At a village clinic in central Congo, separated from the world by a tangle of waterways and forests, six-year-old Angelika Lifafu grips her dress and screams as nurses in protective suits pick at one of hundreds of boils that trouble her delicate skin.
Her uncle, 12-year-old Lisungi Lifafu, sits at the foot of her bed, facing away from the sunlight that pours through the doorway and pains his swollen, weeping eyes. When nurses approach, he raises his chin, but cannot look up.
The children have monkeypox, a disease first detected in Congo 50 years ago, but cases of which have spiked in West and Central Africa since 2019. The illness received little attention until it spread worldwide this year, infecting 77,000 people.
Global health bodies have counted far fewer cases in Africa during the current outbreak than in Europe and the United States, which snapped up the limited number of vaccines this year when the illness arrived at their shores.
But the outbreak, and death toll, in Congo could be much greater than recorded in official statistics, Reuters reporting shows, in large part because testing in underequipped, rural areas is so limited and effective medicines are unavailable.
During a six-day trip to the remote region of Tshopo this month, Reuters reporters found about 20 monkeypox patients, including two who had died, whose cases were not recorded until reporters visited. None of them, including Angelika and Lisungi, had access to vaccines or anti-viral drugs.
The shortage of testing facilities and poor transport links makes tracing the virus nearly impossible, more than a dozen health workers said.
Asked about undercounting, the Africa Centres for Disease Control and Prevention (CDC) acknowledged that its data did not capture the full extent of the outbreak.
In the West, only about 10 people have died of monkeypox this year, figures from the US CDC show. Europe and the United States have been able to vaccinate at-risk communities. Suspected cases are routinely tested, isolated and treated early, which improves survival rates, experts said. Case numbers in Europe and the United States have stabilized and begun to fall.
But in poorer African countries where many people do not have quick access to health facilities, or are not aware of the dangers, over 130 have died, almost all in Congo, according to the Africa CDC.
No monkeypox vaccines are publicly available in Africa.
Without treatment, Angelika and Lisungi can only wait for the illness to run its course. Ahead of them lies a myriad of possible outcomes including recovery, blindness, or, as was the case with a family member in August, death.
"These children have a disease that makes them suffer so much," said Lisungi's father Litumbe Lifafu at the clinic in Yalolia, a village of scattered mud huts 1,200 kilometres (750 miles) from the capital Kinshasa.
"We demand the government provides medicines for us poor farmers, and the vaccine to fight this disease."
The World Health Organization last year called out the "moral failure" of the Covid-19 pandemic response, when African nations found themselves at the back of the queue for vaccines, tests and treatment.
But those failures are being repeated a year on with monkeypox, the health workers consulted by Reuters said. This risks future flare-ups of the disease in Africa and globally, experts said.
While the sudden demand from Western countries sucked up available vaccines, poor countries such as Congo, where the disease has existed long enough to be endemic, have been slow to seek supplies from the WHO and partners.
Congo health minister Jean-Jacques Mbungani told Reuters Congo was in talks with the WHO to buy vaccines, but no formal request had been made. A spokesperson for Gavi, the vaccine alliance, said it had not received requests from African countries where the virus was endemic.
A WHO spokeswoman said that in the absence of available vaccines, countries should instead focus on surveillance and contact tracing.
"History repeats itself," said Professor Dimie Ogoina, president of the independent Nigerian Infectious Diseases Society. Time and again, he said, disease containment in Africa does not get the funding it needs until wealthier nations are at risk.
"It happened with HIV, it happened with Ebola and with Covid-19, and it is happening again with monkeypox."
Without adequate resources, the true spread of the virus is unknowable, he and other experts said.
"In Africa we are working blind," said Ogoina. "The case counts are grossly underestimated."
Monkeypox is spread through close contact with skin lesions. For most, it resolves within weeks. Young children and the immune compromised are especially vulnerableto severe complications.
The Africa CDC says that Congo has had more than 4,000 suspected and confirmed cases and 154 deaths this year, based in part on health authority data. That is far lower than the 27,000-odd cases recorded in the United States and 7,000 in Spain. African nations with outbreaks include Ghana, where there are about 600 suspected and confirmed cases, and Nigeria, where there are nearly 2,000.
"Yes, there is an undercount," said Ahmed Ogwell Ouma, acting director of the Africa CDC. "The communities where the monkeypox is spreading generally don't have access to regular health facilities." He said the CDC could not currently say how big the undercount was.
Congo's health minister Mbungani said testing capabilities were lacking outside Kinshasa but did not respond to a request for comment about missed cases.
THE FRONT LINE
African countries hoped that the WHO's decision in July to declare monkeypox a public health emergency of international concern would mobilise resources.
WHO dispatched some 40,000 tests to Africa, including 1,500 to Congo, said Ambrose Talisuna, WHO's monkeypox incident manager on the continent.
This month, Congo's National Institute for Biomedical Research began a clinical trial of the antiviral drug tecovirimat on monkeypox patients. While no vaccines are available for public consumption, trials are underway on health workers in Congo with Bavarian Nordic's Imvanex vaccine, health minister Mbungani said.
But in central Congo, little has changed.
Yalolia, where Angelika and Lisungi are patients, is reachable only by motorbike tracks that thread tunnel-like through the dense jungle, or by canoes carved from felled tree trunks. An old road connecting to nearby villages was cut off years ago when a series of wooden bridges collapsed.
In August, Lisungi's older brother developed a rash and had trouble breathing. The family thought it was smallpox. When his condition worsened, a doctor put him on an intravenous drip. He died before it was empty.
Grief stricken, Lisungi hugged his brother's infected corpse. Two weeks later, in early September, he too developed a rash and his eyes swelled shut. Then Angelika fell ill.
Lisumbe took the children to Yalolia where they were diagnosed with monkeypox based on their symptoms. He sold his belongings to buy medicine to reduce their fevers.
The nurses caring for them seethe at the lack of treatments.
"If there is a vaccine, it is us who should have it. If there is a treatment, it is us who should have it," said nurse Marcel Osekasomba.
None of the cases were reported to authorities until Reuters visited Yalolia with a local health official called Theopiste Maloko. He only went to the village at Reuters' suggestion.
Without test results, they are now logged as suspected cases.
Tshopo, nearly as big as the United Kingdom, is heavily wooded and carved up by the Congo River and its many winding tributaries. Maloko's job is to track cases over an area spanning 5,000 square kilometres. But he cannot afford gasoline and has no means of transport.
When nurses took samples from sores on Angelika's leg and placed them in a polystyrene cool box strapped to the back of a motorbike, Maloko was sceptical.
To avoid spoiling, samples need to be kept cold and reach a laboratory within 48 hours, but they often do not, he said. The nearest testing lab is in Kinshasa; results take weeks or months.
"We are suffering. This is really our cry of alarm. We are raising our voices so that someone will hear," he said.
Sometimes samples are not even taken.
The village of Yalanga is a day's journey from Yalolia by land and boat. Surrounded by jungle, it has no phone network or electricity. When the light fades, patients at the health centre lie in the dark on beds of hard bamboo.
The clinic, a small building with a tin roof and five rooms, has had three cases in recent months. To notify authorities of a new case, nurses must travel half a day to get phone reception. When they are busy, getting away is impossible. The recent cases were recorded weeks late, said nurse Alingo Likaka Manasse.
Lituka Wenda Dety, a 41-year-old mother, thinks she got sick from eating infected bush meat. At the height of her illness in August, her throat was so sore she struggled to swallow her own saliva.
Round scars still dot Dety's body, and her bones ache. She is grieving. When she was ill in hospital, her six-month-old son caught monkeypox and died. He is buried in a patch of sandy earth beside her mud brick home.
At the end of the day, Dety and her family gather around the small rectangular grave. She whispers prayers.
"We want there to be a vaccination campaign," she said. "Going by what we have suffered, if many people catch this disease it will be catastrophic."