A text message that says, "Stop or We'll kill you."
A knock on the door in the middle of the night.
Leaflets telling your neighbors that you are the enemy.
In the Democratic Republic of the Congo, these are the kinds of threats that health workers in the Ebola outbreak zone have been getting for weeks.
For five days this past week alone, health workers had to stop all operations because of violence directed toward the Ebola response — resulting in a surge of new infections that's brought the total caseload to more than 1,600.
A mob outside the house
For Dr. Joyeouse Kivwira the moment of reckoning came on an afternoon late last month. She was preparing lunch at her home in a village called Magherya when she heard a crowd gathering outside.
She looked out her window and saw a mob of mostly high school students — many of them carrying rocks.
"A horrible, angry crowd," she recalls. "Lots and lots of people — too many to count."
Kivwira has been the doctor at the government-run clinic for this village since December. She was shocked to see who was in the crowd.
"They were the people from here. People I've taken care of when they were sick," she says.
She's from this part of Congo. But she grew up in Butembo — the main city in the area — not in this village.So that makes her an outsider. And after years of conflict between dozens of armed rebel groups and the government, people in the region are very wary of outsiders.
When Ebola hit last August, rumors started swirling that the disease is a hoax — or brought by the government and foreigners as a way to make money and even kill off people in an area that's been a hotbed of government resistance.
"People say that we — the local health workers — are getting money to refer patients to the Ebola treatment centers where they are sent to die," says Kivwira. "The crowd was shouting that they should chase us out — even kill us."
Two teachers and an older man rushed over to defend Kivwira. They shouted to her to barricade her door, shut all the windows.
"At that moment I thought that this would be my death," she says. "I've never experienced fear like that."
For nearly an hour she cowered inside, listening as the men talked the teenagers down. As soon as the crowd dispersed, Kivwira fled the village.
"On foot!" she says.
That same day — Wednesday, April 24—dozens of doctors and nurses were demonstrating in Butembo, threatening to strike unless the government does more to protect them.
While frontline Ebola workers have faced assaults on the job throughout the outbreak, beginning around February, the attacks have become more brazen. Ebola treatment centers have been repeatedly attacked. In late April, gunmen stormed in while a local response team was meeting and shot an epidemiologist with the World Health Organization.
And increasingly, even regular health workers like Dr. Kivwira are being targeted. Often at home.
The head of the area doctors' association has described multiple incidents to NPR — including one in February when attackers broke into the house of a government nurse while he was sleeping and made his wife watch as they shot him dead with a bow and arrow.
Time for a rethink
The barrage of violence has prompted foreign medical workers to float ideas that would have been unthinkable just a few months ago.
Karin Huster, a nurse and field coordinator for Ebola with the aid group Doctors Without Borders, says the takeaway is clear: "We need to really change the way we think about Ebola."
Huster was evacuated from the outbreak zone in March after two Ebola treatment centers run by the aid group were burned to the ground. She argues that the extreme distrust of authority in northeastern Congo has made the usual strategy for combating Ebola totally counterproductive.
She notes that there are many diseases that threaten lives in eastern Congo. Malaria is particularly devastating, for example, and has claimed far more lives than Ebola. But right now Ebola is singled out for special treatment outside of regular health clinics in ways that mystify and alienate the local population.
"Biosafety is still in the forefront — you know biosecurity — you know, bio-everything," says Huster.
As soon as a person shows symptoms, workers in hazmat suits whisk them off for testing at a "transit center" surrounded by orange netting.
A patient who has the disease is sent to a treatment unit that's even more isolated — while teams of foreigners in expensive cars descend on their neighborhood, seeking out anyone who might have been exposed to a patient so they can be vaccinated. And if the patient dies, the family does not get to take home the body. Yet another team of people in hazmat suits shows up to bury the deceased.
The approach makes sense from a purely medical standpoint. But in a country with a history of oppression by authorities, it's practically tailor-made to raise suspicion and resistance.
Huster says instead the government and the World Health Organization — which is coordinating the contribution by foreign experts — need to massively lower the profile of the Ebola response.
"I don't believe we need the hundreds of people, and the hundreds of cars out there," she says.
Most important, "it would be so much better if we could integrate Ebola inside of the health systems," she says. Essentially treat it like any other serious, but manageable disease.
Sure, Ebola is infectious, notes Huster. "But at the beginning [of the infection], it's not something that's easily catchable like measles." And in contrast to the West Africa outbreak of 2013-2016, responders in this outbreak have access to a very effective vaccine.
So, says Huster, if someone shows up at health clinic with a fever, the doctor should just give an Ebola test. Then have the individual wait a few hours for the results in a designated room at the health center "without having the orange netting, you know, the things that scream Ebola."
Similarly, at Ebola treatment centers, says Huster, the staff could provide family members of patients with protective gear and a little training so they can sit bedside and even help to provide care.
"Bring them in with their kid or their dying mother," says Huster.
If a patient still doesn't want to go to a treatment center, adds Huster, maybe even consider helping their families care for them at home.
It's not ideal, she says. But "somehow whatever we're doing now is not working at all."
What does the World Health Organization make of these ideas?
"We have a kind of open mind. We have to think out of the box," says Dr. Michel Yao, who is leading WHO's on-the-ground response to Ebola.
In fact, he says, WHO has already taken steps in this direction.
For instance, the policy is now to start releasing people whose first round of an Ebola test is negative, rather than making them wait an additional day or more at a transit center for a second, confirmatory test.
And they are even letting some Ebola patients get their care at home.
"It's not too many [cases]," says Yao. "But we have a few experiences where people who were resisting to come to the treatment centers remain at home. And we train relatives to take care of them."
WHO has also worked with UNICEF and the government to set up what are essentially neighborhood committees that are picking people from the community to be trained to bury bodies and trace the contacts of Ebola patients instead of leaving the work to outsiders.
But Yao says the problem is that every time there's another attack, health workers have to stop all operations until it's safe to go out again. This includes all the new initiatives aimed at gaining the community's trust — and preventing yet another outbreak of violence.
And so the cycle of halting progress, followed by violence and setbacks, continues.
Dr. Joyeouse Kivwira's experience is a case in point. Early last week she decided to go back to work.
But there was another round of violence in the nearby city of Butembo this past week, and she changed her mind.
"I'm worried about the health of my patients," she says. "But we can't sacrifice our lives for a population that resists us, that's ready to kill us."
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