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Monday mbalimbali: #MalawiFloods edition

19 January 2015

My new year’s resolution was to at least post weekly to haba na haba,* reviving the “mbalimbali”** posts — what others might call “miscellaneous” or “links I liked”.

This Monday’s edition focuses on the floods in Malawi, which began earlier this month and continue to wreak havoc, particularly in the southern part of the country.


* Clearly, as we are almost three weeks into the new year, I’m already failing at keeping this resolution.
** In Chichewa/Chinyanja, mbalimbali has a number of meanings/translations to English. In addition to meaning “around (the sides)“, it can also mean “various” (as could siyanasiyana).

Ebola is only the Kardashian of diseases if you think Africa is a country

27 August 2014

Kim Kardashian in 2008. Photo by Dan Raustadt shared w/CC license.

This post is co-authored with Stéphane Helleringer (@helleringer143).


Yesterday Chris Blattman wrote a post titled, “Ebola is the Kardashian of Diseases.” He had tweeted the same thing a day earlier, followed by “Do not get distracted. Malaria, TB, HIV is what matters.”

[Sidenote: For those who don’t know what a Kardashian is, it roughly translates to being famous for no substantive reason (see a helpful description in the third paragraph of this paper).]

While there’s a bit in Blattman’s post to agree with, we find rather misleading one particular point:

  • Meanwhile, malaria, TB and HIV/AIDS are already at pandemic proportions and I venture destroy more lives, more economies, and perhaps even more politics than Ebola.

As global health researchers, we are well aware of the top causes of death in African countries and the data are clear that across the continent, malaria, tuberculosis (TB), and AIDS will each claim more lives this year than will Ebola.

The World Health Organization (WHO) estimated there were 596,000 deaths from malaria and 230,000 deaths from TB in Africa in 2012 and UNAIDS estimated there were 1.1 million AIDS-related deaths in Africa in 2013.

As a comparison, the total number of Ebola deaths in the current outbreak in West Africa according to the most recent WHO update (8/22) is 1,427. A new, unrelated Ebola outbreak in the Democratic Republic of the Congo has left another two people dead. But even considering there will be more deaths from Ebola before year’s end, the total number of Ebola deaths on the African continent will come nowhere close to the numbers of the top killers.

But Africa is a continent – not a country. If a health problem is only prevalent and problematic in one country rather than in many of Africa’s 54 countries, does that make it as irrelevant as a Kardashian? Continent-wide metrics can mask dramatic impacts of disease outbreaks in countries or even sub-regions. If we consider Ebola in the context where it’s unfolding, it matters a great deal. By the end of 2014, it may matter even more in these countries than the other infectious diseases mentioned by Blattman.


Counting deaths is hard. There are virtually no real-time mortality data in these countries outside of the Ebola case count. What we know about mortality levels and causes in Guinea, Sierra Leone and Liberia comes either from censuses (conducted every 10 years) or from surveys conducted only every five years or so or from statistical models used by the United Nations and other organizations. So we used the 2012 estimates for the leading causes of death in Liberia published from the WHO to put the current Ebola-related mortality in perspective. It shows that, since 5/29, the daily number of Ebola deaths is comparable to the daily number of malaria deaths (approximately seven per day) prior to the outbreak. The daily number of Ebola deaths recorded by WHO has been increasing steadily: in August, it reached an average of 18 deaths per day. This is higher than daily averages for any other cause of death in the country. And it seems to continue climbing (see figure below).

Maybe a reader will be suspicious in reading too much into our daily death rate graph since these data may be capturing a temporary spike in the number of deaths. Over an entire year, the “big killers” that matter could still very well dwarf the total number of deaths due to Ebola. But the current Ebola outbreak is not going away without a fight. The international director of Doctors without Borders said recently that the situation is spiraling out of control in Liberia and Sierra Leone. The outbreak has had a slow and unimpressive response from governments in the affected countries and from the WHO. The heavily affected countries have incredible health care worker shortages and, as more health workers get infected, there will be even fewer to care for those who become sick with Ebola. Just today, the WHO announced it was temporarily pulling its health workers out of Kailahun in Sierra Leone after one of its staff members contracted Ebola under incredibly challenging working conditions.

So, how many deaths from Ebola can we expect by year’s end under these conditions? To try and answer this question, we did some simple arithmetic: at a rate of 18 deaths per day (i.e., the average number reported for August so far in Liberia), it will only be 10 days until Ebola has killed as many people as road-traffic accidents usually kill in the country in an entire year. It will be 20 days until Ebola reaches the yearly level of maternal deaths; 70 days until it reaches the number of deaths from HIV/AIDS deaths and 125 days (i.e., before the end of 2014) until it reaches the estimated annual number of malaria deaths in the country. And of course, these “projections” rest on the very optimistic assumption that the public health response will be able to maintain the number of deaths due to Ebola at 18 per day. In recent days however, the daily number of deaths seems to have been rising quite sharply over time. The number of Ebola deaths may thus catch up with other causes of death this year much sooner than we just calculated.


We have not calculated similar measures for Guinea or Sierra Leone – but given the wealth of publicly available data, we hope others will. Based on reported figures, the outbreak appears better controlled in those two countries and the number of Ebola deaths may not catch up with other causes of death like HIV/AIDS and malaria. It might also be instructive to consider the three countries together in a comparison of the impact of the major causes of death.

But one should still be cautious in sub-regional comparisons. These, too, can be misleading. For example, The Economist called Ebola a “small-scale killer” when comparing it to other infectious diseases in the four affected countries: Guinea, Liberia, Sierra Leone, and Nigeria (at the time of publication, there had not yet been news of the unrelated outbreak in the DRC).


The inclusion of Nigeria in The Economist’s figure, however, biases the assessment of the scale on which Ebola strikes, for two reasons. First, Nigeria has experienced only a very limited number of Ebola cases: 11 infections resulting from one recent “importation”, at the end of July (i.e., contact with an infected traveler, Patrick Sawyer, who flew to Nigeria from Liberia). Later, two infections resulting from contact with patients who came into contact with the index case (for a total of 14 confirmed Ebola cases) were also recorded. Second, Nigeria is also the most populous country in Africa; its population is more than eight times larger than that of populations of the other affected countries combined. As such, any estimates of deaths per day that includes Nigeria in a sub-regional analysis will be heavily influenced by the data from Nigeria.

Two additional points to keep in mind:

  • Despite the very exact counts for Ebola cases published with regularity by the WHO, these cases are very likely an undercount. The WHO even stated recently that their estimates of the number of Ebola deaths likely underestimate the scope of the outbreak. So if that is the case, Ebola may reach the level of other causes of death even faster than we calculated above.
  • This post is ONLY about deaths. Ebola has taken a much larger toll on these countries than through deaths alone. Think of the effects Ebola is having on the local economies in the most heavily affected countries. HIV/AIDS and malaria are serious diseases – but they haven’t stopped commercial airliners from flying to West Africa.

In sum, we know that the Ebola outbreak is unfolding in a context where there are indeed many pressing issues facing the ordinary folks who are themselves trying to navigate the outbreak. Though we appreciate considering the broader continental context, one might generate misleading characterizations of the impact and scale of Ebola when thinking of Africa as a single unit.

a list of who to follow on Ebola that’s more diverse than the one by Vox

8 August 2014

It was flattering to be included on‘s list, “24 Twitter accounts you should follow to understand the Ebola outbreak.” But I had a few problems with the list. Most of us included are white (I’m only half, but you get my drift). Limited diversity is not a new problem at Vox. Unlike earlier situations, however, in the space of informing the public about Ebola via social media, there are many diverse voices. Vox readers are missing out on a lot if they limit their scope to what these 24 mostly-White people have to say about Ebola.

One particularly remarkable omission from the Vox list is any African journalist. All the journalists/freelancers/correspondents are white (except Sanjay Gupta). I was genuinely surprised by this since one of the best things I’ve read about the current Ebola outbreak was penned by Umaru Fofana, a journalist in Sierra Leone who has been very active in posting Ebola updates to Twitter.

Below is my (alphabetically ordered) list of people who you could follow on Twitter that weren’t mentioned in the Vox list but should have been. I’ve also included one of the Tweep’s recent tweets about #Ebola. (Please, if you have recommendations, leave links or Twitter handles in the comments section and I’ll add to the list.)

Adia Benton, Medical Anthropologist at Brown University

Abena Dove, Historian of Medicine and Science at UC Berkeley

Bate Felix, Dakar-based West & Central Africa Correspondent for Reuters News

Umaru Fofana, Journalist writing for Reuters and BBC in Sierra Leone

Stephane Helleringer, Demographer at Columbia School of Public Health

Lamii Kpargoi

Viviane Mbombo in Conakry, Guinea

Cédric Moro, Independent Risk Consultant

Susan Shepler, Professor at American University School of International Service (and recently a Fulbright Scholar in Nigeria)

Abdul Tejan-Cole, Ex ACC Commissioner of Sierra Leone

Jeremy Youde, Professor and author of Global Health Governance

Part of the problem with Vox’s list is that it is limited to Twitter.

I suspect like in many African countries, Facebook is more popular than Twitter in Ebola-affected countries and so including Facebook pages expands the range of topics and issues than we would see on Twitter alone. For example, the Sierra Leone Ministry of Health and Sanitation does not have a Twitter feed, but they have been very consistent in disseminating information on their Facebook page.

Here are a few pages you could like/follow on Facebook, with a few of their recent Ebola posts (again, if you have suggestions for other resources on Facebook, please share in the comments):

FrontPage Africa, a Liberian newspaper

Sierra Leone Ministry of Health and Sanitation

Journalist Nathan Charles, posting from Liberia

Concerned Africans Against Ebola

some of my thoughts on Ebola, via the radio

7 August 2014

In two recent radio interviews, I spoke about my thoughts on the current Ebola outbreak and the response by governments and health organizations. The interviews were with local NPR stations in Columbus, Ohio and Minneapolis, Minnesota.

The great thing about both of these programs is that they’re hour-long shows and they take their time covering topics. There’s no rush for quick and easy answers and so no pressure for “soundbite” material. 

The first interview was yesterday on the show All Sides with Ann Fisher (WOSU). I’m in the final segment of the show with a Peace Corps Volunteer who was just recently evacuated from Sierra Leone (starting roughly 37 minutes in). 

The second interview was this morning on the show The Daily Circuit (MPR). I’m in the throes of writing a post now that goes deeper into the issue of providing experimental treatment in West Africa — what I talk about in the very end of the interview with The Daily Circuit (starting circa minute 33).

Mostly, this blog post is for my mom, who wonders what I do especially when there are no classes to teach. Mom: I’m writing a book. And doing some interviews on radio stations you don’t have in Nevada.

Is the $200 million World Bank pledge toward the $73 million WHO request in fighting Ebola enough?

6 August 2014

Ebola virus disease update from the World Health Organization published on August 4, 2014.

Last week, the World Health Organization (WHO), in partnership with the governments of Guinea, Liberia, and Sierra Leone, released an eleven-page document outlining the planned response to the Ebola outbreak, which is now spreading in four West African countries.

Clearly stated on the second page of the WHO document is a rather exact figure for the amount of external funding needed to support the response to the Ebola outbreak over the next six months: $71,053,413.

Shortly thereafter, the World Bank announced a pledge of $200 million dollars to the Ebola outbreak response — more than double the WHO’s request.

There are also reports that the African Development Bank will be providing somewhere between $50-$60 million in funding the response.

So problem solved, right? Maybe. Maybe not.

The WHO has not been very good at estimating the resources needed to combat Ebola. For example, the same WHO document reports how earlier in the current Ebola outbreak, the WHO issued funding appeals that totaled $4.8 million and the donor community provided $7 million in response to those appeals. All of that money has been exhausted and the epidemic has only gotten more out of control.

The current WHO estimate takes into account finances pledged by governments of affected countries. The total estimated resource needs are actually more than $71 million figure.

Budget breakdown from WHO outbreak response plan.

Budget breakdown from final page of WHO outbreak response plan.

Based on my own calculations from the budget breakdown pictured above, the WHO estimates $103 million is needed for the Ebola outbreak response. Governments in the three affected countries have pledged a total of $32 million toward response efforts (bringing the request for external resources to the $71 million mark).

If governments in affected countries fail to fulfill their pledged commitments, the World Bank and African Development Bank pledges (up to $260 million together) should still cover the estimated resource needs for the response to the Ebola outbreak as estimated by the WHO.

But it’s still hard to know exactly what these budget estimates cover. For example, there is some chance that experimental treatments for Ebola could improve outcomes for West Africans sick with Ebola. Are the costs of those treatments accounted for in the current budget estimates? I doubt it.

The current estimates also fail to account for needs of containing the spread in Nigeria, which only recently reported new cases of Ebola following the death of a man who had traveled there from Liberia. Today, a Nigerian nurse is reported to have died and a doctor is sick with Ebola; both treated the traveler from Liberia.

All of this is to say the resource needs are a moving target. Don’t everyone sit back and think the World Bank and the WHO have this covered.

Ebola patients are real people, deserving of more

31 July 2014

**** UPDATE 8/2/14 *****

Any alarmist comment made out of ignorance about how Ebola is spread — particularly negative comments toward the two Americans being evacuated back to the US — will be deleted. This is the first time I’ve had to take such an action on my blog, but I will not have it used as a platform for disseminating mis-information.


In writing two pieces on governmental response to Ebola, I’ve read a lot about the Ebola outbreak in West Africa. I’ve been particularly interested in firsthand accounts, including news stories sharing the perspectives of doctors treating patients, people who have recovered from Ebola, and, of course, journalists‘ interpretations of how people are responding to the epidemic. They’ve all been really interesting. Sometimes, though, the statements by doctors have gotten under my skin. Many of the characterizations of the people who are themselves navigating the deadly outbreak fail to appreciate the greater context and are downright ethnocentric (e.g., this).

Then, I read this, which has single-handedly restored my faith in international medical personnel treating those suffering from Ebola. Dr. William “Billy” Fischer II, a doctor from UNC-Chapel Hill, went to Gueckedou, Guinea — what is considered the epicenter of the current Ebola epidemic — in late May to work with Doctors without Borders/Médecins sans Frontiéres. UNC collected and edited his emails home to give people an idea of the situation. Billy’s emails are moving. Here are a few excerpts:

June 2, 2014


Today was a pretty tough day – one of the first two patients I admitted on May 30 died.  I walked into his room and he was on the floor half naked surrounded by bloody emesis and diarrhea.  I put him back in bed, bathed him, and put fresh clothes on him and as I finished he died.


It’s pretty emotional to bathe a 27-year- old man who was incredibly strong and rendered completely helpless. His sister is next door and will likely die in the next hour. This is all in front of the other patients in the room, many of whom are family members or neighbors. The despair is suffocating.


June 3, 2014

Unfortunately we also have an 18-year-old woman who is 5 months pregnant, has Ebola, and malaria. I thought being 18 was tough – I can only imagine being pregnant, infected with a near uniformly fatal virus, having malaria, and being in an isolation zone treated with people in space suits. The clinical course of pregnant woman with Ebola is not good, to say the least, and unfortunately she began having contractions overnight and we “helped” her deliver a non-viable fetus this morning. Miserable.


June 4, 2014

Part of what makes Ebola so devastating in addition to the manner in which people die, is that this virus wipes out families.  It penalizes those families who are close and transforms tradition into transmission.  The 18-year-old pregnant woman that I wrote about yesterday died.  After delivering she continued to hemorrhage despite oxytoxin and uterine massage.

When her husband was told about this he responded with, “ma vie est fini” (“my life is over”). Ebola has killed his mother, his mother-in-law, his wife and their unborn child.  I worry that when the fight leaves a person the body is quick to follow.  Similarly, when a woman died last week, her mother, who was also a patient and improving, soon followed. I’m not sure that there is anything worse than dying with despair after watching your child die.

Despite all this suffering there are moments of hope.  There is one older man, who, as soon as I walk in, starts doing calisthenics to demonstrate his clinical improvement.  I can’t help but smile and he has started doing them when he sits outside and we walk by – he is the first person I look for when I arrive at the isolation center.  Another younger man has started to do well and I anointed him team leader for his room.  He has embraced this role brilliantly by helping the other patients in this room encouraging them to drink and helping to translate Kissi into French for me.

And this is the one that broke me down into tears:

June 8, 2014

As the reality of my departure nears I can’t help but feel some sense of guilt—guilt for not having done more, faster, and better. But I think this feeling emanates from the fact that I can leave and the patients in this epidemic can’t. Last night we admitted a young boy who was transported with his mother from Kueldou. They had been locked in a house for four days because they were symptomatic. Unfortunately the delay in presentation was significant as only the boy was admitted because his mother died in transit. A 9-year-old boy sat next to his mother as she died. Now he sits in the isolation ward alone.

His father and brothers walked the 25km today to the isolation ward as the family’s village has rejected them and reported that the father may have symptoms. The MSF team sent a car to pick them up but the father refused to ride given what happened to his wife.

Fortunately, the 3 other siblings do not have symptoms but I’m concerned it’s only a matter of time as the father walked 25km with one of the children tied to his back exposing him to potentially infectious sweat. The estimated 21-day incubation period of Ebola complicates contact tracing given that people can theoretically be symptom free for 3 weeks following exposure. Since we can’t hold the family in the isolation ward for 3 weeks we can only test them now and formulate plans to follow them in case they do develop symptoms.

When the 9-year-old was brought into the treatment facility he barely had a palpable pulse. When I met him he was weak, in pain, but incredibly stoic and most awfully alone. With fluid resuscitation we were able to get a pressure and with that a chance. His clothes were soiled and so we brought a new outfit for him. After some effort I got him to smile and in that smile I found false hope.

With Ebola you can’t have a good death. You are isolated from your friends, your family, your home. You are cared for by people whose primary focus is on stopping transmission from infected to susceptible and from patient to provider rather than comfort and cure.

These people often die without the comfort of a human hand, without seeing someone’s full face or even just knowing that a loved one is near. I think of all the death notes that I’ve written in the United States and the bulk of them usually include the sentence, “they passed away peacefully with family at the bedside.”

I didn’t get a chance to write that for this little boy. Despite the hope that his smile brought me, he died overnight. In the void of darkness he converted to hemorrhagic shock with massive vomiting of blood and I’m told he bled out on the floor of the isolation ward.

I can’t help but think about what his last days were like – being locked in a house with his mother by his family and his community out of fear; then watching his mother die in the back of a pick up truck, being placed in an isolation zone staffed by foreigners in space suits, and finally vomiting blood alone.

I am troubled that I’m not better at this – that I haven’t figured out a way to implement more advanced healthcare infrastructure that would allow us to save more. When this epidemic is over I am sure there will be more time for reflection but now there are more patients and more chances to help.

There are real people suffering from Ebola. Fathers, children, pregnant women. They are scared and the majority of them will die. The resources to stop Ebola are stretched thin. If you read more of Billy’s emails, you’ll note how few medical personnel there are. In Liberia’s capital, they’ve run out of space in the hospital for people suffering from Ebola.

If you are moved, I urge you to make a donation to Doctors without Borders — they’re supplying equipment and medical staff to multiple regions affected by the outbreak. And, judging at least from Billy’s perspective, they’re doing good work.

why I think the fatality rate in the current Ebola epidemic suffers from undercounting

30 July 2014

Two days ago the World Health Organization (WHO) released its most recent update on the Ebola situation in West Africa. Here are the numbers.


One debate about Ebola numbers has been about journalists’ use of a particular statistic: the fatality rate from Ebola. In the worst epidemic ever, 90% of those reported infected died from Ebola (and this is the rate you’ll see cited in many of the news stories about Ebola). The chart of fatality rates since 1976 shows a range from 25-90% for any epidemic with more than one reported Ebola case. This helpful image of Ebola fatality rates created by Brett Keller excludes epidemics with fewer than 30 deaths:

Analysts debate whether using the 90% fatality rate is an effort to dramatize the disease outbreak. According to the WHO’s recent report, the fatality rate is at roughly 56% (divide 672/1201) for reported cases in the current epidemic. So some analysts are reporting this lower figure, citing it as more accurate. But Carl Bialik at FiveThirtyEight points out that the fatality rate in the current Ebola epidemic is just an estimate:

…there are several reasons to interpret the reported death toll as very preliminary; some reasons mean it might rise from here, while others mean it might fall.

He offers four reasons why the fatality rate is a moving target. In brief:

  1. The outbreak isn’t over — there are still many people who are sick and likely to die. Even with no new cases, as the disease runs its course in those already infected, the fatality rate will go up.
  2. False positives (meaning suspected or probable not yet confirmed cases of Ebola that will eventually be ruled as not Ebola) temporarily inflate the number of people infected, making the overall ratio of deaths to infected seem lower than it really is.
  3. Some people may never get tested for Ebola because they recover. Some Ebola symptoms are also symptoms of other diseases (e.g., malaria, flu, etc.) and so these people could self-diagnose as having something else. Those with more severe symptoms might be more likely to seek treatment.
  4. People who die from Ebola without diagnosis will eventually be counted in WHO statistics.

First, I haven’t heard of people suffering from Ebola that mend on their own. (Anyone have more info on this?)

But more importantly, I think it’s most likely that there will be an undercount of deaths and that the fatality rate will be an underreport. Bialik is confident from his conversation with a WHO spokesperson that eventually people who died from Ebola without seeking treatment will be counted. I am not so confident.

With some communities fearful and suspicious of clinics treating Ebola, it is no doubt there are Ebola cases going unreported. As these people die from Ebola (the fate for many of them), what incentive do their families have of alerting health authorities after-the-fact? How could health authorities posthumously test a suspected Ebola case — especially following burial?


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