Congo said Thursday that the second-largest outbreak of the Ebola virus in modern times has ended after nearly two years.
Public health officials have not confirmed a case of the Ebola virus since April 27, when the last known patient suffering from the disease was discharged from a hospital in the city of Beni.
The Ebola outbreak, which began in July 2018 in North Kivu Province, infected more than 3,400 people and killed at least 2,280, according to the Congolese health ministry's latest report. It ripped through several eastern provinces riven by ethnic strife and mass displacement, vastly complicating a national and international response in which health workers became the target of violent attacks.
"You have an outbreak that has no limitation that can cross into a highly insecure area where you have violent groups killing and raping," Michel Yao, the World Health Organization Africa Region's emergency operations manager, said in a phone interview from Kinshasa. "It was the environment in which we operate."
The true death toll is likely far higher than the reports show. Some who were infected either avoided treatment or died before they could reach health care facilities. Only an outbreak in three West African nations that killed more than 11,300 people between 2013 and 2016 claimed more lives.
Health workers faced hundreds of attacks from armed militia groups, and several were killed throughout North Kivu and Ituri provinces. The two provinces are home to dozens of rival groups, and are the frequent targets of attacks from nearby terrorist organizations. The local population has been torn apart by sectarian violence for decades.
"We have hundreds of these security incidents, health workers killed, WHO staff killed," Yao said.
Even without the security threats, residents distrustful of the far-off federal government in Kinshasa feared the worst from both Congolese troops and international health care workers from groups like the World Health Organization, Doctors Without Borders and other aid groups that showed up to help.
"The biggest challenge was winning the trust of the communities that we were there to help and getting community engagement," said Alex Wade, who spent two years coordinating humanitarian activities for Doctors Without Borders in the region. "This epidemic was in a conflict area, so it's a population that was already traumatized by years and years of violence with an entrenched distrust towards outsiders."
Residents of North Kivu and Ituri have been neglected for decades by the national government in Kinshasa. Many were frustrated that authorities would show up to battle Ebola, but not the more endemic diseases like malaria and cholera that kill thousands of people every year.
Public health officials recognized that before they would be accepted, they had to build a deeper connection to the people they needed to help.
"We used social scientists, including local ones, if we were to understand why there was the resistance," Yao said. "We sat with them, explain what the disease is, what we need to do, and what are their expectations. ... Give them more responsibility and accountability, it was positive at the end."
The situation on the ground was so dangerous that the U.S. State Department barred responders from the Centers for Disease Control and Prevention and the U.S. Agency for International Development from participating in the response in the hardest-hit cities of Beni, Butembo and Katwa.
Instead, American responders helped organize supplies in nearby Goma, the largest city in eastern Congo, and trained health care workers and border guards in neighboring nations like Uganda, Rwanda and South Sudan.
The World Health Organization plans to remain behind in the hardest-hit areas for at least three months to monitor for new outbreaks and to support the public health system that still exists. The end of one outbreak, Yao said, does not mean the end to a deeper public health crisis.
"For these people, it's hope that at least it's over, but it's also fear [that they will be] forgotten," he said. "We are trying to advocate that it is an opportunity to address the security issue and to also increase the humanitarian support of the people."
Even before the end of the outbreak in North Kivu, Congolese officials reported a new epidemic 800 miles away, in Equateur Province.
Those cases are not connected to the North Kivu outbreak, studies of the respective genomes of the virus show. It is the second time in two years that Ebola has erupted around cities like Bikoro and Mbandaka.
The new outbreak scares some epidemiologists because the main cities in the region are all situated along the Congo River, which connects Mbandaka, a major trading port, with Kinshasa and Brazzaville, the capital of the Republic of the Congo. Those two cities are home to millions of people, raising new fears of an urban epidemic of one of the deadliest viruses known to man.
But Equateur Province is much more secure than eastern Congo. The earlier outbreak also means local officials and the population is aware of the virus and the danger it poses.
"We are more hopeful that it could be controlled maybe faster than the eastern part of Congo," Yao said.
The Congolese Health Ministry said in its latest update that 18 confirmed and probable cases of the Ebola virus disease had been identified in five towns in Equateur Province. Of those, 12 people had died. Yao said the WHO and Congolese health officials had already administered more than 5,000 doses of an Ebola vaccine in hopes of stamping it out before it spreads farther.