Building Trust to Contain the Spread of Ebola in East Africa

When the Covid-19 epidemic erupted, N95 masks were the top need. In a cholera outbreak, oral rehydration salts and IV fluids are crucial. In eastern Democratic Republic of Congo, where Ebola has killed more than 1,500 people, the critical shortage is in trust.

With Ebola spreading rapidly in eastern DRC, Bilali Emmanuel David Lingo and his colleagues from the International Organization for Migration scan thousands of people each day crossing into South Sudan, watching for high fever and other signs of potential infection. "The risks are very high; they are moving closer to our borderlines," said Lingo, a 41-year-old South Sudanese nurse who has worked for more than a decade for the IOM, a United Nations agency.

In the first two months since the outbreak was reported in May, IOM screened about 700,000 people at South Sudan border posts and reached nearly half a million people with Ebola awareness messages. On market days, the busiest crossings see as many as 1,500 people, Lingo said. Those who show signs of possible infection are isolated while samples are sent for testing; so far, no confirmed cases have turned up among border crossers.

Local staff are trained in infection prevention and control, and IOM materials educate travelers on Ebola's symptoms, including fever, vomiting, severe headaches, and fatigue. Beyond the formal crossings, people also enter South Sudan through informal routes that aren't monitored.

Overcoming distrust is a challenge. "We try to inform them that Bundibugyo (Ebola) virus is real and everyone has to be vigilant, from the communities to the family level," Lingo said. "Through proper education, patience and awareness, we've seen that these beliefs and mistrust are changing."

He described a merchant who entered at the Libogo crossing and angrily resisted screening; after Lingo explained the risk, the man calmed down and cooperated the following week without complaint.

South Sudan is one of the world's most dangerous places for humanitarian workers, and 29 aid workers and contractors were killed there in the first half of 2026, according to the UN. "Humanitarian access is limited in many parts of the country due to insecurity and ongoing violence," said Amber Lynn Christino, IOM South Sudan's communications focal person. "Health systems are extremely overstretched, especially in places where people are coming from Sudan."

Direct Relief made two large donations to IOM in South Sudan last month, including PPE, infection-prevention supplies and oral rehydration salts, distributed to four primary health facilities and to the border posts themselves.

The number of Ebola cases is doubling every 20 days, the UN said on July 29 - far faster than any previous Ebola epidemic. It took less than 11 weeks to reach 3,442 confirmed cases; by contrast, the 2018-2020 outbreak took 58 weeks to reach that level, according to an analysis by Bloomberg News. North Kivu deteriorated sharply in July: cases more than doubled in three weeks, from 158 to 325, while deaths rose from 89 to 223 and the case-fatality rate climbed from 56.3% to 68.6%, according to statistics from DRC's National Institute of Public Health, or INSP.

Uganda, by contrast, declared itself Ebola-free on July 28, after an outbreak of 20 confirmed cases and two deaths linked to travel from DRC.

Direct Relief's response spans all three nations: PPE and infection control and prevention materials to remote South Sudan border posts, more than a quarter million pieces of PPE and a broad range of medicines to DRC, and two large shipments of medicine and equipment for bolstering primary care expected to depart in the coming days for Uganda.

Building Trust in a Region Beset by Violence

Tracking an outbreak is especially hard in a region this fragmented - divided among ethnic groups, armed groups and government-controlled enclaves, with more than 5 million people displaced by conflict in DRC's North Kivu, South Kivu and Ituri provinces alone, according to UNHCR.

Among 391 eastern DRC residents surveyed in June by the nonprofit Ground Truth Solutions, 60% said people in their community don't believe there is an Ebola outbreak. Many blamed a lack of information reaching them (36%), or cited a belief that the disease had been fabricated by authorities for financial gain (36%) or to control the population (19%); some pointed to a belief that Ebola was created or deliberately introduced by white people or foreigners to exterminate the population, or to make money.

Only half of those surveyed thought people felt safe going to a health center - among those who didn't, fear of getting sick there (73%) outweighed distrust of health workers (42%) or fear of getting quarantined (17%).

"Evidence from earlier outbreaks shows that meaningful community engagement, systematic feedback collection and trusted local intermediaries can improve acceptance of public health measures and strengthen outbreak control," the Ground Truth Solutions report said.

The response has also been hindered by health-worker strikes over unpaid wages, and by attacks tied to restrictions on traditional burial practices that risk spreading infection.

Recruiting Neighbors to Close the Trust Gap

Across the border in DRC, VillageReach has trained more than 1,000 community health workers - local volunteers - to bring Ebola information to the region's diverse communities in Ituri, Haut-Uélé and Tshopo provinces. It is also strengthening lab sample transport and outbreak response alongside DRC's Ministry of Health, and has delivered more than 800 lab samples. Direct Relief has supplied VillageReach with two large shipments of PPE and other medical supplies.

After training, the volunteer health workers were given vests that identify them. "This is the very first time for them to be recognized," said VillageReach's DRC Country Director Freddy Nkosi. "This is a small token, but it's a great incentive that unblocks energy."

IOM and VillageReach are just two of the many on-the-ground partners Direct Relief works with: rather than parachuting in outsiders and leaving when the acute crisis passes, the organization delivers medical aid through a network of more than 2,600 partners worldwide, most of them local health providers.

The eastern DRC is one of the world's most conflict-riven regions. "Due to the permanent insecurity in the region, health workers are limited to a certain level because some areas are inaccessible," said Dr. Claude Masumbuko, a Congolese researcher at Université Catholique du Graben in Butembo who studies mistrust and community engagement in eastern Congo.

"In Bunia, the Hema tribe is disliked by the Bira, and vice versa," and outreach teams should include members of the targeted ethnic groups, he said.

"You cannot take the chance of sending a community health worker to a community where he or she doesn't belong or isn't known - that will not work," VillageReach's Nkosi said, noting that more than 50 different local languages are spoken in eastern DRC.

"We recognize that community engagement, addressing these trust issues, continues to be a critical priority," said Dustin Shiau, Direct Relief's emergency response manager working on the Ebola response, describing the organization's strategy of working through "partnerships with local organizations that have long-standing established experience and relationships in communities, as opposed to new organizations that show up in a disaster."

Primary responsibility for fighting Ebola rests with DRC's Ministry of Public Health and its National Institute of Public Health. On July 14, health authorities and Ituri's military governor met with 48 traditional chiefs "to strengthen the commitment of customary authorities, key local actors, in efforts to prevent, raise awareness and interrupt the chain of transmission of the Ebola virus disease," INSP said.

"The experts particularly insisted on the importance of early referral of people with signs compatible with the disease to Ebola Treatment Centers. Prompt treatment not only significantly improves the chances of recovery, but also reduces the risk of transmission within families and communities."

Response teams stressed the cost of delay: keeping sick people at home reduces their chances of survival and speeds the disease's spread.

Additional reporting by Noah Smith.