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People who have contracted Ebola are opting to die at home rather than seek treatment as conspiracy theories fuel distrust of the government and of health workers grappling with the crisis in the Democratic Republic of Congo, according to the workers and aid groups.
Nearly 20 new cases of the deadly illness are being identified daily in two northeast provinces of the country. Both areas are opposition strongholds where political tensions run high.
In addition to combating a lethal virus, health workers are having to dispel rumors that the disease is manufactured and that the millions of dollars spent on the response are part of a money-making scheme derisively referred to as the “Ebola business.”
"We have lost the trust of the community," Tariq Riebl of the nonprofit International Rescue Committee told NBC News from Goma.
A study conducted in September, less than two months into the outbreak, found that 25 percent of people surveyed in the affected areas did not believe Ebola was real, while 36 percent thought it was fabricated to destabilize the region.
“It’s all about money, that we’re getting bonuses for cases we find, that prolonging the response helps the business side,” Riebl said, listing some of the lies that have been spreading among local communities.
Anifa Vahavi is a demographic researcher working in Butembo, which is one of the worst-affected areas.
She has encountered skepticism about Ebola's existence and origins, and questions about why aid workers take extra precautions when treating it compared to malaria or cholera.
Ebola treatment centers established by the central government in conjunction with international aid groups have been met with suspicion. Designed to isolate and treat suspected cases of Ebola and staffed by health workers wearing bulky “space suits,” the centers come with an increased presence of police and military forces.
Some people in Butembo even believe that "when you go there they inject you with the disease," according to Vahavi, 30, who collects data for a Congolese nonprofit.
The Ebola outbreak is also taking place in a part of the country that has suffered regular violence at the hands of armed groups. Health workers have increasingly come under threat, causing further setbacks to the emergency response.
On Friday, the World Health Organization said an Ebola doctor was killed in an attack on Butembo University Hospital.
Hours later attackers armed with machetes tried to burn down another treatment center, the city's deputy mayor said Saturday.
Two centers run by Doctors Without Borders, along with the Ministry of Health, were attacked three days apart in February, forcing health workers to suspend operations.
Speaking after the second attack, Doctors Without Borders President Joanne Liu described the “great hostility” against the Ebola response, adding “the use of security forces and police only deepens the suspicion of those who believe Ebola is being used as a political tool.”
Deeply entrenched opposition to the government in the areas affected by the epidemic means that even the arrival of foreign aid is treated with apprehension.
"The government is seen as profoundly untrustworthy," said Phil Clark, a political scientist at SOAS University of London.
He described the timing and location of the outbreak as an "unfortunate coincidence."
Ebola was confirmed by the World Health Organization on Aug. 1, months before the country was set to head to the polls. Former President Joseph Kabila, who intended to step down after two terms in office, announced in December that he would postpone voting in the Ebola-hit communities to prevent the spread of the disease.
That has triggered rumors that the government was behind the outbreak — either infecting opposition communities with the virus or exaggerating its spread — to allow Kabila's choice of a successor to win at the polls, Clark said.
Health Minister Oly Ilunga Kalenga recently returned from a visit to the affected area of Butembo and told NBC News that "community mistrust" had even been fueled by candidates running for office.
"When the outbreak started in August, it was during the electoral period, so unfortunately some local politicians deliberately spread lies to boost popularity ahead of elections," he said.
He’s more optimistic now that the elections have taken place, saying that a vaccination campaign — which reached more than 100,000 people in the Ebola-effected region — has been effective.
"Things are improving,” he added.
Aid agencies have also taken unprecedented steps to try to assuage local doubts about the Ebola response, including changing how they conduct burials of the dead.
Eva Erlach, who heads the regional community engagement program for the International Federation of the Red Cross and Red Crescent Societies, said the organization has procured transparent body bags for the first time “to show the family that it is actually their loved one that is being buried and it’s not stones or empty coffins.”
The decision was not random, but based on reams of data that IFRC volunteers have collected during home visits with local communities to better understand their concerns. Some 800 volunteers working across eastern Congo have collected over 150,000 comments so far, which are put into a database to share with other organizations on the ground.
“Our role is really to make sure that in anything we’re doing, we are in dialogue with the communities and there is an understanding of what our role is and what is being implemented,” Erlach said.
Riebl, with the International Rescue Committee, said the situation still couldn't be compared to the 2014 outbreak in West Africa that killed more than 11,000 people in six countries in the region, with cases also popping up overseas.
But he still has his concerns. “Ultimately, if you don't connect with communities it doesn’t matter how efficient the treatment system is," Reibl said.