Retrospective on Ebola: Mitigation Blog

To the UN Executive Board and Advisory Committee: My student Blog Retrospective on Ebola

Sheila Bitts

American Public University System

July 16, 2017

Mitigation Blog

The West African Ebola Outbreak of 2013-2015: What Should Have Been Done?

The Protection of the United States and Other WHO Member States

At an August 8th, 2014 press conference in Geneva, Keiji Fukuda, the World Health Organization (WHO)’s assistant director general for health security and environment, located the Ebola “hotspot” as centered in Guinea, Liberia, and Sierra Leone where the borders meet as reported by Hawkes (2014).  Chan, the WHO director general, convened a two-day meeting held by the WHO emergency committee teleconference where the group proclaimed the outbreak as “a public health risk to other states” although no travel ban was implemented as per Hawkes (2014) who added that Chan did however call for those exiting the countries involved to be monitored for 21 days, as the incubation period ranges greatly from 2 to 21 days.

United States Quarantine Policy

Lee (2016) explains, that in the US, the Public Health Accreditation Board (PHAB) only approves of health departments that have a public health ethics board to discuss and deliberate the intervention among stakeholders.  The Center for Disease Control and Prevention (CDC, 2003) in the United States, orders that the communicable diseases which require isolation and quarantine are authorized through a Presidential executive order to control: “cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers,” and lastly, “severe acute respiratory syndrome (SARS),” which was added in April 2003.

The Zaire Ebola Virus as the Cause of the Epidemic

The Ebola Virus Zaire strain, which first appeared in the 1970s, was the “causative agent” of the outbreak which had about a 60% mortality rate, historically, but had a wider area of infection according to Hawkes (2014), who explained that Fukuda discouraged “large gatherings of people” at the hotspot area.  Chan conceded that techniques for containing Ebola’s spread were known, but that it was difficult to implement them in practice, because the areas involved had recently been fighting civil wars, and Hawkes (2014) further explained that Chan welcomed the help of  The World Bank and Médecins Sans Frontières, but knew the African weak medical infrastructure would be overwhelmed, therefore compelling Chan to convince the hotspot areas to shift into “urgent mode” and provide security for health workers as well, but this was to no avail.

The Epidemic Spreads

Initially, the WHO made their declaration in August 2014, when only Guinea, Liberia, Sierra Leone, and Nigeria had roughly 1779 cases with 961 deaths, as per Hawkes (2014), but by Mid-September 2014, the outbreak had spread to five countries in West Africa (Senegal), with approximately 4507 confirmed cases of Ebola, with 2296 deaths according to Team (2014).

Non-Compliance with Quarantine

Non-compliance with many of the African public health restrictions was pervasive.  In a recent publication in Social Science & Medicine, Blair, Morse & Tsai (2017) surveyed Liberian respondents who replied to the questionnaires expressing more distrust in the Liberian government if they had hardships.  Valeri, Patterson-Lomba, Gurmu, Ablorh, Bobb, Townes & Harling (2016) reported that the White regions reported no Ebola cases during the whole study period.

More Educated, The More Money to Bribe?

At the end of the study, Valeri et al (2016) were eventually led to the conclusion that education level did not mean more compliance during the outbreak according to their study on the sociological data from the whole region involved in the Ebola Virus Disease African epidemic of 2013-2015.  In fact, Valeri et al (2016) found that the “more educated areas of Guinea, Liberia and Sierra Leone had more severe Ebola outbreaks as measured by speed of epidemic growth and final epidemic size.”  The fastest growth rates of Ebola affected three capital cities: Conakry, Guinea; Monrovia, Liberia; and Freetown, Sierra Leone according to Valeri et al (2016), which are the same ones with the highest average education levels.  According to Pellecchia, Crestani, Decroo, Van den Bergh & Al-Kourdi (2015), it was common for people to bribe the burial teams for a burial in a private cemetery and to have funeral services at the funeral homes, defying the Liberian government’s cremation order interpretation of Fukuda’s WHO orders to show precaution regarding funerary practices.  In Social Science & Medicine, Blair’s (2017) Liberian questionnaire respondents who expressed non-compliance most likely did not trust the Liberian government even if the WHO was the initial messenger.

WHO Had Asked for Ethical Guidance

Knowing that this situation would have complicated dynamics from the beginning, according to Hawkes (2014), Marie-Paule Kieny, the WHO assistant director general, is quoted as saying in 2014, “We are in an unusual situation in this outbreak.  We have a disease with a high fatality rate without any proven treatment or vaccine.  We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”  Public health Ethicist Lee (2016) asks us to consider what we should do.  For example, Pellecchia et al (2015) explains that there was not only inconsistency in food distribution for those in the Liberian quarantine, but also stigma and hostility between the citizens and the government since the local leaders were not invited to the decision-making forums and no spiritual leaders were consulted, although they were essential for the affected communities.  Knowing that burial and cremation values conflict, citizens affected needed representation to safely and legally resolve the conflict without resorting to military violence. Otherwise, with such distrust due to health inequities, the public beneficence is not present nor authentic for the community involved; the WHO should have intervened to negotiate for inclusiveness for there to have been justice. The result could have saved more lives.


Tags: Public Health Ethics, Ebola, West Africa, Mitigation, Preparedness, Response, World Health organization (WHO), Center for Disease Control and Prevention (CDC), Community Engagement, Quarantine

Sheila Bitts is a graduate student in Public Health at American Public University System, a poet, novelist, and an APUS 3MT Finalist for 2017.

Ebola Vaccine Progress WHO Update:


Supporting Citation Links/References

Blair, R. A., Morse, B. S., & Tsai, L. L. (2017, January). Public Health and Public Trust: Survey Evidence from The Ebola Virus Disease Epidemic in Liberia. Social Science & Medicine172. (pp. 89-97).

CDC. (2003. April 4). Executive Order 13295: Revised List of Quarantinable Communicable Diseases: Former President George Bush.

Hawkes, N. (2014, August 9). Ebola Outbreak Is a Public Health Emergency of International Concern, WHO Warns. BMJ. 349: g5089.

Lee, L.M. (2016, October 19). Ethics and Decision Making in Public Health October 2016. bioethicsgov

Pellecchia, U., Crestani, R., Decroo, T., Van den Bergh, R., & Al-Kourdi, Y. (2015). Social Consequences of Ebola Containment Measures in Liberia. PloS one10(12). e0143036.

Team, W. E. R. (2014, October 16). Ebola Virus Disease in West Africa—The First 9 Months of The Epidemic and Forward Projections. N Engl J Med2014(371). (pp. 1481-1495).

Valeri, L., Patterson-Lomba, O., Gurmu, Y., Ablorh, A., Bobb, J., Townes, F. W., & Harling, G. (2016, October 12). Predicting Subnational Ebola Virus Disease Epidemic Dynamics from Sociodemographic Indicators. PLoS One. 11(10). doi: supporting citation link:




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