A number of recent commentaries have emphasized that as much as a crisis of health, the ebola outbreak in the Mano River region of West Africa is in fact a political crisis, a crisis of governance.
The governments of the three affected countries, Liberia, Sierra Leone and Guinea, among the poorest in the world, clearly lack the capacity to respond effectively to the challenge presented by such a highly contagious and almost untreatable disease. But the deficiencies of the three countries’ health sectors have been greatly compounded by failures of governance, and particularly the widespread lack of trust in the government or any officials representing authority.
In the rural villages of Guinea and Sierra Leone where the virus first appeared, patients were hidden from health workers on the basis that those already taken away for treatment had never returned. In Liberia, many believe that the ebola crisis has been magnified or even created by a cash-strapped government as a ruse to procure aid. This distrust of the authorities, combined with lack of knowledge of the nature of the disease, have been major factors in its continued spread.
The recent ransacking of a centre set up to quarantine suspected cases in Monrovian slum West Point, the first in the city, highlights just how deep this distrust goes in Liberia. Local residents claimed variously that the inmates were being denied sufficient food and water, and that they had been brought in from outside and were putting community members at risk. A small mob forcibly released the patients from the centre last weekend, chanting ‘no ebola in West Point’, before looting its contents, including blood-stained mattresses and used protective gear. The police looked on, helpless. This incident reveals an almost wilful ignorance about the disease, despite concerted public information campaigns, as well as a blind rejection of the government’s first tentative efforts to put into place the mechanisms necessary to control its spread.
But such apparently irrational actions take place in the context of a government that has manifestly failed the people of this community and the country more broadly. There have been only very limited improvements in access to decent public services and infrastructure in the ten years that Ellen Johnson Sirleaf’s government has been in power since the end of the country’s conflict. The health sector was in shambles even before this crisis, along with education, while public electricity provision is practically non-existent, as in Sierra Leone. Corruption, cronyism and impunity - the very governance failures that helped cause the war in the first place - meanwhile remain rampant.
Growing anger that so little has changed despite the years of violence and hardship has therefore undermined people’s trust in the government’s response to the crisis and greatly exacerbated the inherent public health challenges of tackling the disease in a country with such limited capacities.
These local governance failures are in turn compounded by failures at the global level. Until recently, only two international agencies have been working in Liberia to respond to the outbreak. One of these, Medicins sans Frontieres (MSF), with its own capacity under severe strain, has repeatedly called for a massive international response, but this has been extremely slow in coming. Even in the past weeks of World Health Organization (WHO)-led strategic plans and hundred million dollar pledges, little seems to have changed on the ground. Just as the downing of MH17 revealed the defects of mechanisms governing the security of global air-space, this deepening crisis has exposed the glaring inadequacies of global public health governance mechanisms.
It should have been clear from the start of this outbreak in March that the three governments in the region would be absolutely incapable of tackling this crisis without substantial international assistance for every single aspect of the response. The failure to anticipate the extent of local antipathy towards public officials, and the role of this distrust in the spread of the disease, may be defensible. But the continued failure of international public health institutions to coordinate the massive response that is necessary to contain this deadly disease, is less so. This combination of deep-seated local governance failures with the broader failures of global governance mechanisms may yet produce the most challenging and dangerous global health crisis of the 21st century so far.