African Risks

This post was supposed to be about Malaria, but some people think nobody should travel to West Africa right now.  Travel in the developing world does have risks, but often they are not the ones in the media.

The Ebola outbreak in Guinea, Sierra Leone, and Liberia is tragic.  Several years ago, I visited a hospital in that region, and my heart cries out for the poor patients.  There is no real public health infrastructure, and the countries are some of the poorest in the world.  The disease will run a horrible course and is likely to be endemic in the future.

Travel there right now is not only risky, but also risks adding to the burden of the overworked healthcare workers.  These doctors and nurses are heroes who are paying a high price for their devotion.  Unless you are a trained healthcare professional, why visit and be a distraction?

But Africa is far larger than whatever disease/war/famine is making headlines in the cable news shows.  Africa has a billion people in 54(-ish) countries covering over 11 million square miles.  West Africa alone includes seventeen countries, only four of which are affected by the current Ebola outbreak.

Accurately gauging risk is key to successfully visiting friends.  So let’s play a little game!  Match the relative risk in Africa’s most populous nation with the cause…  Match a number from column one with a cause from column two.  Then scroll down for answers.

Match the risk to the cause…
Number Dead in Africa’s

Most Populous Nation

2 ? Cholera
9 ? Ebola
~100 ? Facebook
~5,000 ? Malaria
11,640 ? Traffic Accidents
627,000 (continent-wide) ? Violence

Each of these is a risk to be considered before travel.  A visitor should have mitigation plans for each of them.  That doesn’t make travel risk free, but it does minimize the risk and/or the results.

Here’s the answers…

Number Dead Cause How close… Other Important Info Source
2 Facebook Same State In the last couple of days, Facebook rumors spread that drinking large amounts of saltwater prevents Ebola. [1]
9 Ebola 1000km away Nine is actually the total number of suspected cases in Africa’s most populous nation, not deaths, but since Ebola kills > 60% of its victims, we’ll err on the side of caution. [2]
~100 Cholera Same State Small outbreaks are common in rainy season. [3]
~5,000 Traffic Accidents Same Country Banning motorcycles in towns for security reasons has had the side-effect of reducing traffic fatalities. [4]
11,640 Violence Same Region This number doesn’t include many taken into custody and never seen again. [5]
627,000 Malaria Same Continent Millions sickened; mostly children killed. [6]

Rumors spread on Facebook that drinking large amounts of saltwater prevents Ebola.  You can guess the results.  As many people have died from this in town as have died in the entire country from Ebola.  The mitigation strategy for this risk is easy: just don’t have a Facebook account.  Or have some common sense.

Ebola has, sadly, made it to this country, but only a few isolated cases have been reported.  This risk is judged low because the nearest cases are 1000km away.  This risk illustrates a good risk planning strategy, though.  One issue in risk management is the “frog in the pot” syndrome.  It’s hard to cancel a trip because of one more victim a thousand kilometers away.  Well, then, what about two… or three?  Where to draw the line?  To prevent being sucked in, create a bright line, which will cause a major reassessment.  In this case, if a confirmed Ebola case appears in the capital city, which is only 250km away, travel plans will be reevaluated.

It is rainy season and Cholera is raging in the poorer areas (ok, that could be better phrased, “all but the wealthy parts”) of town.  Firm numbers aren’t available, but about a hundred people – mostly children – have died of it.  Many times that are sick from the disease.  To avoid it, practice good hygiene, drink bottled or filtered water, and avoid green salads which might have unbleached veggies.  Not hard if you can afford clean water, but difficult if you are poor and have contaminated water supplies.  The Doxycycline taken for Malaria (see below) is also effective against Cholera.

We’re done with the “easy” ones.  Now we get to the risks that we should, in fact, really worry about.

Official figures show that about 5,000 people die of traffic accidents every year in this country.  The real figure is vastly higher.  Deadly accidents are common and almost everyone knows someone who has been killed in an accident.  Most of these wrecks involve motorcycles.  Riding a motorcycle is probably the most dangerous thing a person can do in Africa.  So the mitigation is clear: nobody on my team is allowed to ride a motorcycle.  This doesn’t prevent the risk entirely, but does significantly reduce it.

Violence is the other big risk.  It has spiraled out of control in this state and region.  Last year, twice as many people were killed in traffic accidents as violence, but in the first seven months of this year, 11,640 civilians have been killed.  Once again, this number is almost certainly far too low.  Staying in a safe compound and not going into the villages reduces the risk.  Walking back and forth to work is out.  Most importantly, trust and listen to local hosts and drivers.  They know “normal”, and are far more in-tune to the local situation.

The last major risk is Malaria.  It is the real killer in Africa.  Millions get it and every year 627,000 – mostly children – die of it.  There are a variety of malaria prophylaxis, or preventative medicines; all are “mostly effective” and “mostly harmless”.  Each has different side-effects, ranging from sensitivity to sunlight, to psychotic episodes, to your heart suddenly stopping beating… Choosing a prophylaxis is dependent on both the specific geography and your specific health, and should be made by a medical doctor specializing in tropical medicine.  Doxycycline is a popular choice in West Africa.  Sometimes risk mitigation is choosing the lesser of the evils…

Every trip is a risk.  The key is to minimize the chances of an occurrence and/or the impact if it does happen.  This requires a realistic evaluation of the likelihood of each risk.  Sometimes, the good you are going to do is outweighed by the possibility of becoming a burden on those you’re going to help.  My wife is a Field Coordinator for a country where Ebola is raging, and has made the wise choice not to travel there in the near future; she is a translator and program development specialist, not a healthcare professional.  She would be just one more responsibility to our friends there right now.

Going to a region minimally impacted by the disease is a different matter, though.  My hosts have invited me to come, to help build their capacity to carry on independent work.  The work that I will be doing is not something they can do themselves, but that they will be able to assume greater responsibility for once I have trained them.  I have specific goals which can be accomplished without major exposure.  I have experience in the country and a driver that I have seen in tight situations before and trust completely.


[1] This Day Live, 2 Die, 20 Hospitalized From Excess Salt Consumption , 9 August, 2014.

[2] World Health Organization, 6 August 2014 Ebola Update.  Actually this is total suspected cases in Africa’s most populous nation, not dead or even confirmed, but given the death rate > 60%, we’ll give the benefit of the doubt to the dark side.

[3] Global Rescue GRID Event Details, 6 August, 2014.

[4] Daily Trust, 5000 Lives Lost to Road Accidents Annually , 4 July, 2013.  This number is almost certainly far under the actual total.

[5] Nigeria Watch, Public Violence Deaths , 9 August, 2014.  This number, for Jan – July, 2014, is almost certainly far under the actual total, but is the most accurate number by a reputable source.

[6] World Health Organization, Malaria Factsheet, 14 March 2014.  This figure is for 2012.