More than a thousand people have been infected with the deadly Ebola virus in two eastern provinces of the Democratic Republic of the Congo in an outbreak that has claimed hundreds of lives and flummoxed public health officials.
The Congolese health ministry said Sunday the virus has killed at least 629 people and infected 1,009 people, making it by far the worst Ebola outbreak in Congo's modern history, and the second-worst outbreak in the world, behind an epidemic that struck three West African countries beginning in 2014.
Worryingly, the number of cases rose precipitously in recent weeks, spreading faster than in December and January.
Health officials say the rising case count comes as they struggle to make inroads with communities that are not used to dealing with Ebola, or even with aid workers hoping to help. Those officials have been frustrated in recent weeks as the epicenter of the outbreak moved south from the town of Beni to the cities of Butembo and Katwa.
More than half the cases that have emerged in the last three weeks came in those two cities. Two other smaller cities, Masereke and Mandima, account for most of the rest of the new cases over the past 21 days.
"The current epicenter of the epidemic is still very squarely in the twin cities of Butembo and Katwa," Michael Ryan, the World Health Organization's assistant director general for emergencies who is overseeing the global response to the outbreak, told The Hill in an interview Saturday. "We've had real challenges in Butembo and Katwa and the surrounding areas."
North Kivu Province has been riven for decades by ethnic strife, and at least a million of its eight million residents are internally displaced. About two dozen armed rebel groups are operating in the region, and some of those groups have attacked health care workers. The situation is so dangerous that the U.S. State Department has not allowed aid workers from the Centers for Disease Control and Prevention or the U.S. Agency for International Development to operate in the area.
Health responders have encountered deep suspicion and resistance in communities that rarely interact with international aid workers, or even with their own federal government, based in far-off Kinshasa.
In the last month, angry mobs have attacked health facilities dedicated to treating Ebola victims in both cities. Medecins Sans Frontieres, known in the United States as Doctors Without Borders, pulled their workers out of the region after the attacks. The WHO has reopened the center Butembo, and they are in the process of rebuilding the center in Katwa.
The mistrust runs so deep that families and relatives of those infected with the virus -- those who are most susceptible of contracting Ebola themselves -- are sometimes reluctant to receive a vaccine being deployed in the region.
The vaccine has been given to more than 90,000 people in North Kivu and Ituri, and to thousands more health workers in Uganda, Rwanda and South Sudan in case the virus spreads across international borders. Health workers use a strategy called ring vaccination, giving the dose to those who have come into contact with an Ebola victim and to those who have come into contact with the contacts, in hopes of stopping the virus.
The Ebola virus has killed about 62 percent of those who become infected. But the outcomes are much different for those who seek and receive treatment immediately, who are much more likely to survive, and those who wait days to seek treatment, who die at higher rates.
Those who delay seeking medical attention tend to put their families at risk of catching the virus as they care for loved ones. Ryan said global health officials are working to build trust to ensure those infected seek treatment right away.
"The median time for detection and transport to an [Ebola treatment unit] came down in places like Mangina, places like Beni and Tchomia and Komanda," he said, referring to cities that got control of local Ebola outbreaks.
"But it remains pretty resistant in Butembo and Katwa," Ryan said. "A lot of patients are arriving quite sick. Five, six, ten days after infection. It's also bad for their families, it's also bad for their communities, because they're transmitting the disease before they are isolated."
About 17 chains of transmission -- separate groups of infected patients spreading the virus independently of each other -- are active in Butembo and Katwa, Ryan said. He said health officials are working to build trust in both cities, through religious leaders and local councils run by residents themselves, rather than by foreigners.
"They're very self-sufficient, they're very business oriented. They move and they trade, and they have a deep distrust of anyone from the outside," Ryan said. " They are mistrustful. They see a lot of resources being assigned to Ebola, and they have other health issues that haven't been addressed for years."
"At the end of the day, this whole response is based on early detection of cases, exhaustive identification of contacts, contacts of contacts," Ryan said. "We have the operational capacity to deliver all of that, but none of that is possible if the community doesn't accept the intervention."
The international community has pledged more than $90 million for the latest stage of the response, though much of the money pledged has yet to arrive.
"It is by no means fully funded. We're still $50 million short," Ryan said. "It's one thing to have pledges of $90 million. It's another thing to have the money in the bank."
The WHO has more than 700 health workers on the ground in North Kivu and Ituri provinces. Other aid groups are still working in the region. American officials have helped vaccinate health workers in safer areas across borders, and they have backfilled positions at WHO headquarters in Geneva as those staffers deploy to Congo.
Robert Redfield, the CDC director, visited the region earlier this month. He was scheduled to visit the Ebola treatment unit in Butembo, though it was attacked hours before he arrived.