The last text message from Jean arrived on April 26.

The severely underweight 20-year-old man with diabetes wrote to Alfred Kakisingi on WhatsApp to say, once again, that he could not find enough food.

Jean, a pseudonym used because his family could not be reached, required insulin. According to Kakisingi, manager of the Goma-based Association des Diabétiques du Congo, or ADIC, Jean's mother had almost no income and his father opposed the treatment because he believed a traditional healer could treat Jean more quickly and effectively.

"His father formally prohibited him from taking insulin," Kakisingi said, forcing Jean to inject himself secretly, often in a bathroom.

Kakisingi had been helping Jean with transportation and small amounts of money. Both Kakisingi and the clinic provided him with porridge, avocados, and doughnuts.

"He frequently asked me for help finding something to eat, repeatedly saying that he was in real danger because of the lack of food," Kakisingi said.

Then he disappeared.

After returning from a trip to Nairobi, Kakisingi realized that Jean had stopped coming to the center. Kakisingi called Jean on June 3 and received no answer. He sent another message the following day. Later that day, a street vendor told clinic staff that Jean was dead and had already been buried.

The exact circumstances remain unknown. ADIC initially reported that he had died from hypoglycemia, but Kakisingi later said the precise cause could not be confirmed because no clinician saw him during his final days. His impoverished family could not afford to keep his body in a morgue and buried him quickly in a cemetery near their home.

Jean's story illustrates an underreported reality of an epidemic: it can endanger people through the disruption of ordinary care, whether or not they become confirmed outbreak cases.

Official Ebola statistics count infections and deaths from the virus. They usually do not capture the people harmed when an outbreak disrupts ordinary care, such as the diabetic patient who dies at home, the mother who misses prenatal visits, or the child whose medicine becomes unreachable when roads close.

The current Ebola outbreak did not create all the forces that endangered this young man. He was already living in extreme poverty, weighed only 27 kilograms when admitted to ADIC and had dangerously uncontrolled diabetes. But an outbreak can tighten every existing constraint at once by closing borders, restricting roads, increasing transportation costs, disrupting food markets and making patients afraid to seek care.

For someone with diabetes, that disruption can become lethal.

"Most people with diabetes express greater fear of diabetes than of Ebola," Kakisingi said.

In addition to medicine, diabetes treatment requires food, glucose testing, transportation, and regular medical supervision. Too little insulin can lead to severe outcomes like hyperglycemia and diabetic ketoacidosis. Insulin without adequate food can drive blood sugar dangerously low.

In eastern Democratic Republic of Congo, Ebola restrictions have compounded the effects of armed conflict and poverty. ADIC patients have delayed appointments because they fear infection or must cross areas controlled by armed groups. Kakisingi said some can no longer afford transportation to the clinic.

The barriers are also psychological.

Dr. Claude Kasereka Masumbuko, a Congolese public health researcher who studied resistance during previous Ebola outbreaks, said distrust grew from decades of violence and a widespread sense that the population had been abandoned.

"Ebola kills, but the rebels kill more," he said, describing a common sentiment.

According to Masumbuko, some residents believe Ebola responses serve foreign interests or generate money for outsiders. Others mistrust vaccines, isolation centers and medical teams that do not include people from affected communities. Masumbuko said responses work better when they involve local health workers, religious leaders, customary authorities and representatives of the region's different ethnic groups.

That mistrust affects more than Ebola containment. A patient who fears entering a health facility may also miss an insulin refill, a blood sugar test or treatment for an infection.

Local organizations are trying to keep routine care operating inside the emergency. ADIC has introduced temperature screening, chlorinated handwashing, surface disinfection, distancing and protective procedures for blood sugar testing. Direct Relief has sent insulin and other medical aid, including PPE, to partners in the region, including ADIC and Jericho Road's Wellness Center in Goma, VillageReach in Ituri, and IOM on the DRC-South Sudan border.

But maintaining services does not mean health workers can see what is happening in every patient's home. Jean's case unfolded amid extreme poverty, food insecurity and opposition to his treatment, largely beyond the clinic's reach.

The young man's final weeks remain largely undocumented. Kakisingi does not know whether he reached a hospital, had insulin available, or ate before he died.

"Often, these deaths occur in silence, because the person chooses to return to their village to spend their final days with their family," Kakisingi said.

As of July 23, Congolese health officials had recorded 2,536 confirmed Ebola cases and 1,033 deaths, while Uganda had reported 20 cases and two deaths.

Jean is unlikely to be counted among them.

Read more about Direct Relief's response to Ebola here.