Two major setbacks hit the Democratic Republic of Congo in the midst of the central African country’s ongoing struggle to contain an Ebola outbreak that has claimed the lives of more than 1,700 people. After a confirmed case in Goma, home to 2 million people, the World Health Organization declared a Global Health Emergency on July 17.

But a less reported development might prove to be more ominous.

On July 13, two community health workers were killed by locals in the North Kivu province, which is one of two provinces that has seen over 2,500 people catch the disease during the current outbreak which began last year and is the second biggest on record.

The violence against the workers suggests that, even as medicine has advanced — notably with an effective vaccine — pernicious underlying social and infrastructure issues remain.

“The outbreak is occurring in a region of country that is really very steeped in violence,” said Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases in an interview with Direct Relief. “It is interfering with the normal way you respond to Ebola outbreaks.”

Citing a lack of trust in authorities among people in northeast Congo, Fauci said healthcare workers have been unable to undertake contact tracing, which is identifying, and then isolating, individuals who have been in contact with an infected person.

“We don’t have a good feel for the spread of the disease,” he said.

One way to interrupt that spread is by continuing normal healthcare operations, according to Dr. Raj Panjabi.

Panjabi is a leading proponent of deploying community health workers as a way to provide care to individuals who live in areas without access to healthcare.

Though defined slightly differently across countries, community health workers are usually local persons other than doctors and nurses who receive some basic level of training such that they can identify, and sometimes offer basic testing and treatment to people suffering from illnesses.

Importantly, they can be trained to identify symptoms of infectious diseases like Ebola and can then expeditiously alert authorities.

“It’s the best emergency system that could reach all people,” said Panjabi, who was awarded the $1 million TED Prize for his efforts through Last Mile Health, his nonprofit which trains and manages community health workers in Liberia.

Panjabi believes that the key to overcoming the lack of trust in health care systems in Liberia during the last Ebola outbreak was to keep providers everyday health services operational, such as prenatal care and malaria treatments.

“Those are things that make or break an epidemic response,” he said, referring to trust among the population and effective front-line medical care even and especially in remote areas.

Dr. Rick Sacra pointed out that routine care can also help combat the spread of Ebola.

“You don’t know who has Ebola when they walk in the door with a little fever, and they say ‘No, I haven’t been exposed to anyone,’” said the Massachusetts-born, Liberian-based doctor, who is an Ebola survivor.

In addition to these complicated factors, basics like personal protection equipment, or PPE, for healthcare providers is also necessary. Panjabi related a story about a clinic he visited during the outbreak in Liberia where the staff had to recycle gloves by leaving them on the roof and waiting for rain to rinse them.

Whatever other complications exist on a societal, civil, or physiological level, not having and properly using the basics can prove to be disastrous.

“PPE is definitely a critical part of the approach to protecting health care workers,” said Dr. John Fankhauser, CEO of the Ventura (Calif.) County Medical Center. Fankhauser lived in Liberia from 2013-2018, where he ran ELWA Hospital.

Sacra recounted that in August and September of 2014, boxes of regular medical gloves were selling for $50 a box, due to shortages.

To bolster the response, the DRC Ministry of Health requested support from Direct Relief. In response, Direct Relief purchased and donated more than $100,000 worth of PPE and medicines, shipped in coordination with Jericho Road Community Health Center, which operates a health facility in Goma.

Other basic, but necessary, supplies such as IV fluids, needles, syringes, and catheters are also at-risk of being in short supply during outbreaks, said Sacra, who also pointed to support for local clinics as a critical step for building trust among the population.

“Half of the battle is psychological,” Sacra said.

For the other half of the battle, there is the vaccine and emergency declaration, which has historically brought influxes of funding. Other positive steps are four new treatments that are being tested and given out on a compassionate use basis, according to Fauci. Fankhauser added that clinics in the DRC have much more access to laboratory studies now and can also use the CUBE, a biosecure emergency care unit that allows healthcare providers to observe and offer some care to patients without donning PPE.

Given the vaccine, and the promise of these new therapeutics, Fauci expects the disease to stay relatively contained, if not easily defeated.

“I’m not so sure it’s going to get worse. It’ll smolder and take quite a while,” Fauci said.

“Just because they declared a global health emergency, it’s not going to make the disease magically go away,” he said.