A year ago, Guinea’s Ministry of Health and Médecins sans Frontières received reports from health centre staff of a mysterious disease killing people in rural southern Guinea. Within weeks of the reporting, the infection was identified, and cases were being investigated in the bordering countries of Liberia and Sierra Leone. A toddler named Emile Ouamouno was eventually identified as the first victim of what we now call the Ebola crisis – a crisis that has since bestowed tragedy on tens of thousands of affected people and families in West Africa.

The extent, impact and grave difficulties in controlling the disease since its identification last March have not been haphazard. Far from it. Rather, the Ebola crisis has revealed the consequences of deep-seated, unequal global social and economic relations that international development, as practised in recent decades, has had a role in creating.

Indeed, if anything positive is to come out of the Ebola crisis, it is the unmasking of this truth.

Causes of epidemic disease

Since his death, little Emile has become known to most simply as ‘Patient Zero’, and widespread attention has focused on the role of bats (the likely carrier of the virus that killed Emile) and the consumption of bushmeat (which is not likely to be the origin of this epidemic).

However, epidemics of diseases like Ebola do not have simple, single causes. They arise from the interaction of ecological, economic, social and political factors. It is important to remember that following Emile’s death, each of the thousands of incidences of Ebola virus disease in this epidemic has been transmitted from one person to another, primarily in the care contexts of hospitals, home care of the sick, and care for and burial of the dead.

The current Ebola epidemic is unprecedented in terms of duration, deaths, livelihood losses and geographic scope. Also, in terms of the resources allocated to avoid spread to richer more privileged settings. Survivors will feel its social, economic, and bodily consequences far into the future.

These circumstances highlight just how central to our wellbeing are the ‘ecologies’ that we create.

Opening the debate

As we near the first anniversary of the identification of the Ebola epidemic in West Africa, it is past time to examine the conditions that created an environment for a disease like Ebola to flourish.

Bringing together a diverse group of key policymakers, NGOs and researchers, today marks the launch of Ebola and Lessons for Development: Inequality, Structural Violence and Infectious Disease, an Institute for Development Studies initiative. Authors present nine briefing papers that argue that we must look beyond the immediate issues of response and control to reflect on bigger and broader questions and lessons learned about relationships between international development practice and the current crisis.

Global health and health systems

For much of the past decade, global control of infectious diseases has been largely oriented around developing mechanisms to link health and security concerns. The World Health Organization (WHO) has made strengthening global health security a strategic objective, but was unable to marshal a rapid international response to the epidemic due to the organisation’s institutional structure and recent cutbacks affecting its emergency response capacity.

International efforts around containing the outbreak were relatively powerless when confronted with the lack of effective and accessible treatments or vaccines for Ebola, and with weak national health systems in countries experiencing the worst of the raging epidemic. Guinea, Liberia and Sierra Leone have all experienced the repercussions of harsh social and economic reforms that have been pushed as a condition of international aid, weakening states and decimating their public sectors and services, including health systems. 

Beyond the Ebola crisis response

Guinea, Liberia, and Sierra Leone have unique national political, economic, and social histories. Yet, in recent years their pathways have been linked through international agreements, policy reforms, and conflicts. Prior to the outbreak, they were all recovering from major socio-political and economic ruptures, including over a decade of violent armed conflict in Sierra Leone and Liberia that spilled over into Guinea.

At the same time, they have recently experienced dramatic economic growth. Economic growth is often assumed to lead to mass improvements in quality of life in developing countries, but this has not been the case in these three countries. Rather, recent growth has been largely inequitable, benefitting international investors but not resulting in equal improvements in public services and economic opportunities for everyday people.

These trends are related to important ecological changes in the region as well. Primary causes of environmental change in West Africa involve expansive ‘land grabs’ – deals in which companies and foreign governments lease large areas of land in lower-income countries for the commercial production of food or fuel crops. These grabs are facilitated through policy reforms designed to attract and incentivise international investment in large-scale mining, timber, and commercial agriculture, especially for the production of hybrid oil palm, one of the world’s most rapidly expanding cash crops due to its use in producing biodiesel.

Across West Africa, establishing large oil palm plantations causes massive changes to ecosystems, and fragments the habitats of wild animals (like bats) that are the natural hosts for diseases like Ebola. As wild animals face large-scale environmental changes, often changing migration patterns and feeding behaviour to survive in ways that can increase people’s risk of exposure to diseases.

Gender, community and control in context

In another facet to this complex epidemic, vulnerability to Ebola infection is highly gendered, and women have made up as many as three-quarters of the cases in Liberia, Sierra Leone and Guinea. This is related to the important roles that women play as providers of professional and home-based care in giving life, and in burying the dead.

Elizabeth Mills (Institute of Development Studies) and Jennifer Diggins (University of Sussex) highlight that ‘Livelihoods, and especially women’s livelihoods and the wellbeing of female-lead households, have been heavily impacted by epidemic control measures. In Sierra Leone and Liberia, for example, where women play a critical role in food production and cross-border trade, restrictions and border closures have greatly diminished women’s earning power.’

Control efforts have been structured around curfews, mass cremations, lock-downs, quarantines – of houses, villages and entire regions – and the use of military force to maintain these measures, severely rupturing fundamental features of social, political, economic and religious life.

During the crisis, much attention has been focused on the fact that people in Guinea, Liberia, and Sierra Leone have avoided health facilities and actively resisted public health teams, which is often attributed to ignorance of biomedicine and refusal to abandon ‘traditional culture’. In fact, these ideas encourage those working in international development to underplay the persistence of inequitable policies and practices of exclusion and neglect that create atmospheres of mistrust between states, citizens, and response partners. These practices underpin the vulnerability of people who live in some of the world’s poorest communities.

These powerful ideas, too, distract from the importance of learning from and supporting local responses to hazards like Ebola. Evidence emerging from the current epidemic and previous outbreaks of Ebola and other diseases shows they can be better addressed through coordinated collaboration between medical response teams and those with a range of other forms of expertise, including community members with deep knowledge of the social and environmental context of the outbreak, and sometimes long experience with the disease itself.

Lessons for development

There is now an urgent need to reinvest in global health and national health systems to support the development of sustainable rapid response programs and build trust across sectors.

Linda Waldman (Institute of Development Studies) argues that ‘we must bring people at the social and economic ‘margins’ of urban societies to the forefront of development planning. Only in this way can urban communities help to dismantle institutions that have functioned to exacerbate and entrench inequities and foster atmospheres of mistrust.’

We must invest in the capacity to learn from local experiences and support local responses. Pervasive stereotypes about ‘traditional culture’ can have dire consequences when they misdirect planning and interventions. Local knowledge and perspectives must be at the heart of the political, public health and biomedical responses to development planning and crisis response.

Legacies of inequitable development create the vulnerabilities that result in hazards turning to disasters. To focus only on the immediate circumstances of the Ebola epidemic is, to use the language of medicine, to address the symptoms of a pathological condition rather than the underlying and complex dynamics that allow the problem to arise in the first place.

In this context, we must learn from and address underlying causes to build a more just, resilient and sustainable future. If we are to take an overarching lesson from this Ebola crisis, it is quite simply, that now is the time to radically rethink development.

Read the IDS briefings Ebola and Lessons for Development: Inequality, Structural Violence and Infectious Disease