by China Scherz
Media accounts of the current Ebola epidemic often cite culture as a key factor causing the virus to spread. Since the summer, images of funeral practices, bush meat consumption, and villagers fearful of biomedicine have filled the pages of our newspapers. While a nuanced understanding of culture can be helpful in crafting more culturally sensitive interventions, to focus on an understanding of “context” in which “they” are the ones with culture can also serve to racialize and naturalize Ebola. In this vision Ebola becomes attached to a racialized African body and to a set of cultural practices that are seen as highly unlikely to change. As in Charles Briggs’s writings on the Venezuelan cholera epidemic in the early 1990s, such narratives can easily justify the abandonment of the populations depicted as the irrational actors who can be blamed for the epidemic’s spread (Briggs 2001).
This is not to say that culture has not contributed to Ebola’s spread—rather it is a different set of cultural beliefs and practices that we need to consider if we want to understand why this epidemic has spread so quickly, why the medical systems of Sierra Leone, Liberia, and Guinea were so profoundly unprepared, and where the vulnerabilities in the American health care system may lie. Understanding the tragic spread of this disease is less a matter of teasing out the cultural logics of funeral rituals than it is a matter of drawing out the beliefs and norms that have shaped the market based development policies that have left the hospitals of these countries so profoundly under resourced. I want to be clear that my aim in opening this space of reflection on the ethics, politics, and practices of global health and development is not critique itself, but rather I hope that such moments of reflection may help us all to think carefully about what we might be able to do to contribute to creating conditions capable of withstanding future outbreaks.
The problem of crumbling under-resourced hospitals has not gone unnoticed in reporting on Ebola. But stories, such as the graphically illustrated article entitled “A Hospital from Hell, in a City Swamped by Ebola” which appeared in the October 1st issue of the New York Times, unintentionally naturalize this situation by leaving the circumstances that created these tragic spaces unspecified—thus providing readers and viewers with a comfortable narrative of an Africa that is always and already a space of lack.
To be fair, perhaps the absence of context in such stories stems not from the reporters’ lack of interest in the broader historical narrative, but rather from the tremendous complexity of the story. To truly understand how one ends up with this “Hospital from Hell” in the center of Makeni, Sierra Leone would require bringing readers up to speed on centuries of history. When historical sources are noted, we are generally brought back to the equally exotic and horrific scenes of a series of interrelated civil wars and coups—most famous for their amputations and blood diamonds—that were fought in these countries in the 1990s. And these wars did have devastating impacts on health systems, particularly in terms of the destruction of medical facilities—“of the 293 public health facilities operating in Liberia before the war, 242 were deemed non-functional at the end of the war due to destruction and looting” (WHO 2010). Many physicians also left Liberia and Sierra Leone and found jobs abroad. There were also very few new doctors trained during the wars. All contributing to abysmally low doctor to patient ratios. The WHO marks a cutoff of 23 doctor, nurses and midwives for every 10,000 people as a minimum standard for health care provision. Even prior to the great losses of life among medical practitioners during this epidemic, the ratio in Liberia stood at 3 for every 10,000, and only 2 per 10,000 in Sierra Leone. To put these numbers in perspective, Nigeria comes in at 20, the US comes in at 98 (WHO 2009).
Since the end of these wars a decade ago, Guinea, Liberia, and Sierra Leone have received billions of dollars in foreign aid, raising the question of what has been done to shore up these systems since these wars ended. First off, the vast majority of this money has gone towards reestablishing and retraining their militaries, but millions of dollars have also gone into projects related to health care. So why are the health systems of these countries still so weak?
Part of this answer stems from the way this money has been spent. Spending for health-related development since the 1990s has primarily been directed by neoliberal principles that have called for dramatic reductions in government spending on services including health care and education—shifting donor funds towards local and international non-governmental organizations which write grants to compete for funds for specific projects. While these NGOs are often housed in or next to existing hospitals and institutions, these projects are not themselves designed to support or build up these institutions. Rather they are designed to deliver cost effective, narrowly defined interventions often targeted at a specific disease such as HIV. To take but one example, while we can say that PEPFAR’s provisioning of anti-retroviral medications for 6.7 million HIV positive people has been an unquestionable success, it has also allowed health care to be defined as access to a targeted set of pharmaceuticals to treat a limited range of effectively politicized conditions—what anthropologist Joao Biehl has referred to as the pharmecuticalization of public health (Biehl 2007). While this situation has made it challenging to scale up existing interventions around these diseases, the Ebola epidemic further highlights the need for strong institutions capable of managing a wide range of health issues, including unanticipated epidemics.
To make matters worse, many of these narrowly mandated organizations are capable of paying salaries that are 5 to 20 times higher than the salaries paid by African ministries of health, leading many of the few physicians who have not gone abroad to take jobs in these more disease-specific organizations (Pfeiffer 2008). The departure of many foreign volunteers in the wake of the Ebola epidemic also brings some of the problems of substituting foreign volunteers for local medical personnel into stark relief (Fassin 2007, Redfield 2012).
The good news is that some actors and organizations in global health and development are already giving more careful consideration to the need for substantial health systems and seeking to remedy the problems of NGO-based aid through instruments such as the NGO Code of Conduct. The challenge now is to find ways to move through the current crisis so that its lessons might fuel the important work yet to come.
China Scherz is an assistant professor of anthropology at the University of Virginia. She
is the author of Having People, Having Heart: Charity, Sustainable Development, and
Problems of Dependence in Central Uganda (Chicago University Press 2014).
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Works Cited
Biehl, Joao (2007) “Pharmaceuticalization: AIDS Treatment and Global Health Politics.” Anthropological Quarterly 80(4): 1083-1126.
Briggs, Charles L. (2001) “Modernity, Cultural Reasoning, and the Institutionalization of Social Inequality: Racializing Death in a Venezuelan Cholera Epidemic.” Comparative Studies in Society and History, 10/1/2001, Vol. 43, Issue 4, p. 665-700.
Fassin, Didier. “Humanitarianism as a Politics of Life.” Public culture 19.3 (2007): 499.
Pfeiffer, James, et al. “Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations.” American journal of public health 98.12 (2008): 2134.
Redfield, Peter. “THE UNBEARABLE LIGHTNESS OF EX‐PATS: Double Binds of Humanitarian Mobility.” Cultural Anthropology 27.2 (2012): 358-382.
WHO Bulletin of the World Health Organization 2010;88:527-534. doi: 10.2471/BLT.09.071068