Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study

PLoS One. 2019 Sep 26;14(9):e0223104. doi: 10.1371/journal.pone.0223104. eCollection 2019.


Background: The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams.

Methods: We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires.

Results: Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort ("herd medicine"), suspicion of mercenary motives, and violation of cultural burial mores ("makeshift plastic morgue"). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance.

Conclusions: We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aggression*
  • Cooperative Behavior
  • Democratic Republic of the Congo / epidemiology
  • Disease Outbreaks / prevention & control*
  • Ebolavirus / pathogenicity
  • Female
  • Focus Groups
  • Hemorrhagic Fever, Ebola / epidemiology
  • Hemorrhagic Fever, Ebola / transmission*
  • Humans
  • Male
  • Middle Aged
  • Surveys and Questionnaires / statistics & numerical data
  • Trust
  • Young Adult

Grant support

This study was supported by Association for Health Innovation in Africa (AFHIA, Grant Number 2018-03 [KMC]). This work was also supported by the Women and Children’s Health Research Institute and is a Distinguished Researcher, Stollery Science Lab to MH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.