Professor Thandika Mkandawire is a development economist with a sharp mind and an even sharper tongue – one of Africa’s finest. Last week I moderated a discussion on health and governance in Africa at a conference in Cape Town in which he gave the keynote address. He demonstrated why he is such a celebrated public intellectual. In front of an audience of over one thousand scientists, doctors and health systems researchers, Mkandawire paraphrased Georges Clemenceau’s famous quip that war is too important to be left to generals, by suggesting that ‘health is too important to leave to health practitioners.’
In the midst of an Ebola outbreak, and at a conference taking place in Africa, the words – which were intended to be light-hearted – stung. In part I suspect that this was because they rang true.
While health professionals are crucial frontline responders, the Ebola crisis is indeed too important to be left to medical personnel. Like most responses to humanitarian disasters that are mounted by the international community, the Ebola response is focused too narrowly on the technical aspects of containing a problem, and too little on the underlying social and political reasons why the problem has been allowed to fester in the first place.
Liberia has been especially interesting in this regard. Ebola has certainly foregrounded the reality of Liberia’s non-existent health system but the failure of Ellen Johnson Sirleaf’s government to contain Ebola is emblematic of much larger problems of governance, leadership and trust. The virus has emerged from the nexus of these overlapping problems.
The Ebola crisis in Liberia has also shone a spotlight on the faults of the international development system that has propped up Sirleaf’s political leadership. In many ways, one could argue that Ebola serves as a cautionary tale about the dangers of ignoring cronyism in countries where a government that is friendly to Western governments is in place. Liberia is one of the most dependent countries on Earth: 73% of its gross national income comes from aid agencies and Monrovia, its capital city, is crawling with aid agencies. There are literally hundreds of international NGOs with offices in the city, and in addition to the 800 million the country receives in foreign assistance each year, the UN spends an additional $500 million annually on maintaining a peacekeeping force.
So one might have expected that the easiest place to contain Ebola would have been Liberia. There are already 7500 UN troops on the ground who would be able to mount the kind of logistical effort necessary to reach homes and communities with chlorine bleach, to transport the sick and to ensure stability should panic spark violence. The reality has been the opposite. From day one, the handling of the Ebola outbreak has been a study in the dysfunction of the aid system. The aid community has created a mentality that the country cannot act on its own. Instead Liberia’s leaders have chosen to wait for the slow moving bureaucracies that have occupied it for a decade to wake from the inertia of the well-fed aid system. They have convened press conference and made pledges, but there is no plan in place for a comprehensive response.
Efforts thus far have been so externally driven that even the identification of the virus itself took place in France. MSF staff who first picked up on the outbreak early this year had to fly blood samples to a lab in Lyons because there is not a single institute for tropical health and medicine on the African continent. This bears repeating: despite the existence of tropical medicine institutes on the continent, the blood samples were sent to Lyons for checking.
The Liberian Ebola situation can be summed up thusly: a virus that is deadly but can be effectively contained with good planning and logistics has managed to escape from a country that has one of the largest concentrations of ‘helpers’ in the world.
It is no wonder then that those requiring the help – the ordinary people of Liberia – have largely refused to take the advice that is being given to them. The questions about whether or not Ebola is real began to emerge in April when the media picked up on the story of a group of Monrovians who had attacked a clinic. The looters had insisted “there is no Ebola here.” So little did they trust their own government that they thought that Ebola was invented by Ellen Johnson Sirleaf and others as a ploy to get more development aid. They were saying, in no uncertain terms, that the hand that feeds them is also the hand that pinches them.
There can be no more damning an indictment on the aid industry than the fact that these deeply held suspicions exist.
In the Democratic Republic of Congo, numerous outbreaks of both Ebola and the Marburg virus have been stopped in their tracks in the past few years. In part this is because health workers in the DRC know what to do when they suspect Ebola, which is to act quickly and tell everyone. They have also learned not to leave people behind when they suspect they might be infected. Health worker’s trips to Ebola-affected communities factor in extra days to convince those who might be ill to come back with them. This is fairly common knowledge in the public health community, and therefore cannot be unknown to Liberia’s leaders.
The American troops who finally arrived after Liberia’s leaders berated them for taking so long to respond are struggling to acclimate to the heat; their US-made tractors are failing in the terrain and their estimates for how long it will take to build the first centre are projected further and further into the future. For some reason in the minds of the leaders of those countries most affected by the current Ebola outbreak, Kinshasa is further away from Monrovia and Conakry and Freetown than Washington.
The World Health Organization has also come under fire from Liberia for taking too long to declare Ebola as an emergency. In doing so, they are pointing the finger outwards, but they are also suggesting that their country has no autonomy and can do nothing on its own. This is not true of course, but to a nation whose leaders are so well trained in the politics of dependency, it is difficult to think outside this paradigm.
For all of their recent economic progress, too many African countries are in a similar position to Liberia. Like Johnson Sirleaf and her ministers, many of Africa’s leaders have been unable to imagine a future without Western aid. For its part, the West too has been unable to re-imagine African countries as the complex geo-political entities that they are. Neither side is able to recognize that African countries have valuable indigenous experience and can move quickly and relatively cheaply in the face of disasters if they leverage one another’s expertise. Most importantly, African self-help comes without the overhead and the strings that have come to define Western aid.
The failure to recognize this is understandable. Africa is ground zero for the devastation wrought by decades of bad development advice and poor planning. Ebola is simply a mask; the ugly face of a global aid system that is broken. And so the outbreak – in the context of a country that is all helped out – provides a heart-breaking reminder of how little Africans trust the Western governments on whom they rely during disasters.
We may need them, but we are loath to trust that they have our best interests at heart.