In the political economy of global health and illness, the Ebola crisis in West Africa exposes the failures of ‘quick fix’ and ‘magic bullet’ solutions in African Development. These failures have been most dramatic in the three worst affected countries – Guinea, Liberia, and Sierra Leone – where already weak infrastructures have collapsed.
Why, after a decade of producing preparedness propaganda, was the global health community so unprepared for an epidemic of this magnitude? To answer this question, we first need to situate Ebola in the recent history of public global health, including policy failures (Structural Adjustment Policies of the ’80s and ’90s, and the current Millennium Development Goals), along with the obsession with bio-preparedness that came out of the Bush administration. Out of this there has grown a whole discourse around global health failure, and when it comes to the uncontrollable spread of Ebola, the World Health Organisation (WHO) is currently the number one scapegoat. Looking toward the future in light of policy scrambling and setbacks, the focus is now firmly on reform and the strengthening of healthcare systems. But what about the most important actors in any public health policy fight – the survivors? How will they, and the wider communities to which they belong, navigate post-Ebola lives, and how will it impact their economic futures?
Historical context and the new era of ‘global health’
It has been argued that the West African Ebola crisis is the result of two decades of wrong-headed political choices and actions – especially the introduction of the Structural Adjustment Policies (SAPs) and global policy obsession with the idea of bio-preparedness – which are considered the main culprits in Africa’s enduring healthcare problems[i].
The story begins with the Berg report, published by the World Bank in 1981. This study highlighted the crippling effect the economic distress of the 1970s global debt crisis had on poor countries, which was evidence enough to blame excessive government spending on social programmes, including healthcare. The World Bank responded by aggressively advocating deep cuts in public spending on healthcare services and healthcare infrastructure in the Global South. To the World Bank, it didn’t really matter that hospitals, clinics and primary healthcare facilities were already understaffed and underfunded, nor did it matter that there was hardly any functioning equipment available in hospitals. Their only concern was to increase production in the most profitable export sectors, such as mining and agriculture, in order to strengthen the global economy (and therefore the capitalist paradigm).
The failure of the SAPs led to the establishment of the Millennium Development Goals (MDGs) in 2000, which initiated a strong mobilisation of Private-Public Partnerships (PPPs). The focus of the new public health policies was on vertical disease programmes in order to fight single diseases. These programmes emphasised the ‘big three’: Aids/HIV, Malaria and TB, with lesser attention paid to ‘other’ diseases including Neglected Tropical Diseases (NTDs). The focus on these vertical, short-term and life-saving interventions drew even more resources away from public healthcare systems as private NGOs and humanitarian organisations established parallel health care systems, which required local healthcare workers in order to operate. This led to a fragmentation of healthcare provision which in turn resulted in massive uncertainties for patients. Ulli Beisel calls this development “the spatial logic of global health programmes”[ii].
The failure of SAPs and MDGs is just one part of a bigger package of failed global public health ‘initiatives’. The bio-preparedness obsession during the Bush administration was another part of that package[iii]. Pandemic preparedness became the watchwords, with research funds devoted to ‘bioterrorism’ and ‘emerging diseases’. The implementation of preparedness programmes took up masses of funding and led to heavy political pressure on African governments, requiring by way of return an element of public pageantry. Almost invariably, each new programme was kicked off with simulation exercises: in large conference room’s ministers and WHO expert’s simulated military, police and public health interventions so far removed from the reality on the ground – where equipment, human resources and infrastructure were seriously lacking – that the whole process became absurd. Just as the SAPs drew away resources from extant public healthcare systems, these bio-preparedness exercises drained away the energies of African health authorities, which would have been far better utilised on urgent health emergencies present in their respective countries. In this new backward global health paradigm, real diseases took a back seat to the speculation on policy and bureaucracy.
However, not all blame can be laid at the feet of these flawed health policy programmes, particularly in the case of the Ebola crisis – African governments and bureaucratic leadership are known for rampant corruption with regard to foreign aid and interventions. On the other hand, it’s impossible to overlook the glaring connections between international development, African politics, and the legacy of colonialism. The exclusion of Africans in colonial administration, leading to a dearth of qualified bureaucrats in newly independent nations, created the highly competitive, nepotistic toxicity in modern African governance. Resulting systems of decentralised despotism within commodity-based economies have had a hugely negative impact on medical infrastructure in ‘priority’ African countries, which has made the heavy-handed efforts of the SAPs especially inappropriate in local contexts[iv].
Current discourse on the global public health failure
The current global public health crisis has three aspects: Humanitarianism, Biosecurity and Pharmaceutical capitalism[v]. Pharmaceutical capitalism sometimes enables the former two regimes to operate, as pharmaceutical companies might or might not invest in new drugs and trials. This is very much dependent upon whether a disease is deemed to be ‘profitable’ or not. Before this current crisis, Ebola was not profitable as it only sporadically came out of its ‘dormant’ state, and when flare-ups did occur, they were limited to the Global South, an area promising no returns for the capitalist-driven pharmaceutical companies. This very much resembles the ‘dormant’ state of the global public health community, of which the WHO is the symbolic figurehead. Global public health, according to Theresa MacPhail[vi], is much like a virus: it helps to eradicate and control and it cannot survive outside of a healthy ‘host’, that is the existence of effective local and national public health agencies.
Figure 1: taken from http://www.limn.it.
Like a virus, global health responses reconfigure themselves in response to each unique challenge. Such responses are always dependent upon the host environment: if the local public health systems are weak, the global response will be slow or ineffective. The WHO oversees global response efforts as it coordinates the response ‘networks’, which consist of different local, national and regional public health agencies. And this, according to MacPhail, was one of the major issues in reacting to the current Ebola crisis. Each of these different response networks have their own institutional culture: different protocols, routines and priorities. Despite being united under the umbrella of global public health, the operations on the ground remain distinct, removed from each other, and more often than not uncoordinated, leading to the patchy healthcare landscape which is so common in the Global South. Blaming the WHO for the slow response henceforth is counterproductive.
The WHO did not have the capacity nor the funding to deal with such a wide and fast spreading epidemic. It was not so much an organisational failure as it was a failure of administrative imagination. Ebola has undergone a conceptual mutation since its first discovery in 1976: from a fearsome emerging disease, requiring extensive research into pathogens and transmission, to a neglected disease which is manageable by localised humanitarian care, combined with straightforward public health techniques such as surveillance and contact tracing. A shift from one emergency to another. This was reflected in the initial response alert level (Grade 2 out of 3) given to Ebola by the WHO, as the confidence level in being able to control this disease was high. This confidence only vanished when the disease spread to Nigeria’s capital, Lagos, and when it threatened to spread to the US and other Western countries. It was also at this point that the WHO declared the Public Health Emergency of International Concern (PHEIC), some six months after the disease started to spread through West Africa. Ebola shifted again to a fearsome emerging disease which threatens the global biosecurity and economy.
Ebola also underwent a conceptual shift – from a biological to a techno-political meaning of the disease where the global public health understanding of the disease had to take other elements into consideration: the extent in which its virulence and transmissibility depended on the condition of the local public health infrastructure in which it appeared[vii]. With this in mind the focus of the global public health community shifted (back) to a healthcare strengthening paradigm.
Future Outlook: Healthcare strengthening approach
Healthcare System Strengthening (HSS) has been advocated for years by social scientists and health experts. Even prior to the Ebola crisis the global public health community started to pay attention towards HSS and ever more funding was directed towards this goal. However, most HSS initiatives still carry the legacy of the vertical interventions introduced with the MDGs (as explained above) and therefore are limited in their scope and reach. Another concern was raised by Alice Street[viii], who argued that the focus on systems might lead to abstractions, as they are imagined from afar where public health experts depict such systems in diagrams and numbers. It remains to be seen whether such an abstraction will take place in the upcoming European Donor conference at the beginning of March 2015 in Brussels, or whether the attending public health experts from Guinea, Liberia and Sierra Leone can keep the delegation’s feet on the ground and stick to the reality of the public healthcare situation in their countries. According to Margret Harris[ix], a spokesperson of the WHO, the healthcare systems in the three most effected countries have to be built almost anew, and importance should be laid upon consulting, engaging and empowering local communities. She points towards the necessary healthcare reforms within these countries and beyond: stronger surveillance systems, healthcare which will work even when international partners leave, and longer-term structural changes (which changes were not explicitly stated). Furthermore, to harness and build upon the newly established Ebola infrastructure is considered to be a priority in order to be able to re-launch newly established Ebola Community Units (ECUs) into community-based health facilities.
Community-based response (CBR) programmes, which the humanitarian organisation Medicines Sans Frontiers (MSF) recently initiated, might be a step into the right direction. CBR programmes are thought to help to slow down transmission by expanding the biomedical frontier from the centres of expertise to the uncertain realm of communities[x]. This has been done on two fronts: through the support of home based care and through ECUs. The former involves the distribution of kits (e.g. PPEs and disinfectants) to every households. It is hoped that over time this will result in expert care, as family members know how to prevent to become infected when caring for an Ebola patient. Survivors are already playing an important role as they are trained to distribute materials and to provide counselling support to the care givers. The latter intervention, ECUs, are providing basic medical care and are understood to be a triage point where suspected Ebola patients are tested, and if confirmed, being transferred to Ebola Treatment Units (ETUs). People are also tested for Malaria and other diseases. If tested negative for Ebola, but positive for Malaria, for example, they ideally are given medications. However, it has been reported that many vital medicines are scarce and that people with clear Ebola symptoms are sent away, which in turn causes indirect effects of Ebola (e.g. fatal malaria, pneumonia or TB cases)[xi]. ECUs are ideally supported by minimal trained volunteers, preferably survivors, and can only effectively be operated when run in a socially acceptable way. High quality of care – not so much in biomedical terms, but in socio-cultural terms – make ECUs social welcoming places. With this system it is hoped that social trust can be generated and people with Ebola symptoms are less afraid to come to the ECU.
Post-Ebola survival effects
Physical after-effects, also known as Post-Ebola Syndrome (PES), are amongst the most pressing problems Ebola survivors face[xii]. Symptoms include: Joint and Muscle Pain, Uveitis (which if untreated can lead to blindness), Deafness, Autoimmune Disorders, Extreme Fatigue Syndrome and Reproductive Health Disorders. To date little is known on what causes PES. Researchers suggest however that PES might be caused by the virus itself, by Ebola drugs, the heavy use of disinfectant and chlorine, or by stress. It is not clear how long symptoms will last or whether they will persist long-term. Furthermore, poor medical records might make it difficult to separate any new symptoms from existing conditions. Hardly any scientific literature has been published on the medical/psychological (long-term) effects of PES, nor on the Post-Ebola long-term social effects.
The sparse literature documenting the long-term social effects indicates that Ebola survivors experience stigmatisation and exclusion from their communities and families due to fear of Ebola transmission. Nothing to date, however, has been reported on the disabling symptoms of PES, such as blindness and deafness, and how they might impact upon the economic status of survivors, their families and the wider communities. In addition, no studies have investigated how reproductive health disorders related to PES (Impotence/Amenorrhea) might impact upon existing relationships, marriage potentials, and how this might lead to obsolesce in the survivor population. Ebola survivor clinics are gradually being established, but it remains to be seen how and by whom these clinics will be run once the epidemic has ceased and whether the healthcare strengthening reforms and the (hopefully) resulting newly established healthcare infrastructure will cater for the disabled Ebola survivors.
The Ebola crisis has certainly shone a spotlight on the shortcomings of past global public health interventions. With the newly acquired attention towards healthcare strengthening policies and reforms one can only hope that these new policies will not lead to yet another failed vertical intervention, leaving African healthcare infrastructure even more fragmented and weak. Instead the global public health community should take this crisis as an opportunity to help bring about real change, with the empowerment of existing local healthcare infrastructure as the main priority. This would not only equip African countries with better surveillance and preparedness capacities for future epidemics. The strengthening of the local healthcare infrastructure would also provide a platform from which the double burden of communicable and non-communicable diseases can be successfully tackled, and it might also guarantee universal healthcare coverage for all.
[i] See for example: Jones, J. (2011). Ebola, Emerging: The Limitations of Culturalist Discourses in Epidemiology. The Journal of Global Health. 1 (1): 2-5.
Nkwanga, W. (2015). The Ebola crisis in West Africa and the enduring legacy of the Structural Adjustment Policies. Africa at LSE. Available at: http://blogs.lse.ac.uk/africaatlse/2015/01/26/the-ebola-crisis-in-west-africa-and-the-enduring-legacy-of-the-structural-adjustment-policies/. Accessed on 09/02/2015.
[ii] Beisel, U. (2014). On gloves, rubber and the spatio-temporal logics of global health.Somatosphere. Available at: http://somatosphere.net/2014/10/rubber-gloves-global-health.html. Accessed on 16/01/2015.
[iii] Lachenal, G. (2014). Ebola 2014. Chronicle of a well-prepared disaster. Somatosphere. Available at: http://somatosphere.net/2014/10/chronicle-of-a-well-prepared-disaster.html. Accessed on 16/01/2015.
[iv] Jones, J. (2011). Ebola, Emerging: The Limitations of Culturalist Discourses in Epidemiology. The Journal of Global Health. 1 (1): 2-5.
[v] Lakoff, A. (2015). Two States of Emergency: Ebola 2014. Limn. Available at: http://limn.it/two-states-of-emergency-ebola-2014/. Accessed on 10/02/2015.
Nading, A. (2015). Ebola, Chimeras, and Unexpected Speculation. Limn. Available at: http://limn.it/ebola-chimeras-and-unexpected-speculation/. Accessed on 10/02/2015.
[vii] Lakoff, A. (2015). Two States of Emergency: Ebola 2014. Limn. Available at: http://limn.it/two-states-of-emergency-ebola-2014/. Accessed on 10/02/2015.
[viii] Street, A. (2014). Rethinking Infrastructures for Global Health: A View from West Africa and Papua New Guinea. Somatosphere. Available at: http://somatosphere.net/2014/12/rethinking-infrastructures.html. Accessed on 16/01/2015.
[xi] Leach, M., Martineau, F., and Oosterhoff, P. (2014). Increasing Early Presentation to ECU through Improving Care. Anthropology Ebola Response Platform Policy Brief. Available at: http://www.ebola-anthropology.net/key_messages/increasing-early-presentation-to-ecu-through-improving-care/. Accessed on 10/02/2015.
[xii] Lee-Kwan, S., DeLuca, N., Adams, M., Dalling, M. Drevlow, E., Gladys Gassama, G., Davies, T. (2014). Support Services for Survivors of Ebola Virus Disease — Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep 63 (50): 1205 – 1206.