On 18 September, the UN Security Council, in its first ever emergency meeting on a public health crisis, declared that “the ‘unprecedented extent’ of the Ebola outbreak in Africa constituted a threat to international peace and security”. NGOs have been sounding the alarm for some time. Médecins Sans Frontières’s international President Joanne Liu, said that “six months into the worst Ebola epidemic in history, the world is losing the battle to contain it.” The World Health Organization warns that things are going to get worse before they get better.
We are talking about a very complex situation in which preventive and curative responses need to be implemented quickly and simultaneously, but where the policies, capacities, resources and political factors that need to be coordinated to stop thousands more people dying or falling seriously ill are mainly absent.
The scale of this crisis and the potential destructiveness are massive. Apart from human suffering, the World Bank has warned that if the virus continues to surge in the three worst-affected countries, Guinea’s economic growth could be reduced by 2 percentage points in 2015, Sierra Leone’s by 8 percentage points and Liberia’s by 11 percentage points. But complex situations where multiple stresses act at the same time are not that uncommon, particularly in countries with a history of conflict and weak institutions. In theory there should be a lot of international experience in dealing with situations of fragility and crisis of different natures.
The issues in the current crisis are resources, capacity and trust.
Let’s start with resources. The UN has asked for $1 billion to combat Ebola. Over $50 billion in Official Development Assistance (ODA) is spent each year in the 51 so-called “conflict affected and fragile states” according to the OECD’s 2014 Fragile States Report, 2014). Some low-income fragile states, including Liberia and Sierra Leone, are among the most aid-dependent countries in the world. Maybe the ODA provided was not effective, or not enough, or not allocated to building the capacities needed to face such an epidemic. Both more and different funding is needed.
There is plenty of experience out there is setting up Multi-Partner Trust Funds to respond to particularly challenging situations. Such funds have been established in most recent crisis affected situations, from Afghanistan, to Iraq, to South Sudan. Sometimes they were slow to be set up and did not work well, in others they provided the resources needed by key actors in country to focus on their priorities. This option could, perhaps be considered for the region.
There is also a need to tap into private money and expertise, and encourage the private sector to follow the example of the Gates Foundation, that has pledged $50 million to the fight against Ebola. In some contexts, private sector operators provided basic services to the population, given the lack of state capacities or willingness (e.g. Somalia). The policy response can rest with the specialised agencies and the government of the concerned countries, but can private sector actors be brought in with funds and expertise, not only to research a vaccine, but also to help manage the response on the ground?
On the capacity issue, not only doctors and nurses who are needed, but also people who can boost the government and local civil society organisations’ capacities to manage the crisis, but also keep everything else going. A sort of a “capacity surge” to prevent weak institutions collapsing and the gains achieved in other sectors to disappear as the Ebola epidemic takes centre stage and sucks up all the resources and capacities. Maybe this could be done quickly with the help of the African Development Bank, the World Bank and the UN?
What about the governments and people in West Africa themselves? The current response, focused on the emergency health response and fundraising, has to factor in the need for a much-missing commodity: trust. Sierra Leone, Liberia and Guinea are grappling with a history of violence, mistrust of government and of others, and extreme poverty. Although things were looking up before the disease struck, these factors go a long way to explaining why the perfectly reasonable health and security messages being spread are being actively being ignored by the population. To the outside world it is baffling that they would ignore calls to check in for treatment; throw stones at doctors and burial boys; destroy treatment centres. The World Bank emphasises the urgency of combating “aversion behaviour” – a fear factor resulting from peoples’ concerns about contagion, which is fuelling the economic impact. But these countries’ history has also produced fear and mistrust of the government and authorities.
In Liberia, the West Point slum in Monrovia (also the opposition’s stronghold) was reportedly quarantined without prior consultation. It led to widespread rioting. The slum’s 50,000 to 120,000 dwellers had to suddenly pay more for increasingly scarce water, food and basic necessities. The effectiveness of the quarantine is disputable given that it took only four dollars to bribe one’s way out. Working with Paramount Chiefs, women’s associations and imams, as in some districts of Sierra Leone, is time consuming, but it is the only way populations can understand, buy into and participate in the fight against Ebola.
The risk of compounding the health crisis with a humanitarian crisis by quarantining the whole region is real. Shutting off the region entirely will be like replicating the West Point experience on a grander and more dramatic scale. It will cause rioting and will not be effective. Just as people escaped from West Point, people can escape from larger quarantine zones.
How can the international community respond effectively, now?
Don’t ignore the big political and social elephants in the room. The WHO roadmap and the Word Bank’s plans will only change behaviours if issues of trust and mistrust are factored in.
Help the region’s new generation of leaders identify priorities. These leaders should be engaging with and communicating with their citizens. No one can do it in their place.
Transparency and accountability are not a luxury. They are needed to build trust and get people on board. There are many promising big data initiatives in this area, a must given the lack of data or reliable statistical systems. What is missing is an aggregation of this emerging data and access to it.
In short the fight against Ebola can only be won with the people concerned – not without or, even worse, against them.