By Ayesha Jacub · 16 Sep 2014
Sometimes it takes a crisis to test existing structures and expose all the fault lines. Ebola has been pummelling its way through West Africa and in addition to the lives claimed by the epidemic, it has exposed the state of Global Health’s leadership as well as the current paradigms through which we view health at the global level.
When the first warning calls about the severity of the current Ebola epidemic came from the quarters of the NGO Medecins sans frontieres, and not the World Health Organisation (WHO), it was indicative that the WHO was losing its grip on being at the forefront of Communicable Disease control. The tardy response by the WHO culminated in the ‘Ebola Response Roadmap’ issued on August 28. The Roadmap is replete with technical advisories, but as Brice de le Vingne (MSF’s director of operations) pointed out, "Huge questions remain about who will implement the elements in the plan."
What is playing out now seems like a chaotic attempt to plug holes through desperate funding appeals. Where are the global financial reserves earmarked for such emergencies? Something along the lines of the CFIA trust fund for influenza action. The WHO’s lack of clear leadership and decisive action around the management of the Ebola outbreak unmasks some of its own funding issues. In a sobering New York Times piece, Sheri Fink describes how the the global financial crisis lead to budgetary cuts, with project specific work lead by donor preferences being undertaken. She describes downscaling of the WHO’s pandemic and epidemic unit as well as their emergency response section.
The Securitisation of Health
Not only has Ebola exposed the lack of authoritative leadership in global health governance, it has also uncovered the lack of a framework to understand health and disease on a global scale at the diplomatic level. Given the interconnected nature of health and disease, what are the paradigms through which health is viewed?
Seen as a security threat, the response to the Ebola outbreak by the United States has been to increase funding to combat the disease as well as to commit military aid. President Obama, on NBC’s Meet the Press said that Ebola may eventually become "more easily transmittable. And then it could be a serious danger to the United States". This reflects the concept of Ebola (a communicable disease) posing a threat whether as a direct threat (although the medical journal, The Lancet states that "the notion of a global outbreak of Ebola, fostered by parts of the mass media, seems unjustified") or whether the threat is posed through instability in the affected countries and possible downstream repercussions for the US.
The urgency that comes with the concept of a ‘potential threat’ has lead to the accelerated testing of the vaccine ZMAPP whose initial development Al Jazeera reports, "was partially funded by the US department of defence". It may then be argued that the securitisation of health does produce positive results by way of medical innovation and positive health interventions. This paradigm, however, offers a very insular view of health and wellbeing. It is morally dubious to engage in health research and positive health action only when it has the probability to affect ‘us’. This perspective enforces a laager mentality, which props up health systems in developing nations regardless of the health conditions in less developed countries. In a globalised world, this viewpoint seems counterproductive.
The Problem of Self Interest and Collaboration
The Ebola outbreak has exposed the paucity of global collective action in instances where health concerns are not immediate to wealthier nations. A Lancet article titled ‘A Failure of international collective action’ points to the need for health systems strengthening in developing countries. It goes on to state that "a vaccine would probably exist today if Ebola affected a large number of people in high-income countries, making research and development financially attractive to drug companies."
As a result of this crisis, global health is sure to be given priority on the global diplomacy agenda. When all the bodies are buried, it will be important to ask whether a paradigm of global health can be explored wherein national selfinterests do not dominate, and when they feature, they are then viewed through a lens of equity. Will it be possible to explore a truly collaborative framework?
To Aid or Not?
While mentioning securing a measure of equity in health systems, it would be important to steer away from a paternalistic interventionist approaches. Much discussion around ‘help’ to LMIC’s (low and/or middle income countries) is centered around financial aid. In the midst of this Ebola crisis, it seems as though aid in its various forms is the only means to assist the situation. This may hold true for this crisis and subsequent others, but this type of emergency pooling of funds in the midst of an outbreak indicates a severe lack of planning and would not be sustainable. For a long term and future solution to effective communicable disease control, another plan is needed.
Lawrence O Gostin, in an article published in The Lancet, makes a case for an international Health Systems Fund. He says that ‘A dedicated International Health Systems Fund would build national capacities not only to respond rapidly to public health emergencies, but also to enable low-income and some middle-income countries to deliver comprehensive health services.’ This solution is still centered firmly within the Aid discussion.
Alternate solutions to ‘helping’ less developed countries in the health sphere are proposed by Health Economist Angus Deaton in his book ‘The Great Escape’. Deaton outlines a host of arguments against current aid programmes and theories, concluding that often intervention with Aid does more harm than good. He affirms some of the positive health gains made by aid intervention but critiques them against the context of poor governance which the aid system as a whole, he believes, perpetuates. He outlines a few suggestions as an alternative to aid pouring into LMIC countries. Deaton quotes economist Jagdish Bhagwati as saying, “it is hard to think of substantial increases in aid being effectively spent in Africa. But it is not so hard to think of more aid being spent productively elsewhere for Africa.” With regards to health, Deaton’s suggestions include investing in disease research for diseases that do not threaten Western countries, reviewing obstructive medicine patent systems and using aid to incentivise the production of new drugs and vaccines for which there is no financial incentive to do so.
Ebola is leaving West Africa reeling. It has untidily exposed the fault lines in our views and management of health. In its aftermath, will the global health community step back and do some earnest introspection or will we sluggishly await the next epidemic to provoke a messy kneejerk reaction?