Why Africa Gets So Many Outbreaks

On 20 July 2014 a Liberian-American man called Patrick Sawyer collapsed at the airport in Lagos and was taken to First Consultant Hospital. He said it was malaria. He had a conference to get to in Calabar and he wanted discharging.

The consultant physician who saw him was Dr Ameyo Stella Adadevoh, who had been at that hospital for twenty-one years. She did not believe the malaria. She had him tested, put him behind a barricade she had built herself, and refused to let him leave. The Liberian ambassador rang and asked for his discharge. She said no, for the greater public good, and kept saying it. The hospital did not have proper protective equipment.

Sawyer died. On 4 August, Adadevoh tested positive for Ebola. She died on 19 August.

Nigeria recorded 20 cases and 8 deaths, and on 20 October, three months after Sawyer landed, the World Health Organization declared the country free of the virus. A WHO representative called it a spectacular success story. Lagos is one of the largest cities on Earth, and Ebola got into it and did not get out. There is a film about her, 93 Days, if you want the version with the music.

Hold that in mind, because the question this piece is about gets asked with a shrug, and the shrug is wrong. Africa does get more outbreaks than anywhere else. It is not because the people there are careless, or dirty, or bad at public health.

The number is real

Between 2001 and 2022 the WHO African Region logged 2,234 public health events, of which 1,886 were substantiated. That is about a hundred a year, every year, for two decades. Ninety-two percent of them were infectious disease. The region reports the heaviest burden of public health emergencies of any WHO region, and it is not close.

So the question is a fair one to ask. The usual answers to it are not.

Africa is not a country

Fifty-four of them, actually, and the outbreaks are not spread evenly across any of it. Of 566 zoonotic outbreaks in that period, spread across 43 of the 47 member states, twenty-one countries accounted for eighty percent. Uganda and the Democratic Republic of the Congo alone were around 8.7 and 8.5 percent.

That distribution is the first clue. If this were about culture or competence you would expect it smeared fairly evenly across a continent of 1.5 billion people. Instead it clusters in particular forests, particular river basins, particular bands of rainfall, and it clusters in the same places decade after decade.

Most of it is decided by latitude

Around thirty percent of those events were zoonoses, meaning diseases that live in animals and occasionally cross into people. Ebola and the other viral haemorrhagic fevers make up nearly seventy percent of that group. The rest is dengue, anthrax, plague, mpox. Ranked by frequency the leaders are yellow fever at 20.8 percent, dengue at 10.8, Lassa fever at 10.4 and Crimean-Congo haemorrhagic fever at 9.7.

Every one of those has an animal reservoir. Fruit bats, rodents, ticks, mosquitoes, primates. Tropical regions hold far more mammal and insect species than temperate ones, which means more reservoirs, more vectors and more chances for something to make the jump. Central Africa has the wet forest that fruit bats like, and fruit bats are the probable natural reservoir of Ebola. West Africa has Mastomys, the multimammate rat that carries Lassa, and it does not live out in the bush being avoidable. It lives in and around houses, in the food stores, all year round.

The clearest case is a belt of wind

If you want the argument in its purest form, look at meningitis.

There is a band across the continent, running roughly from Senegal to Ethiopia, covering eighteen or more countries and about 300 million people, where bacterial meningitis behaves unlike anywhere else on Earth. Big epidemics arrive every five to twelve years. They come in the dry season, December to June, and fade when the humidity returns. The belt was mapped by rainfall: it sits almost exactly where mean annual rain falls between 300 and 1,100 millimetres.

What drives it is dust and dryness. The Harmattan blows off the Sahara, the air dries out, the lining of people's noses and throats gets damaged, and a bacterium many people carry harmlessly gets its opening.

Nobody living in Niger or northern Nigeria did anything to deserve that, and nobody can behave their way out of a wind.

Then the roads got better

Here is the part that is genuinely uncomfortable, because it involves progress.

WHO found that zoonotic outbreaks in Africa rose 63 percent in the decade to 2022, compared with the ten years before. Part of that is a growing population needing more animal protein, and cities expanding into habitat that used to be wildlife's. But the regional director, Dr Matshidiso Moeti, named something else: transport. Poor infrastructure used to act as a natural barrier. A virus that emerged in a remote village burned through that village and stopped, because there was no good way out.

Now there are roads, rail, boats and flights. A pathogen that emerges on a Monday can be in a capital city by Wednesday.

That is what development looks like from a virus's point of view. No government could reasonably choose worse roads to keep its outbreak numbers down, and none should be asked to.

Some of the rise is that somebody is finally looking

There is an honest caveat that belongs here, and it cuts against the alarm in the numbers.

An outbreak only exists on paper if someone detects it, tests for it, and reports it. Africa CDC started work in 2017, laboratory networks have expanded, and genomic sequencing that barely existed on the continent fifteen years ago is now routine in a number of countries. Some of the increase in recorded outbreaks is an increase in recorded outbreaks.

This produces a result anyone working in public health will recognise. A country that invests in surveillance starts finding things, its outbreak count climbs, and on paper it looks worse than a neighbour with no laboratory. The reward for building the capacity to see is a worse set of statistics.

The outbreaks that do most of the killing

There is also a mismatch between what gets counted as an emergency and what actually empties a village.

Ebola is terrifying and it is rare. The West African epidemic, the worst there has ever been, killed 11,323 people in Guinea, Liberia and Sierra Leone between December 2013 and June 2016.

Malaria killed an estimated 610,000 people in 2024. About 95 percent of them were in the African Region, and roughly three quarters of those were children under five. That works out at roughly 1,600 deaths a day in Africa alone, which means malaria gets through the entire West African Ebola toll about every week, and has done every week for decades, without anyone calling a press conference. Cholera arrives with the rains in places where the water and sanitation were never finished. Measles returns wherever a vaccination round gets missed, and a missed round is usually a funding gap rather than a refusal.

These are the ones that do the work of dying, and they almost never make the news anywhere else, because they are not novel and they do not threaten to get on a plane. A great deal of the suffering here is quiet, chronic and entirely treatable with things that already exist.

The part that is about money

Then there is the gap that turns an outbreak into an emergency.

The African Region carries roughly a quarter of the global burden of disease with about three percent of the world's health workers and under one percent of global health financing. A needs-based study puts the shortfall at 6.1 million health workers by 2030, and that is after assuming numbers grow by 40 percent between now and then.

It is not for want of saying so. In 2001, African Union states signed the Abuja Declaration, pledging at least fifteen percent of their national budgets to health. When WHO checked in 2010, one country had reached it. Twenty-six had increased spending without getting there, eleven had cut it. Health budgets in many of these countries compete directly with debt service, and debt service does not negotiate.

So a nurse in a district hospital is doing the same job as a nurse anywhere, with a fraction of the staff, the drugs and the beds, against a pathogen list that is longer and stranger than most countries will ever face. Then the outbreak arrives and the world asks why it was not contained faster.

Who actually contains these

Mostly, the people who live there.

Nigeria stopped Ebola in three months with contact tracing and a hospital consultant who would not be talked into signing a discharge form. Uganda has contained repeated Ebola outbreaks, often before most of the world noticed one had started. Senegal, Ghana and Rwanda ran COVID responses that were studied elsewhere rather than pitied.

The story that gets told is the one with the foreign hazmat suits arriving, and those teams did real work. But the routine, unglamorous business of stopping outbreaks in Africa is done overwhelmingly by African health workers, on budgets that would be considered unserious anywhere else, and it usually works.

Adadevoh had no protective equipment worth the name. She had a barricade she put up herself, a diagnosis she trusted, and an ambassador on the phone telling her she was making a mistake. She held the line and it cost her everything, and a city of millions never found out how close it came.

Sources

• Wikipedia, "Ameyo Stella Adadevoh" (her 21 years at First Consultant Hospital, the refusal to discharge Patrick Sawyer, the ambassador's call, the lack of protective equipment, her positive test on 4 August and death on 19 August 2014).
• Wikipedia, "Ebola virus epidemic in Nigeria" (Sawyer's 20 July arrival, the 20 cases and 8 deaths, and the WHO declaration of 20 October 2014 with the "spectacular success story" line).
• Ouma et al, "Trends in public health emergencies in the WHO African Region" (2,234 events logged from 2001 to 2022 with 1,886 substantiated, about 102 a year, 92 percent infectious, 566 zoonotic outbreaks across 43 states, the 21 countries accounting for 80 percent, and the disease rankings).
• WHO Regional Office for Africa, "Africa: 63% jump in diseases spread from animals to people seen in last decade" (the 63 percent rise, the share of events that were zoonotic, the dominance of viral haemorrhagic fevers, and Dr Moeti on transport infrastructure having acted as a natural barrier).
• Wikipedia, "Meningitis belt" (the Senegal to Ethiopia span, the 300 million people, the 300 to 1,100 millimetre rainfall band, the five to twelve year epidemic cycle and the December to June dry season).
• Ahmat et al, "Projected health workforce requirements and shortage in the WHO Africa Region, 2022-2030" (the projected 6.1 million shortfall by 2030 even after 40 percent growth).
• WHO Regional Office for Africa, "Health workforce" (the region's share of global disease burden against its share of the world's health workers and health financing).
• Wikipedia, "Abuja Declaration (2001)" (the 15 percent pledge and WHO's 2010 assessment of how many states had met it).
• Wikipedia, "Zoonosis" (animal reservoirs and the mechanics of spillover).
• Wikipedia, "Western African Ebola virus epidemic" (28,646 cases and 11,323 deaths across Guinea, Liberia and Sierra Leone from December 2013 to June 2016, the largest outbreak of the disease on record).
• WHO, "Malaria" (an estimated 610,000 deaths in 2024, about 95 percent of them in the African Region, and roughly three quarters of those children under five).
• WHO, "Ebola virus disease" (fruit bats as the probable natural reservoir and the history of outbreaks since 1976).