David Gressly is not a medical expert. But he has just taken on what has to be one of the toughest jobs in global health.
On May 23, the United Nations' secretary-general named Gressly to a new position overseeing the organization's effort to stop the 10-month-long Ebola outbreak in Democratic Republic of the Congo. (His official title is U.N. emergency Ebola coordinator.)
Until then, Gressly had been deputy head of the U.N. mission in Congo, which includes a massive force of peacekeepers. His appointment amounts to a recognition by the U.N. that it's no longer an option to leave coordination of the international Ebola response solely to its health officials — specifically the staff of the World Health Organization. That's because the biggest obstacle to ending the outbreak is a problem that WHO officials say has ballooned beyond their purview to address: Since late February, there's been a dramatic surge in violent — and sometimes deadly — attacks against Ebola response teams.
The violence keeps forcing Ebola responders to pause key activities such as identifying and treating people infected with the virus, vaccinating their contacts and safely burying those who die of the disease. The result has been a spike in infections. Since mid-March, the new case count has jumped from about 25 per week to more than 120 in some weeks. And the total number of cases over the 10 months of the outbreak has just topped 2,000.
Perhaps the biggest challenge to ending the violence is that it's still not entirely clear who is behind it — and why.
Reached by phone in Congo, Gressly said that understanding the dynamics driving the violence will be "essential" to his mission: "It's important to figure that out at a detailed, granular level."
But like many local and international observers in Congo, he said it's already clear that "it's not just a simple matter of [local people] not understanding the importance of the [Ebola] response. It goes much deeper and may have political or economic reasons behind it."
What are those reasons? Gressly laid out several theories.
A turning point
The first is that local political figures are fomenting and even organizing the attacks as a way of undermining their rivals, presumably officials of the central government or local leaders aligned with them.
Many analysts hold that it was actually the national government that set the stage for the use of the Ebola crisis as a political tool, and Gressly largely echoed that account. Last December, he noted, just days before presidential elections, national electoral officials announced that voting would be suspended in the two largest cities in the outbreak zone, Beni and Butembo.
The stated justification was to prevent Ebola from being spread at the polls. But a candidate opposed to the then-ruling party's choice was projected to win in Beni and Butembo. So the decision "created a perception that the Ebola outbreak was manufactured," said Gressly.
Deprived of votes from Beni and Butembo, and amid wider allegations of vote-rigging by the ruling party, the opposition candidate ended up losing to a third candidate — Congo's new president, Félix Tshisekedi.
Butembo, in particular, was fast becoming the current hot spot in the outbreak. Tariq Riebl is emergency coordinator for the aid group International Rescue Committee, which has teams helping to isolate suspected Ebola patients at health centers across the city and surrounding countryside. He says the rage that many people feel over the vote suspension is still palpable.
"If you need a seminal turning point it's that one," said Riebl. "People are really seething because of being disenfranchised."
Questions about whether the Ebola outbreak was the product of some kind of government plot had already been swirling. But starting in late December and on through local parliamentary elections in March, the conspiracy theorizing went into high gear, said Rachel Sweet, a Harvard-based researcher.
Sweet has been monitoring WhatsApp texts, radio broadcasts and leaflets about Ebola, working with colleagues based in the outbreak zone. She's found that for months mostly anonymous authors have been claiming that Ebola is a hoax, perpetrated by the government to drum up foreign aid and corral residents of communities that are hostile to the government into treatment centers.
In recent weeks, she said, another rumor has been gaining ground: that Ebola is a real disease, but the government and international health workers are infecting local people with it on purpose. For instance, said Sweet, some rumormongers have written that "the Ebola response team was dumping the Ebola virus into latrines."
Who's pushing the rumors?
As far-fetched as these rumors may sound, they are believable to many people, said Gressly, because "authorities or security forces have often in the past been in opposition to this community."
The outbreak zone is in an eastern, resource-rich area that has long sought greater sway over its own affairs and was the site of several regional wars in the 1990s sparked by the Rwandan genocide just across the border. Some of the foreign guerrilla armies involved, particularly one with roots in Uganda, remain active in the area. The conflict also sparked the proliferation of about two dozen local self-defense militias — called by the umbrella term "Mai Mai" — that have continued to compete with each other as well as with factions of Congo's military in an ever-shifting series of shadowy alliances.
Civilians have often been the pawns in these power struggles, said Sweet. Beginning in 2014 there have been a mysterious string of massacres around Beni in particular, in which, according to U.N. accounts, at least 1,200 people have been shot or hacked to death with machetes.
According to the United Nations, a general of Congo's army was implicated in one of these attacks. And although most of the other massacres remain unsolved, the effect has been to foster among the population a deep distrust of not just government forces but of international peacekeepers and aid workers — who are blamed by many locals for failing to protect them.
While all this created a receptive audience for the anti-Ebola rumors, both Sweet and Gressly maintain that they didn't simply spring up or spread spontaneously. Various people appear to have actively promoted the conspiracy theories for their own gain — including as part of campaigning for parliamentary elections last March.
"There are those who want to make use of the distrust that's already there to advance a political agenda," said Gressly. "Some people actively pushed that narrative. Politicians really played it up."
Violence on the rise
The wave of rumors coincided with a steady increase in the violence against Ebola responders.
At least one type of attack appears very much linked: Many of the incidents seem to be outbursts by members of the community who have heard the rumors and believe them. An Ebola team will arrive in a neighborhood to bury a suspected Ebola patient or vaccinate their relatives, and people will throw rocks and chase the team out. Similarly, doctors and nurses at regular health facilities have been threatened by mobs, who are angry that the health workers refer Ebola patients to treatment centers. In one case, a nurse was killed.
But there has also been an increase in seemingly well-coordinated assaults by well-armed assailants. More than half-a-dozen times, gunmen have shot up Ebola treatment centers and health facilities where Ebola teams are based, including on April 19, when a group of armed men burst into a hospital where an Ebola team was meeting and killed an epidemiologist with the World Health Organization.
And here the chain of responsibility becomes murkier. The nature of these attacks, said Gressly, suggests they are part of a deliberate strategy: "It seems to be motivated by those who are trying to specifically disrupt the response."
The government has publicly blamed various Mai Mai militia – and arrested several of their number.
But it's possible, said Gressly, that as with the rumors, the ultimate sponsors of these types of well-coordinated attacks may be political figures with political motives.
If you look at the history of the different militias, said Gressly, over time "you'll see they sort of divide on ethnic lines, and then on clan lines, and become more numerous but smaller. So they often have linkages to local traditional leaders and local politicians."
Sweet added that "local Mai Mai groups are oftentimes up for purchase by different political sponsors or local bidders. These are available guns for hire."
And she believes that it's notable that leaflets left at some of the attacks on Ebola treatment centers specifically mentioned political concerns. "They were invoking their inability to vote in the elections as a reason for these escalating attacks," said Sweet.
The money angle
But it may not just be politics. Gressly said he's also prepared for the possibility that the most important driver of the violence is cash.
"There's a lot of money to be made illicitly" in the region, he noted. Specifically, a lively — and largely under-the-table — trade in timber, minerals and other resources. And various Mai-Mai groups in conjunction with local leaders have evolved into what are essentially criminal networks. "You have protection rackets for the movement of those goods," said Gressly.
Gressly said he suspects that some of those networks may feel threatened by the influx of foreign aid money and teams of Ebola responders. "When those interests are disturbed in any way there can be a violent reaction," he said.
In addition, Ebola itself has become a big business. The government has used the money to hire thousands of workers for the Ebola response – creating winners but also losers.
"I think we're competing with people for income," said Gressly. Including, he said, traditional healers who might resent the money flowing to medical professionals.
Looking ahead
Whether their motivations are financial or political, the assailants who are mounting the organized attacks pose a particular problem for aid workers like the IRC's Tariq Riebl.
Six members of his organization were caught up in the attack in which the WHO epidemiologist was killed. "Three were able to get out quickly," said Riebl. "But three more were trapped for hours."
In the aftermath, he said, it's hard to know how to keep his teams safe. When it comes to the attacks by ordinary people in the community who are simply misinformed, "you can mitigate it — do community outreach, improve your communication strategy, discuss with communities what their troubles are and usually you can resolve these things," said Riebl. But when attackers seem to be targeting aid workers as part of a larger strategy, "you can't negotiate with people that have these sorts of intents."
Gressly said he'd like to try. And he said he plans to draw on several tools from the U.N. mission in Congo not available to the WHO officials who had been heading up the response: "We have civil affairs officers who maintain really close relationships with communities. We work with them all the time. That gives us a level of access to the population that WHO could never match."
He also plans to build on his prior role mediating between the government and Mai Mai militias. The idea, said Gressly, is "to work basically as an impartial entity between the two to find solutions that allow these groups to re-enter society." Even just getting those kinds of negotiations underway could have a calming influence on violence, he said. And of course, he added, if necessary "we can deploy forces."
But what if — as many analysts in Congo suspect — some of the sponsors of the organized violence turn out to be power brokers who are either tied to the government itself or who are too powerful an opponent for the government to want to name, let alone take on directly? The concerns are all the more heightened because of an ongoing controversy over the U.N.'s handling of the killing of two of its researchers in another part of Congo in 2017, allegedly at the hands of people with ties to the government. American news outlets like Foreign Policy and The New York Times have raised doubts about whether the U.N. has fully called out the government or pulled its punches in order to preserve its ability to work in Congo. Will similar questions dog the effort to uncover the perpetrators of the attacks on Ebola teams?
Gressly said one of his objectives is to "end impunity for these kinds of actions." He noted that the U.N. has specialized support teams that can help Congolese prosecutors with their investigations. And he said he intends to deploy them in pursuit of the sponsors of the organized attacks on Ebola teams, including the killing of the WHO epidemiologist, who was a U.N. employee.
"We have a strong policy for our own personnel — U.N. personnel — that we want to pursue these cases and see justice done," he said. "And if there's a requirement to follow this up a chain of command, then that's what we want to see as well. We will continue to do so until we feel that justice has been done."
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