“I was really shocked,” says Dr. Babou Rukengeza.

He’s talking about the footage he saw on social media of flames and charred bedframes at an Ebola treatment center in the eastern part of the Democratic Republic of Congo. Community members attacked the facility on Thursday, May 21. By the end of the weekend there were two other attacks on a different medical facility treating Ebola patients. Staff and suspected Ebola patients fled in the midst of the chaos.

Rukengeza found himself asking: “What will be our response?” And he had an answer: “We have to build trust.”

Rukengeza is the Ebola Response Health Lead for Save the Children in his native Democratic Republic of Congo, where he is based.

It’s been less than two weeks since the World Health Organization declared the Ebola outbreak a public health emergency of international concern. In that short time, mistrust between communities and health providers has been evident.

While Rukengeza was shocked by the attacks, he admits, he is not entirely surprised. This has happened during past Ebola outbreaks — and the tension is particularly evident around the death and burial of Ebola patients.

Attacks fueled by panic and rumors

Dr. Micaela Serafini — president of Doctors Without Borders Switzerland — has worked on Ebola response efforts since 2007. She remembers vividly when, in 2019, an Ebola treatment center in the DRC that her organization ran was attacked.

“They believed that everyone that came in [to the clinic] was killed,” she says.

Since the death rate of Ebola patients was “extremely high,” people imagined that aid workers were murdering them.

She says this type of panic, fear and misinformation fuel the tension that emerges in the wake of a growing outbreak.

Today, rumors circulating on social media in the DRC include false claims that Ebola is not real, that humanitarian workers are descending on the area solely for their own profit and that aid groups are withholding the best care available.

“They believe that medicines and vaccines exist, but we don’t want to give them,” says Dr. Jean Kaseya, the director general of the Africa Centers for Disease Control and Prevention, who is currently visiting the DRC to help with the Ebola response. Although, he adds, his sense is that it is a minority of the community that believes the false information.

Serafini does not want a repeat of what happened in the past. Now, she’s adamant that taking the time to build trust must be a priority. If aid groups don’t take that time, she says, “then it will backfire.”

There are a variety of strategies for addressing the breakdown in trust, including embedding in the community over the long-term, hiring local staff and engaging community leaders.

Kaseya says some leaders will be given motorbikes so they can more easily travel across the community dispelling rumors and educating them about this virus. There are also efforts to get accurate information out on WhatsApp groups, in churches and on community radio stations, he says.

But it’s not just learning about the virus. Death is often a flash point for communal anger.

Focus on death and burials

Although the DRC has roughly 450 tribes and lots of different death customs, Rukengeza says, it is, generally, “very important culturally to take the body and to honor this relative.” The funerals often last multiple days and rituals can involve washing the body and sitting with or sleeping beside the corpse.

During an Ebola outbreak, this is risky behavior.

When someone dies of Ebola, their body continues to be highly contagious for seven or so days, with the virus spreading through bodily fluids.

Burial practices have to be carefully adapted to make sure the virus doesn’t spread further. This doesn’t always happen. The World Health Organization estimates that in the West Africa outbreak a decade ago, funeral practices may have contributed to 80% of cases in Sierra Leone and 60% of cases in Guinea.

In one of the attacks in this outbreak, the community members who stormed the clinic had clear demands: They wanted the body of their loved one back for a traditional burial, even though the medical staff had told them this was too risky.

Safe burial practices often involve having a designated team — clad in protective medical equipment such as gowns and masks — burying patients in sealed bags while mourners observe from a distance.

Local authorities near the epicenter of the outbreak have capped the size of funerals to 50 people in the hopes of limiting the spread of the virus. And as tension has flared, some burials have required armed guards to ensure the gatherings don’t turn violent with frustrated family members trying to access the bod

Shifting burial practices

Serafini says one innovation from earlier outbreaks has improved the experience for families who can’t touch the body: bodybags with windows.

She recalls how her teams used to put the body of a deceased Ebola patient “inside a black bag, and we were zipping it. The family couldn’t even recognize the body.” But when her team redesigned the bags to “have a transparent area in which the face of that loved one can be seen,” she says, it really helped — especially when the family knew what to expect.

That’s one reason why now, at clinics run by Doctors Without Borders, she says, the family of a suspected Ebola patient is incorporated into the communications with the health team the moment the sick person comes in – including protocols around death. “There’s a briefing to the family on what could happen during that stage, including how we’re going to treat that body the moment that life is not there anymore,” says Serafini.

Max Lieblich, the emergency program manager for Catholic Relief Services in northeastern DRC, says having religious leaders on board with safe burial practices — and present at a wake or funeral — can ease some of the tension.

He says his team is in preliminary conversations to train religious leaders on these protocols. “What we found in the past is that having a local religious leader on that team — particularly in this context, where people are really religious — can be really helpful,” he says.

Rukengeza says he’s seen that families can change customs once they understand the science. He recalls when families of the deceased “came to the mortuary, and we tried to explain to them how to proceed [and] they agreed.”

He says, “wow, we need to bring those successes to other tribes.”