Practical activity 4

Jose Rodríguez Romera

University, Health and Society — March 20, 2019

1 Origins and development of Ebola

Ebola virus is one of the most severe causes of viral haemorrhagic fever with a death rate over 50%. The
virus was first discovered in 1976 in the Democratic Republic of Congo (DR Congo), after that, outbreaks
of Ebola virus disease (hereinafter Ebola) have occurred in countries all over Africa, for instance, in DR
Congo, Sudan and, most recently, Liberia, Sierra Leone and Guinea [1]. This virus may be endemic in bats
or wild monkeys and can be spread to humans and between humans. Contact with the animal reservoir
or direct contact with infected blood or secretions can spread de disease [1]. In spite of this, during the
outbreak of 2014 Ebola virus showed not to spread as quickly as other infectious diseases like Small pox
or Measles, in which an infected person can pass the disease onto ten times more people than Ebola virus,
the real problem about the Ebola is its deadliness. Even though other viral diseases, like flu, have greater
mortality in elderly people with other co-morbidities, in the case of Ebola, according to Prof Mabey “you
can be a perfectly fit 20 tear-old and be dead [from Ebola] within 10 days” [2].
The first Ebola death of the 2014 outbreak is thought to have occurred in December 2013 in Meliandou,
in south eastern Guinea, close to the border of Sierra Leone and Liberia. Small villages in the middle of the
rainforest like Meliandou are used to deal with diseases with early symptoms mimicking those of Ebola.
As a consequence, the first few deaths failed to set off any alarm. On the other hand, the poor controlled
border of Guinea was regularly crossed by the locals to Liberia and Sierra Leone in search of markets to
sell their products, which lead to the rapid spreading of the virus [3]. It was not until 14 March 2014
when the Ebola outbreak was first reported by the Guinea’s ministry of health as a “mysterious disease” in
the south-eastern regions of Guéckédou (the region of Meliandou), Macenta, Nzerekore and Kissidougou,
all of them in Guinea. The World Health Organization (WHO) alter confirmed the disease as Ebola. By
the end of March more cases of death from Ebola were reported in central Guinea and north Liberia,
afterwards the Ebola was confirmed in Sierra Leone in May [4].
The disease kept spreading rapidly throughout all western Africa reaching Nigeria in July, Senegal
in August and Mali in October 2014. Partially thanks to the international action (see next point) the
Ebola virus did not spread throughout countries outside western Africa, however, 26 cases of Ebola where
reported during the outbreak in Europe and America. The countries affected where USA, Spain, Germany,
France, UK, Switzerland, Netherlands, Norway and Italy. In all but three cases the patients were infected
with Ebola while in Western Africa. Infection outside Africa has been restricted to health workers in Madrid
and in Dallas (USA) [4].
There needs to be 42 days without any new cases for a country to be declared Ebola-free. The outbreak
was firstly controlled in the least affected countries like Senegal (transmissions halted in October 2014)
or Mali (January 2015) [4]. The three main affected Sierra Leone, Guinea and Liberia where declared
Ebola-free last, on 7 November 2015, 29 December 2015 and 16 January 2016 marking the end of the
Ebola outbreak in West Africa after 28,637 reported cases and 11,315 deaths [4], [5].

2 Local, national and international reaction, MSF and WHO

As stated before, the first reaction to the Ebola outbreak was the report of the Ministry of Health in Guinea
on 14 March 2014. First known as a “mysterious disease” with very high mortality, the description of the
report had all the obvious signs of Ebola, according to Dr Van Herp, Medecins Sans Frontieres (MSF)’s
senior viral haemorrhagic fever epidemiologist in Brussels, who studied the report [6].
The first international help came just 4 days after the report. Following suspicion of Ebola, three
MSD emergency teams were deployed to Guéckédou (Guinea) on 18 March. The first actions carried

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by MSF teams where caring for the sick in Guéckédou hospital, training local health staff on how to
protect themselves, raising awareness of the virus in the community, conducting safe burials, and running
ambulances [6].
Despite of the rapid action of MSF, Ebola virus was already widely spread throughout Guinea when
the help came. Jus days after the arrival of MSF new alerts of suspected cases came from the border with
Liberia and Guinea’s capital, Conakry, more than 650km away from Guéckédou. The virus kept spreading
the following weeks through Guinea finally reaching Liberia on 31 March. By this time, MSD publicly
declared the outbreak as “unprecedent” due to the geographic spread of the cases. Following the report of
new cases, MSF set up Ebola management centres in Guinea and Liberia whilst tracing alerts of possible
new cases. During this phase, the MSF teams had to face a very disperse outbreak which forced them to
strategically split its resources trying to gauge where they would be best placed to act fast. The last straw
came with the onset of a new outbreak in Sierra Leona which worsened the situation in Guinea and Liberia
[6]. With more than 60 actively transmitting points throughout Western Africa, the MSF raised the alarm
publicly (again) on 21 June declaring that the Ebola outbreak was out of control and asked (again) for an
urgent and stronger international response [7].
After this announcement, the WHO presented a three-phases plan in response to the Ebola outbreak
in August 2014. The first phase focused on scaling up the response by increasing the number of Ebola
treatment centres, hiring and training teams and strengthening social mobilization capacities [8]. During
this period the United Nations (UN) started the UN Mission for Ebola Emergency Response (UNMEER)
in September 2014, leaded by the WHO, to deploy financial, logistical and human resources to Guinea,
Liberia and Sierra Leone to meet immediate needs related to the fight against Ebola [9]. The first phase
ended in December 2014 and leaded to the second phase, focused on finding and tracing new cases to
ensure a better response. Finally, the third phase (August 2015 – midyear 2016), with the goal to interrupt
all remaining chains of Ebola transmission, leaded to the end of the outbreak [8].
Even though the WHO started and leaded an international response to Ebola, initial global efforts were
not enough to face the outbreak. One of the main hurdles to face the outbreak was the mistrust of the local
and international governments about the warnings of the MSF. On 10 May, Guinean media reported the
president of Guinea complaining that MSF was spreading panic in order to raise funds [6]. Even the WHO
response in to the warning in June was not enough. according to MSF “there was a clear lack of leadership
from the WHO: decisions on setting priorities, attributing roles and responsibilities, ensuring accountability
for the quality of activities, and mobilising the resources necessary were not taken on the necessary scale”.
There was not until August, when a US doctor after coming from Western Africa tested positive for Ebola,
that the international recognition of the severity of the outbreak finally hit home as the developed world
realised that Ebola could cross the Ocean, according to MSF [6].
In the local and national level, the response where variable with the course of the outbreak. As was
commented before, the first warning calls of MSF remained unanswered by the national governments,
in fact, this first mistrust by politicians constituted one of the reasons for the uncontrolled spreading of
Ebola [6]. Moreover, when the governments realised the dimensions of the problem the lack of experience
and resources proper of poor countries like Guinea, Liberia and Sierra Leona difficulted even more the
broaching of the problem [10]. However, that does not mean that the governments stood aside, once they
knew the disease, the governments started a series of policies devoted to the prevention of the spreading
of Ebola. For example, the government of Liberia banned any public celebration over Christmas and New
Year because of the Ebola Crisis [11]. On the other hand, the population on the villages were at first
distrustful of health workers, there was necessary an extra effort to explain the population the purpose of
the activities that the health workers performed.

3 Impact of Ebola inside and outside Western Africa

The outbreak of Ebola did not pass as a regular disease, after the outbreak the incalculable losses affected
families, rural areas, towns and even the economy and the healthcare system of the poor countries affected.
In Western Africa Society, Ebola was considered not only deadly but also socially insolating disease due
to its highly contagious capacity. For instance, there was a contempt to those who had survived to Ebola
as they where thought to be able to pass the virus [12]. On the other hand, some countries like Liberia
changed well stablished social behaviours in order to prevent the spread of the virus, such as the highly
affective greetings typical of Liberian people [13]. Moreover, Sierra Leone, Liberia and Guinea closed their
schools for safety reasons. This measure, along with the death of the family member in charge of bringing

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money at home put contributed to school abandoning in those countries [14]. In the rest of Western Africa,
like in Nigeria, borders where closed and hospitals with Ebola patients shut to avoid the contact with the
disease [15].
At the international level we have already discussed the measures adopted by the different organiza-
tions to combat Ebola outbreak. Since the majority of the impact of Ebola affected Western Africa and the
cases of the disease in the rest of the world was minimal and well controlled the social impact of Ebola
outside this African Region did not caused any major impact in occidental population. However, as far as
clinical research is concerned, Ebola outbreak leaded to an unprecedent use of relatively untested drug,
followed by a unique collaboration between scientists, public health organisations and drug companies
which resulted in trials for vaccines being set up as early as in a few months. This response calls into
question whether medicines for other diseases could be made more rapidly [16].
In conclusion, Ebola outbreak was a turning point in Western Africa countries, debilitating its economy,
population and infrastructures, but moreover it was a call for attention to the developed countries. As
admitted Margaret Chan, Director-General of the WHO “The world, including WHO, was too slow to see
what was unfolding before us” [17], this outbreak not only showed the lack of ability for the international
nations to respond to a local crisis but also demonstrated that the delay in the action was not due to a
unprepared infrastructure but a lack of willingness, as the international response came mainly after the
arrival of the disease into a developed country. Ebola showed the world that we are not as advance in
tackling health emergencies as we originally thought and gave us an opportunity to think whether the
universal right to health that UN defends is, in fact, universal.

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References
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0-323-29956-5.
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