Africa's Ebola outbreak isn't just a health care problem. It's also about a crisis of governance.
There was a tragic irony to the discussions in Washington last week between President Obama and African leaders. The meeting took place even as the Ebola virus was brutally exposing the lack of capacity, antiquated health systems, and dearth of governance in one corner of the continent. The outbreak is gathering pace. Over 1,000 people have now died in West Africa. Hospitals and health clinics are overflowing and anger is rising as dead bodies are being left to rot in the streets.
The governments in the region and the international community are finally getting serious about a coordinated response to Ebola. Sadly, however, these measures only treat the symptoms and not the causes of the problem — which at their core are issues of corruption, mismanagement, and a lack of accountability of those in power to their people.
There are parts of Africa that have made incredible progress in the past two decades. Think of Mozambique, where poverty levels have been cut by almost 15 percent since 1996. Or Senegal, where equal numbers of girls and boys are now enrolled in primary school. In Liberia, one of the countries worst hit by Ebola, successful elections have been held twice and economic growth has averaged over 7 percent in the past 10 years.
The Ebola crisis is quickly exposing how rapidly progress can be undermined, however, when it is not grounded in a fair, inclusive social compact between governments and their citizens. It is no coincidence that, in the countries at the heart of the outbreak, large groups of people have been systematically excluded from power and decision-making at all levels for decades. This means many citizens are unwilling to believe that the government can serve their interests. The health system in Liberia is a case in point. Despite millions of dollars of investment in the decade before the Ebola outbreak, there were only 150 trained doctors in the entire country of 3.5 million people. As a result, access to services is inevitably exclusionary, lending itself to networks of corruption as patients do anything they can to receive care.
In recent years, kleptocratic and nepotistic behavior by the ruling elites have led to long civil wars in Liberia and Sierra Leone; deep ethnic tensions, a coup d’etat, and civil strife in Guinea; and a low-level insurgency and the rise of Boko Haram in Nigeria. These are places where the social fabric has been ripped apart, and trust between those in power and ordinary people is almost absent.
Sadly, by some measures governance in Africa is getting worse, not better. In 2009 there were 12 African states ranked in the lowest 30 countries of Transparency International’s Corruption Perceptions Index; last year this increased to 15 countries in the bottom 30 of the list. The Ibrahim Prize for Achievement in African Leadership, awarded to democratic leaders of integrity in Africa at the end of their mandated terms, has only been awarded three times in seven years. The aid system has become part of the problem as African governments have often focused on international funding flows rather than efforts to generate the confidence of their own people.
There is a clear link between this governance failure and the current health crisis. In places where governments are so rarely willing or able act in the interests of their citizens, we can begin to understand why the disease continues to disseminate. Health services, which barely exist in many places, are shunned because the unsanitary conditions of hospitals and heath centers have made them hubs for the spread of the virus. Many hospital staff — already underpaid and ill-equipped — have become victims themselves. Foreign health workers sent to help are ignored and even chased away by scared locals. A group of Liberians explained to us recently that they think Ebola is a ploy by the government to steal even more money from Western donors.
As a result, the Ebola challenges are now evolving into larger problems of instability in the region. Economic activity has ground to a standstill as borders have closed, movement is restricted, and flights are canceled. This is happening in countries where up to 50 percent of the population already earns less than 50 cents a day. Mistrust, misunderstandings, and ill-will are growing as people continue to die. In Liberia, the president has declared a national emergency and the vice president has stated that Ebola is threatening the progress made since the end of the civil war. The use of riot police to put down a recent protest against the government’s failure to deal with the crisis does not bode well.
Public outreach campaigns, infection control measures, and coordinated international technical support will control the virus in the short term. But in the longer term, we must empower the governments and people of the region to build mutual trust with each other and get to grips with the corruption, mismanagement, and capacity issues that prevent effective management of these types of crises.
This requires support to ensure that laws against graft are enforced fairly and are matched with institutions mandated and resourced to do their jobs. The Liberia Anti-Corruption Commission (LACC), for example, has just two lawyers — something that makes prosecuting corrupt officials extremely difficult.
Finding solutions also means encouraging administrative bodies to allow people to have a greater say in how they are governed. Decentralization — delegating decision-making to local governments — can help with this, as can processes like participatory budgeting where citizens can decide how public funds are spent. Finally, it requires a clear emphasis on funding for flexible, grassroots mechanisms for holding governments to account for the delivery of services.
These kinds of prescriptions are difficult and time-consuming, and they rarely generate front-page news. But they can allow for a process through which governments in West Africa can begin to build the trust that is essential in times of emergency. This is the real cure for Ebola.