22 July 2026 Articles

Community trust should be earned, not assumed

As health actors rush to curb the ongoing outbreak of the Bundibugyo virus in the Democratic Republic of the Congo (DRC), one question risks to remain unanswered: What have we done to earn the trust we assume we will receive from the local communities?

What 'resistance' really means

Over the past few weeks, media outlets have extensively reported on the ongoing Bundibugyo virus outbreak in the DRC: the rising number of cases and deaths, the spread of the disease, and the clinical and research interventions to fight this rare variant of the Ebola virus. But amid this coverage, a quiet but telling signal emerges: health centres have been set on fire, some residents are fleeing rather than engaging with the outbreak response, and some communities are reportedly refusing public health interventions and treatment.

Prof Laurens Liesenborghs and Prof Raffaella Ravinetto

For Prof Laurens Liesenborghs, Professor of Clinical Emerging Infectious Diseases at ITM, who has been in Bunia since the start of the outbreak, this comes as no surprise. When a community "resists" an outbreak response, that "resistance" is rarely irrational. "It's a clear sign that the community was engaged too late. The media calls it 'resistance' or 'refusal to participate', but that framing gets it wrong," he explains. "It places the problem with the community, when in fact the community holds the key to a successful response".

Prof Raffaella Ravinetto, Professor of Pharmaceutical Public Health and Department Head of Public Health at ITM, shares that view. "This is especially important in the current Bundibugyo outbreak, because it's unfolding in a context debilitated by poverty, neglect and conflict, where trust in the health system is already fragile. Research institutions and donors should genuinely engage with the communities to gain their trust," she says.

There cannot be trust when, despite lessons from previous outbreaks, little is being done to build it.

The roots of distrust

Distrust does not come from nothing. According to Laurens, outbreak response has long prioritised containing the disease over caring for the individual patient. Layered on top of that are rumours that, however implausible on the surface, are rarely baseless. The context of the outbreak response can also fuel distrust: a dangerous disease that carries a lot of stigma, treatment centres that resemble prisons, health workers sealed into full protective suits, and patients isolated from their families at the exact moment they need them most.

Few consequences of that isolation are more painful than its impact on burials. In many affected communities, death is not seen as an ending but as a transition, which makes burial rites, sometimes lasting several days, one of the most spiritually significant events a family will experience. Response teams typically follow 'safe and dignified burial' protocols, designed to let families take part where it's medically safe. But even with those adaptations, families are left with a burial that falls far short of what their customs require: they can't wash or touch the body, can't hold the rites they normally would, and are often left wondering what happens to their loved one's remains afterward.

Meanwhile, outside the spotlight of the outbreak, the structural gaps that shape all of this distrust remain unresolved. "For example, people still lack access to many essential medicines and vaccines: Ebola is not the only cause of preventable death for them," Raffaella points out. "It's a fragility that existed before the outbreak and will continue after it has ended."

Maya Ronse (third from right), Alexandre Delamou (fourth from left) and a few members of the Ebola-Tx team at the national transfusion centre in Conakry, Guinea (2014)

Building trust from day one

None of this is new. As Raffaella says, this is largely a matter of applying lessons the sector has already learned, outbreak after outbreak. But there are solutions, and they start with doing things differently.

The first important factor is time: engaging communities from the very start of a response, not after "resistance" has already set in. Laurens points to a stark before-and-after in Ituri province itself. A site where treatment tents were once burned after the medical response bypassed the local population, now hosts a treatment centre built by, for, and with that same community.

Just as important is identifying the right people to engage. Traditional and religious leaders remain an important entry point because, as Laurens says, they "have the ear of the population". Maya Ronse, a researcher at ITM's Unit of Socio-Ecological Health Research, found during the Ebola-Tx survivor plasma donation study in Guinea (West African Ebola outbreak, 2014-2016) that different groups place their trust in different people. Reaching young people or women, for example, often means identifying the individuals those groups already look to, rather than assuming a single group of community leaders represents everyone.

Survivors themselves can become some of the response's strongest allies. In the Ebola-Tx study in Guinea, trained survivors acted as peer educators, informing and motivating others to take part in the trial, not simply as messengers, but as people who understood, firsthand, what they were asking others to go through. Laurens sees the same potential in Ituri: survivors returning to their communities are credible advocates, and getting them on board early as equal partners pays off. Yet this approach comes with a challenge: Ebola's stigma, combined with the lack of trust between communities and health actors, can make survivors reluctant to speak publicly, a tension already seen in Guinea and likely to resurface in Ituri.

Building trust itself also requires time and resources. It means visiting people in their homes, listening without an agenda, and staying flexible. Maya found that home visits, which are rare in these settings, were consistently appreciated, and may have carried something close to a therapeutic effect for the people receiving them. Yet these are often the first activities to be scaled back when outbreak responses, and related resources, come under pressure.

Finally, Raffaella argues that community engagement and anthropological research into what communities actually expect from an outbreak response should be funded from the outset, not added once problems arise. Accountability, she argues, should not rest solely with communities expected to trust the response. Donors, health systems and research institutions should be held to a higher standard and asked whether they have done enough to earn that trust.

Trust, in other words, isn't a communication problem to be solved once "resistance" shows up. It has to be built into a response from the very first day. "The community isn't the problem," Laurens says. "It's the solution."

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Ronse, M., Marí Sáez, A., Gryseels, C., Bannister-Tyrrell, M., Delamou, A., Guillard, A., Briki, M., Bigey, F., Haba, N., van Griensven, J., & Peeters Grietens, K. (2018). What motivates Ebola survivors to donate plasma during an emergency clinical trial? The case of Ebola-Tx in Guinea. PLOS Neglected Tropical Diseases, 12(10), Article e0006885. https://doi.org/10.1371/journal.pntd.0006885

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How do you build trust?

1. Engage early, before 'resistance' sets in

Start community engagement from day one, not after distrust has already taken hold.

2. Reach the right people, not just the obvious ones

Traditional leaders matter, but specifically identify which people to engage, rather than assuming one leader speaks for everyone.

3. Bring survivors in as equal partners

Their firsthand credibility makes them powerful peer educators, but stigma can make them reluctant to step forward, so this needs active, early support.