for their people. Then they would report new Ebola cases. Then the situation could be brought under control. Shako promised to return the following Monday. The Maji-Maji were to bring their men with them. Shako wanted to see how he could recruit those who can read and write.

"I believe things will get better after this meeting," he said on the way back. He was mistaken.

The Village Pariah: A Grieving Father

But Shako has to believe. Without faith, he couldn't go on. He used to be a priest, but he couldn't stand the sight of children who were dying of cholera because nobody in their villages helped them, out of fear of the militias that controlled the area. That's why he studied epidemiology.

On the way back, in a different car in the convoy, a WHO employee said, "It won't work."

The next morning, Kalungero, the man tasked with calming people down, walked down a narrow valley path to the village of Makangala. The day before, a 21-year-old nurse died of Ebola here.

Kalungero had almost passed the fenced-in water hole when the drumming began. The villagers had started pounding menacingly on their corrugated iron fences and shouting. A dull, screeching rhythm accompanied the arrival of the WHO team. By the time Kalungero reached the two houses belonging to the victim's family, more than 30 people had gathered on the dark cliffs that towered above. They silently stared at the helpers in their protective suits as they spread out the dead man's belongings in the dust in front of the homes and sprayed the walls with chlorine solution.

"Stop spraying poison," one person screamed from the top of the cliff. The dead man's father was standing on the wall of the house. A sturdy man in a red polo shirt, he was tired and anxious.

"Go away!" people shouted from above.

The father said they didn't recognize the virus at the hospital. That's why they thought the son had been poisoned. The mother had nursed him with medicinal plants. The mother was now probably infected as well. She sat apathetically under a tree. At one point, she got up, grabbed one of the photos of her son lying on the ground and looked at it. Tears filled her eyes.

"Only when he died did we recognize that it was Ebola. Now I'm the enemy of the village because I brought the Ebola teams here," the father said.

Next to him, a blue plastic chair shattered. He flinched. At first, he couldn't see the stones flying at him. Then Kalungero's hand rushed into the air and caught a piece of flying rock. Kalungero ran to the top of the cliffs and tried to calm the mob. He told them the government was not out to kill them, that there can be no such thing as a government without the people. Then another punch was thrown at one of his coworkers. "Do not react," he said. He kept talking to the enraged mob. In the end, his team dared to leave. A fire burned behind the house. It was the victim's last belonging. His mattress.

Ebola Wins Again

When Shako returned to the old Belgian hotel -- his headquarters and makeshift residence -- after an early dinner that same day, he was still confident that the meeting with the militia leaders the day before made a difference. At 5:30 p.m., the dull sound of gunshots could be heard, at first only a few, then a couple of rounds as the sun set. Shortly thereafter, Shako stood in front of the wooden door to his residence and stared at his three mobile phones.

"I need an armored car," he said. But the car was nowhere to be found. The driver was getting drunk at a bar. "I can't wait!" he shouted. "I'm leaving now!"

He got into a silver Land Cruiser, still clutching his three phones. The minister called. Shako spoke with one phone on each ear. His operation was in danger of collapsing. Then another phone rang. "They're still shooting. I'm going there now." He hung up. The car made its way up the dark road edged by eucalyptus trees. No one said a word.

Dark-blue police pickups were parked in front of the MSF treatment center. The officers were still waiting on the beds, the contours of their dark uniforms barely visible in the black night. They stood there staring at the center as if petrified. A policeman had just been beheaded behind the clinic. Nobody dared pass through the destroyed grounds for fear of getting infected.

Shako walked past the men. The fighting had subsided, someone told him. The attackers had disappeared. They weren't able to catch any of them, unfortunately. Later, it would emerge that most of the policemen fled when the attack began.

"Don't touch anything," Shako said. He walked past a charred MSF Land Cruiser, its radio inside blaring static. Sometimes it beeped. The warehouse had been almost completely burned down. The air was filled with acrid smoke from burning plastic. Voices could be heard from inside a stone villa with smashed windows. Two men were removing the iron plates that have been placed in front of the doorway. Shako entered and saw the fear of death in the faces of the doctors and nurses who had barricaded themselves inside.

They recall how a machete whizzed past the head of a Congolese nurse and slammed into a tree trunk. They hid, while dying patients ran away in panic. Highly infectious people carried the virus out of the center and into the surrounding darkness; they ran home, and brought Ebola back to their villages. One patient would be found the next morning in a nearby tree.

Shako squeezed himself through the crowd. "What happened to the patients?" he asked an MSF doctor. No one knew. Shako went out, walked past the rooms with their plastic windows slit open. They looked inside with flashlights, calling people's names, but hardly anyone answered.

There was a child lying in room 26. The doctor looked at his list. "Anita," he shouted. The child didn't move. Shako stopped. He looked in disbelief. "Anita?" No answer. Shako's eyes filled with tears. For the first time, he lost control. "I'm going in there. I can't leave this child here like that." His people could barely stop him from storming into the room.

A short while later, Shako was standing in front of the isolation wing, staring at his phone. He opened WhatsApp and clicked on his wife's profile picture. He looked at the smiling woman in the orange dress for a long time. Then he wrote a message to his boss in Kinshasa. "Of 38 suspected cases, 32 have fled. Of 12 confirmed cases, four have fled. One dead."

The virus had won another battle.

'Dead People Can't Save Lives'

That evening, the MSF team decided to evacuate its white personnel. There was a rumor going around that white people were to be kidnapped. By 10 a.m. the next day, they were at the runway in the west of the city, a small strip of red earth, waiting for the Russian helicopters of the UN World Food Program to fly them out.

That day, one of the heads of security from the WHO said that protection measures were to be massively increased. There were to be more escorts, 180 men would guard the WHO hotel. UN peacekeeping soldiers would protect the headquarters, and the military would guard the clinics. "Dead people can't save lives," he said.

Shako told his superiors that they need to give more to the local communities: wells, hospitals and schools. That was just the way it was. They had to bribe the locals to keep them from sabotaging their fight against the virus.

Three days later, the treatment center was reopened under Congolese leadership. In a statement, Doctors Without Borders criticized the deployment of the police and the armed forces. It only serves to alienate the surrounding communities, MSF wrote, adding that this is counterproductive, since the outbreak is not under control.

On the evening of the attack in Butembo, Shako stood in front of the isolation ward. A labored coughing sound could be heard from within. A dying baby was evacuated. Then Shako's phone vibrated. A coworker in Kinshasa warned Shako that rebels had threatened to burn down his hotel tonight. The rebels had threatened to kill him, too.

He drove back to his hotel. As he later recalled, he spent the entire night talking to his wife. Neither the UN blue-helmet peacekeeping troops from Tanzania that were promised to guarantee his safety, nor the Maji-Maji, came that night.

In the early morning of March 9, the clinic in Butembo was attacked again. On Thursday, another clinic near Lubero was as well.

Shako perseveres. He meets with rebel leaders. He negotiates.

He tries to explain.

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