With Ebola abating in the three most affected countries (Liberia, Sierra Leone and Guinea) there are now ex post reflections on what went wrong. There is much that did.
We can first ask why these countries were unable to deal with the outbreak when it began. The simple answer: extremely weak health systems, too few health workers, recent and devastating civil conflicts and governments still not trusted by many of their citizens. The more complex answer is that these proximal causes are embedded in 35 years of a dominant neoliberal economics characterized by liberalization, privatization and minimal government interference in increasingly integrated global markets.
In the year before the Ebola outbreak, the three countries reported success in their fiscal achievements but failure in meeting social spending targets, including health.
The weak health systems in these countries were partly consequent to structural adjustment conditionalities attached to IMF and World Bank loans in the 1990s and 2000s, which emphasized fiscal restraint in order to avoid debt and to prevent defaults to international creditors. The IMF no longer advises cuts in health or social spending as part of its policy advice. Nonetheless, in the year before the Ebola outbreak, the three countries reported success in their fiscal achievements but failure in meeting social spending targets, including health.
Although health spending in Liberia and Sierra Leone has been increasing in recent year, and in 2012 hovered around 16% of GDP (higher than Canada’s), the almost non-existent GDPs of these countries means that health spending per capita is among the world’s lowest. (Guinea does worse on both measures.) Much of this health spending is private, doing little to build a functioning public health system. Most public health spending flows from a multitude of disease-oriented and results-focused donor funds. This also fails to build a functioning public health system, and represents a failure in global health financing long recognized but not yet acted upon.
So there was neither a public health workforce nor a history of trust-building relationships with community members in these countries. Those health system elements were present in Nigeria, enabling it to engage immediately in the labour-intensive work of contact tracing its 19 Ebola cases and quickly snuffing out a potential epidemic in populous Lagos. The three Ebola countries, by contrast, have among the world’s lowest density of health workers and the highest rates of health workers migrating to OECD countries – coincidentally saving these wealthier and better staffed nations millions of dollars in workforce training costs, a perverse subsidy of poor to rich.
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The dysfunctional health systems and under-supplied health workforce in these countries are a function of their entrenched poverty. But part of their poverty derives from years of following IMF advice to keep taxes low in order to attract foreign direct investment. While Canada taxes about 32% of its hefty GDP (a ratio on its own neoliberal decline), Sierra Leone and Liberia manage only 11% and 20% of their much tinier GDPs, respectively. (Guinea’s tax data is elusive.) All three countries still grant tax holidays to foreign investors, mostly for mining or other resource extractions.
Sierra Leone, for example, spends about $244 million on tax holidays for global corporations annually, but only $25 million on health and $32 million on education. The country also loses about 12% of its GDP yearly to illicit capital flight, both criminal as well as corporate and corrupt, and all of it abetted by tax havens that generally operate under the aegis of rich countries and their banks.
Even the wildfire nature of the Ebola outbreak has a global driver. A 2015 WHO report documented how growth in ‘conflict timber’ harvesting and other natural resource exploitation for global consumption (and private, mostly untaxed, profit) had driven the fruit bat (the reservoir of the Ebola virus) out of remote areas of the country and into the cities—a reason for the rapid spread of this outbreak compared to 20 years of earlier episodes.
As for the failure in global response, much of the attention focused on the WHO, which is structurally conditioned to fail. Since the 1980s, country contributions to the WHO budget have been frozen. Almost 80% of its funding now comes from donor nations or philanthropies who, paying the piper, have considerable influence in calling the tune. The WHO has been in fiscal chaos for some time, and the year before the Ebola outbreak it halved funding for its in-house expertise on pandemic risk. Its structure of six autonomous regional offices and well over 100 country offices works against a nimble response to crises and adds unnecessarily to administrative costs at the expense of building technical and intervention capacities.
The good news is that many of these drivers of the Ebola outbreak are fixable, and Canada can help. First, Canada can lead the charge for (rather than position itself against) an end to the freeze on country contributions, easing the WHO out of its reliance on influence-peddling donors. As a recently appointed member of the organization’s Executive Board, it can lead on structural reform of the WHO.
- Ronald Labonte, Time for an Open Debate on the Trans-Pacific Partnership Agreement
- Rieky Stuart and Stephen Brown, Mr. Harper’s Maternal and Child Health Summit: What’s Still Missing?
Second, Canada can apologize for and reverse its travel ban on people from the Ebola countries. This ban violates the intent of the WHO’s International Health Regulations, which Canada pushed to revise after suffering a WHO travel advisory during the SARS episode.
Third, Canada can recognize that its recent shift in donor policies (i.e. aid donations to advance Canada’s economic interests), its tax breaks to global mining companies and its reluctance to support global taxation measures will keep many countries in a position where they will be unable to respond to a new outbreak or recurrence with the speed and capacity needed to prevent a global pandemic.
Finally, let’s avoid Ebola sensationalism. According to the new Commissioner for the European Commission’s Human Response, “The Ebola epidemic is putting the entire international community to the test.”
But notwithstanding the 8,800 largely unnecessary Ebola deaths, why not sensationalize the more easily and readily preventable holocaust of the 100,000+ children and 7,000+ pregnant women who died in these three countries over the same time?
There, at least, is one area where Canada has been providing some global leadership.