By David McCoy

The Ebola virus is finally receiving attention after years of being ignored as just another deadly disease in Africa. Yet it was only when the current outbreak got out of control and threatened commercial and western interests did the story became news.

I am hopeful the epidemic will eventually come under control. While Ebola is lethal and dangerous, it is not an airborne disease. There is no carrier state and no real period of being asymptomatic and infectious. However, the crisis won’t end before tens of thousands have died – either from the disease or indirectly due to clinics and hospitals being shut down and the economy being damaged.

There have always been two core requirements for the control of this outbreak. The first is a health system with sound management, personnel who can follow simple protocols and basic resources (beds, quarantine units, disinfectant, gloves, transport etc). The second is trust, so that information can be transmitted, understood and acted upon.

Both Sierra Leone and Liberia – the two countries which have been hit hardest – suffer from decrepit, under-resourced and fragmented health systems; as well as a lack of trust within communities and between communities, the government and health workers. Thus has the virus spread on the back of ignorance, fear and paranoia, with no resistance offered by health systems. The world is now playing catch-up with an outbreak that could and should have been nipped in the bud, and which will now be hard and costly to control.

Broken health systems cannot be fixed overnight; but a disease control system can be rapidly deployed through the injection of adequate personnel, equipment and funds. Similarly, while trust can’t be created overnight, it can be generated if there is recognition of the need to earn trust, and that this requires respect, humanity and honesty. But this will not be straightforward: the people of Sierra Leone and Liberia have suffered war, conflict, violence, dispossession and rampant exploitation for decades. They have good reason to mistrust those in authority.

We must hope that the international response works effectively and efficiently. Though many individuals and organisations are performing heroically, the international response has generally been slow and characterised by self-interest and bickering. The militarised nature of assistance provided by the US in particular may help build hospitals and establish command-and-control systems to help break disease transmission chains, but could also hinder the building of trust. The more developmental and social approach to disease control offered by the Cubans, which has received little attention in the mainstream media, possibly offers more hope.

Equally, I expect development organisations such as Action Aid and Health Poverty Action, with a history of facilitating community-based and community-led development, to play a vital role. It will be critical that control programmes are facilitated by external agents but led and implemented by local people and organisations. This is no longer a concentrated outbreak: it is a generalised epidemic that needs a generalised response built on the cooperation and coordination of multiple organisations and communities across a large and difficult geographic terrain.

But we will never eradicate viral and bacterial threats to human health. Current patterns of travel, trade, industrialised farming and unregulated antibiotic use – juxtaposed with widespread poverty, concentrated living arrangements, social inequality and ecological degradation – point to growing microbial threats and increasing vulnerability. After we control this epidemic, we will still be left with the certainty of new and virulent disease outbreaks in the future, and with the conditions for outbreaks turning into cross-border epidemics.

So, even as we play catch-up with the current epidemic, we need to be asking some important questions. Will we find the means and ways to build decent health systems in Sierra Leone and Liberia in the future? Will we fix the problems in global health governance that have been so starkly exposed by Ebola? And will we treat the social, economic and ecological pathologies that underlay the current crisis?

If we are to do the right thing, we need to explain why Sierra Leone and Liberia have such weak, ineffective and under-resourced health systems. In both countries, external funding makes up a big proportion of total health expenditure: about 50 per cent in Liberia and 20 per cent in Sierra Leone. External actors, notably the USA and UK aid agencies, the Global Fund for AIDS, TB and Malaria, GAVI (a global funding agency that promotes vaccines and immunisations) and the World Bank, are key players who shape health systems priorities and policies in both countries; while a multitude of international NGOs populate the health system in a fragmented and inefficient manner.

While there have been some health improvements in both countries, Ebola should prompt a critical review of all health improvement efforts over the past ten years. Specifically, we need to interrogate the balance between investment in long-term health systems strengthening and short-term models of health improvement that are centred on selected interventions for a selected number of diseases. We need answers to the question of why coordination between donors, NGOs and the government over the past decade hasn’t been better and why human resource plans and policies for the health sector over the last decade have failed so spectacularly.

The Ebola crisis must also make it imperative for the global health community to find long-term and effective solutions to the problems of the World Health Organisation (WHO). We don’t need more fingers pointed at the financial, technical and management problems of WHO, particularly its regional office in Africa. These problems have been known for many years. What we need is a frank and independent enquiry that will highlight the role of specific actors in undermining the public health mandate and functions of WHO. There is culpability and there must be accountability.

But more importantly, we need to look beyond the health sector. We need to understand why Sierra Leone and Liberia languish at the bottom of United Nations Development Programme’s (UNDP) human development index in spite of being rich in natural wealth. More than 80 per cent of Liberia’s population live on less than US$1/day and more than half the Sierra Leone population live in extreme poverty while hundreds of millions of dollars flow out of both countries every year, leaving behind a trail of massive social and environmental damage.

Blood diamonds’, ‘conflict timber’ and ‘land grabbing’ are terms that appear in the mainstream media and are virtually synonymous with Sierra Leone and Liberia. But we need more truth about the on-going pillage and environmental destruction occurring in both countries, facilitated by corruption, illicit financial outflows and arms dealing. Understanding how environmental damage is changing the interface between human populations and the natural environment may also be important for understanding the genesis of the Ebola outbreak from its primary natural reservoir.

Ultimately, both the Ebola virus and the broken health systems of Sierra Leone and Liberia are connected by a shared set of deeper pathologies that extend from the local to the global, and which are simultaneously social, political, economic and ecological in nature. Significantly, these pathologies also lie at the root of the widespread poverty, malnutrition and illiteracy that have been killing thousands of children every month before Ebola.

The global health community has tended to ignore such pathologies, but Ebola is both a call and an opportunity to change this. We can confront finance capitalists and multinational corporations as vectors of disease that bribe governments and extract wealth in ways that are unjust and ecologically destructive. We must describe bankers, lawyers and accountants who enable illicit trade, tax avoidance, theft and corruption as agents of poverty and illness. And we should view the arms trade as a pathogen that fuels violence and enables repression.

Those of us who work in the global health complex (with its epicentres of power and influence in Geneva, London, Washington, New York and Seattle) must do more than provide humanitarian relief and disease control, or call for new vaccines and medicines. We must act as social and political change agents.Declaration of interest: This article was requested by ActionAid and I also have a professional association with Health Poverty Action—both are health and development charities that work in west Africa, and which are mentioned in the article.

David McCoy

David McCoy

Professor of Global Public Health at Queen Mary's, University of London
David is a public health physician and academic, and former Director of Medact.

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