Why Africa Still Has Ebola Outbreaks

Microscopic image of Ebola virus

Kennedy DuBose, Julia Duffy, Sania Farooq, Sucaad Mohamud, and Maggie Sanders

Bachelor’s Students in Public Health

Ebola virus disease (EVD) outbreaks have periodically occurred in affected regions of West and sub-Saharan Africa since the emergence of EVD in 1976. EVD remains endemic in these regions to this day, while it has been eradicated in other areas. Thus, it is important to identify and understand the systemic social and environmental issues surrounding EVD’s continuous resurgence, particularly in the African countries of Liberia, Sierra Leone, and Guinea. We aim to dive into the impact that a lack of resources can have on the occurrence of outbreaks, in addition to addressing violence that is often a result of poor leadership. By gaining an understanding of how these factors play into the spread of disease, we will be better fit to create lasting interventions.

Pathology of Ebola

EVD is spread through close contact and enters the body through the mucous membranes in the eyes, nose, and mouth, or through broken skin. Contact with the following items can result in EVD transmission:

  • Blood or bodily fluids, such as saliva, urine, sweat, vomit, breastmilk, and possibly semen from a man who has recovered from EVD
  • Infected non-human primates
  • Contaminated objects, such as clothes, medical equipment, and bedding1

The incubation period for EVD may last from 2 to 21 days.2 Transmission cannot occur until the infected person develops symptoms, and symptom onset is sudden. Infected individuals experience fever, fatigue, muscle pain, headache, and sore throat, followed by vomiting, diarrhea, rash, internal bleeding, and symptoms of kidney/liver impairment.2 EVD is diagnosed through laboratory diagnostic tests, and once the diagnosis of EVD is confirmed, public health officials are notified to initiate isolation and contact tracing.3

Lack of Resources

EVD has had devastating effects in impacted areas of sub-Saharan and West Africa, such as Liberia, Sierra Leone, and Guinea, due to the high case-fatality rate associated with EVD in these settings. In these regions, around 70% of EVD patients end up dying.4 However, of the nine cases of EVD in the US in 2014, only one patient died.4 Along with this drastic difference in case fatality, the US was able to contain the spread of the infection quickly, and hasn’t seen a case of EVD since, illustrating that the pace of spread and case fatality rates are interrelated. When there is a surplus of resources available to treat EVD, such as medical staff and technology, the case fatality rate decreases. This showcases the stark disparities in resources and outcomes between the US and these African countries.

The way to prevent death from EVD is via treatment of symptoms, and the US is highly equipped to do so. This requires tools such as IVs for rehydration, antibiotics, blood pressure medications, and dialysis in case of kidney failure.4 In normal times, major medical centers in the US are overstocked with such tools, and also have the resources for infection control necessary to prevent spread within the hospital. In many sub-Saharan and West African cities, on the other hand, supplies, equipment, and specialized training may be in short supply. For example, during the 2014 West Africa Ebola outbreak, some medical facilities stocked only one medication for blood pressure, which may not work on certain patients.

In terms of staffing shortages, the US has around 245.2 doctors per 100,000 citizens, while Liberia, Sierra Leone, and Guinea have only 1.4, 2.2, and 10 doctors per 100,000 citizens, respectively.4 Combined with the limited medical resources, this staffing shortage makes containment of EVD nearly impossible in sub-Saharan and Western Africa.


Prior to and during the 2014-2016 EVD outbreak, some areas hard-hit by Ebola were already dealing with civil conflict and political violence that had weakened their economies, public health infrastructures, road and transportation systems, and telecommunication.5 Sierra Leone, Guinea, and Liberia had recently experienced civil unrest that made it difficult to respond to the spread of the virus.5-6 Due to the years of conflict in these countries, distrust in the government was prominent, resulting in attacks on medical staff, impacting the transmission of the virus⁵⁻⁶. Distrust of the government and misperceptions patients had about the origins of the virus resulted in countless attacks on aid workers.

A common theme in outbreaks and epidemics worldwide is that when cultural beliefs and practices collide with control efforts, the results can be unpleasant and counterproductive.5 During the 2014 EVD epidemic in West Africa, violent resistance was most likely when communities were unfamiliar or disagreed with suggested preventive steps needed to reduce the spread of the virus, such as sanitizing homes and not performing ancestral funerals.5-7 Although aid workers, such as Doctors without Borders, traveled to these countries to combat the virus, the dangerous incidents they experienced and threats received from local militia were never-ending.

Our Call to Action

To combat systemic issues such as the lack of resources and violence that exacerbate EVD in Africa, we recommend that international organizations intervene to address the root causes of these problems. Although some resources have come into Liberia, Sierra Leone, and Guinea in the wake of the 2014 and 2017 outbreaks, there still remain large inequities that can only be mitigated with constant support and outreach.

We call on international agencies, such as the World Health Organization, to provide a continuous supply of resources such as medical equipment, transportation infrastructure, and culturally and contextually appropriate health education to Liberia, Sierra Leone, and Guinea. By doing so, transmission can be decreased by spreading awareness of practices that prevent communities from becoming infected, as well as the resources to do so.

Moreover, we call on political leaders from wealthy countries with strong public health infrastructures, such as Canada and England, to collaborate and communicate with African leaders on the best ways to mitigate violence and EVD, in order to strengthen the health of their communities.

With the help of international aid, the health inequities that African countries continue to face can be mitigated, and thus EVD transmission can be controlled.


  1. Transmission. Centers for Disease Control and Prevention, January 14, 2021.
  2. Ebola virus disease. World Health Organization, February 10, 2020.
  3. Diagnosis. Centers for Disease Control and Prevention, November 5, 2019.
  4. Belluz, Julia. "Why Is Ebola Less Deadly in America than in Africa?" Vox (October 28, 2014).
  5. Factors that Contributed to Undetected Spread of the Ebola Virus and Impeded Rapid Containment. World Health Organization, January 2015.
  6. Belluz, Julia, "Health Workers Trying to Fight Ebola Keep Getting Attacked." Vox (September 24, 2014).
  7. Sy and Copley. "Understanding the Economic Effects of the 2014 Ebola Outbreak in West Africa." Brookings (October 1, 2014).

About the Authors

Julia Duffy is a Senior in the School of Public Health Bachelor of Science program. She is hoping to pursue an MD and further public health research, particularly in environmental health. She enjoys the outdoors and hiking.

Maggie Sanders is a senior in the Public Health Sciences Program at the Undergraduate School of Public Health. Maggie is particularly interested in health disparities and underserved populations. She plans to continue her passion for health by pursuing an MD after graduation.

Sucaad Mohamud is a senior pursuing a Bachelor of Arts Public Health degree at the University of Michigan’s School of Public Health. Her areas of interest are health and language literacy, cultural competency, and global health.

Sania Farooq is a senior in the Public Health Sciences Program at the School of Public Health. Her passions involve integrating cultural humility into healthcare and uplifting the narratives of the underserved. She hopes to integrate her love for public health with an MD or MPH following graduation.