All 29 beds at an Ebola treatment center in Congo’s North Kivu province were occupied this week as a surge in infections overwhelmed health facilities, even as transmission showed signs of slowing in parts of the country’s hardest-hit province.

At the Kitatumba Ebola treatment center in Butembo, a city of about 2 million people, a critically ill patient lay on oxygen support as medical workers wearing masks, gloves and protective aprons moved around him.

"Over the past two weeks, we’ve seen a very sharp increase,” said Stephanie Hoffmann, project coordinator for the international medical charity Doctors Without Borders, known by its French acronym MSF.

"There are sometimes patients who know they have Ebola but cannot find a bed,” she said.

Local authorities opened two additional treatment centers this week to meet the growing demand, bringing the number in the city to four. But doctors say some patients are arriving too sick to survive.

Hoffmann said a 10-year-old boy died in triage Tuesday before he could be admitted for treatment.

The situation highlights the challenge of containing Ebola across eastern Congo, a vast region where health systems are already strained by conflict, shortages of medical workers and limited resources.

Cases spread to new areas

Researchers believe the Bundibugyo species of Ebola had been circulating for months before the first cases were confirmed in Ituri province in May.

The response has been hampered by funding cuts, gaps in disease surveillance, armed conflict and the lack of approved vaccines and treatments for the strain.

As of Tuesday, Congo had recorded 7,820 confirmed cases and 3,779 deaths, according to government data.

Ituri remains the worst-affected province, but North Kivu has recorded a sharp increase in new infections this month. The World Health Organization said Sunday that North Kivu accounted for about one-third of newly confirmed cases and deaths.

South Ubangi became the seventh affected province last week, prompting the WHO to warn of a "pronounced geographic redistribution of transmission.”

There are signs that transmission is slowing in some of the hardest-hit areas of Ituri, where health workers have been racing to establish treatment centers, identify cases, trace contacts and educate communities about prevention.

But the overall outbreak remains "massive,” said Julien Harneis, the United Nations special Ebola coordinator.

Health workers warn that a decline in admissions at some treatment centers should not be mistaken for an end to the outbreak.

"Assuming the outbreak is under control because some Ebola treatment centres are admitting fewer patients would be a mistake,” Anthony Kergosien, MSF’s emergency coordinator in Congo, said in a Sept. 18 statement. "The outbreak is not shrinking; it is moving.”

Mistrust complicates response

In North Kivu, health workers and local leaders say shortages of funding and trained personnel are being compounded by deep mistrust of Ebola responders.

More than 60% of people diagnosed with Ebola in the province have died, compared with a national fatality rate of about 48%, according to government data.

Health workers say limited public awareness and fear of treatment centers are causing some patients to delay seeking care. By the time they arrive, the disease can be too advanced to treat effectively.

Dr. Michel Paluku Mukuloli, who runs a hospital in Butembo, said some patients fear that going to a hospital means they will automatically be transferred to an Ebola treatment center.

"Patients think that if they arrive at the hospital, they will be immediately sent to the treatment centre to die,” he said.

The city’s daily life also shows the difficulty of enforcing preventive measures. Crowded minibuses continue to operate, while markets remain busy.

Pablo Paluku Lwanzo, head doctor of the Butembo health zone, said some residents refuse temperature checks and hand-washing requirements at city entry points and outside public buildings.

Only two of the zone’s nine health checkpoints are operating because of staffing shortages, he said.

Mistrust has also fueled doubts about whether Ebola is even real.

A welder in Butembo said his 12-year-old son, who had respiratory problems, died after being transferred to an Ebola treatment center. Because none of the relatives or neighbors who accompanied the boy became ill, the man said he concluded that his son had been misdiagnosed.

"For me, Ebola does not exist,” he said, speaking on condition of anonymity.

Attacks add to pressure

Fear and anger have also led to attacks on Ebola response teams.

Teams responsible for disinfecting homes and conducting safe burials have faced hostility from residents. Lambert Maboko, a member of a burial team, said one person attacked him with a machete, fracturing his knee.

Team members now pray together before deployments, he said.

Earlier this month, residents set fire to a health post they accused of working with Ebola responders, forcing patients to flee into the community, according to staff.

Microscopes, solar panels, medicines and hospital beds were destroyed.

"I’m at a loss for words,” said Kakule Mahamba, head of the Hope health post, as he surveyed the burned building.

Congolese authorities and the WHO say they are trying to rebuild confidence through public awareness campaigns, household visits and greater involvement by religious, traditional and community leaders.

Steve Ahuka, Congo’s incident manager for the Ebola response, said Wednesday that authorities had gained greater access to communities during the previous four weeks.

"While pockets of resistance remain, we believe that with the involvement of traditional, religious and neighbourhood leaders ... we can make progress,” he said.

The WHO said cases in North Kivu had declined in recent days following several weeks of sharp increases, but warned that shortages of funding, staff and treatment beds remained serious problems.

"The pressure is particularly acute in North Kivu, which ... has seen a significant increase in transmission with limited bed capacity for patient care,” the organization said in response to Reuters questions.

Memories of earlier outbreaks

North Kivu was the epicenter of three previous Ebola outbreaks, including the 2018-2020 epidemic, which was Congo’s largest and deadliest until the current outbreak.

Those outbreaks were caused by the Zaire species of Ebola, a different strain from the Bundibugyo species currently circulating.

Less is known about Bundibugyo Ebola. Responders say its early symptoms can be relatively mild and resemble more common illnesses such as malaria and typhoid fever, making detection more difficult.

The absence of approved vaccines and treatments for the strain has also fueled suspicion among some residents, particularly those who remember the medical tools used during the previous outbreak.

"People remember the 2018 outbreak and ask why vaccines and treatments existed then but not today,” said Pepin Kavota, a civil society coordinator in the nearby city of Beni.

Trust was further damaged by reports of sexual exploitation and abuse involving responders during the 2018-2020 outbreak, including some WHO personnel, Kavota said.

The WHO said it recognizes that "trust must be continually earned” and has strengthened measures to prevent and respond to abuse since the previous outbreak.

Last month, provincial authorities recruited pro-government fighters known as Wazalendo to protect responders and encourage compliance with Ebola prevention measures. Armed men now operate some hand-washing stations on roads leading to Butembo.

A leader of the force warned that people who repeatedly refused to follow Ebola control measures could be forcibly taken to treatment centers and whipped.

Health officials fear such coercive tactics could deepen the mistrust already hampering the response.

"We should not need to use the police or the army in a response,” Lwanzo said. "The population must be sensitised and willingly adopt the measures that are being put in place to protect them.”