Background

The 2014 West African Ebola outbreak was the first recorded in the region, and the largest on record.^{Footnote 1} Researchers estimate it began in Guinea in December 2013 in Méliandou Village, Guéckédou District (Baize et al. Reference Baize2014). It was not until March 21, 2014, however, that Guinea’s Ministère de la Santé et de l’Hygiène Publique (Ministry of Health and Public Hygiene) reported its first suspected Ebola cases to the World Health Organization (Dixon & Schafer Reference Dixon and Schafer2014). By the end of March, Liberia reported Ebola cases in Foya District, located near Liberia’s border with Guinea. By late May Ebola cases were reported in Sierra Leone in Kailahun District, which borders both Foya District in Liberia and Guéckédou District in Guinea. Ebola has since spread within these countries and beyond.

The outbreak is ongoing, and by the end of 2014 20,206 people had been infected. Of those, 7,905 died (WHO 2014a). Previous Ebola outbreaks often occurred in remote locations and were contained in a single country. This outbreak, in contrast, has been regional in scale, spreading into densely populated urban areas and across multiple international borders. More than 99 percent of recorded infections have been in Guinea, Liberia, and in Sierra Leone. Cases linked to this outbreak were also reported in Mali, Nigeria, Senegal, Spain, the United States, and the United Kingdom (see map below).

Map of the West African Ebola Outbreak, 2014

Historical and Contemporary Political Economy in Ebola-Affected Countries

Initial international media coverage of the 2014 Ebola outbreak focused largely on the cultural practices that heightened risk for contracting and transmitting the disease (e.g., Fox Reference Fox2014; Thompson Reference Thompson2014; see also McGovern Reference McGovern2014). However, analysis of earlier epidemics demonstrates that an emphasis on individual behavior or “exotic cultural practices” often obscures the larger political economic context shaping the likelihood of a major disease outbreak and the ability of relevant actors to respond. In this commentary we follow the advice of Schoepf (Reference Schoepf1991), who, writing about HIV/AIDS in the 1990s, urged analytical approaches to epidemics that use a social lens and consider a dynamic relationship between political economy and culture, rather than viewing them as a function of institutional failures, cultural practices, or individual behaviors. We focus in particular on international political economy—what has been described elsewhere as “geographically broad and historically deep” analysis (Farmer Reference Farmer2006:xiii)—and how it has shaped the conditions that spurred and intensified the spread of Ebola in the region. Following chronological order, we examine the continued relevance of (1) the trans-Atlantic slave trade, (2) colonialism, (3) structural adjustment policies, (4) civil wars at the turn of the millennium, and (5) postwar foreign aid dependency.

Responding to Ebola in 2014

Early in the outbreak, ordinary people navigating the epidemic in their communities were—unsurprisingly—frightened and mistrustful. Ebola patients would leave treatment centers out of fear and suspicion of health workers dressed in head-to-toe protective gear (Fofana Reference Fofana2014a). Many of the region’s residents questioned whether Ebola was real (Fofana Reference Fofana2014b). In Liberia there were rumors that medical personnel treating the infected were spreading the disease on behalf of political leaders motivated to solicit foreign aid (Epstein Reference Epstein2014). In the forest region of southeastern Guinea, a group of young men attacked and killed members of a team of journalists and health educators (Tinti Reference Tinti2014). Regional observers understood these actions within a larger pattern rooted in deep-seated suspicion of earlier government interventions (McGovern Reference McGovern2012; American Anthropological Association 2014). Citizens have expressed dissatisfaction with their governments’ responses to the epidemic. In July 2014 a Liberian man set the country’s health ministry offices on fire to protest the government’s handling of Ebola, reportedly after losing a relative to the disease (Williams Reference Williams2014). In November residents of the Guinean village where journalists and health educators were attacked launched a hunger strike in front of Parliament to protest military occupation of their community (BBC 2014). Given the historical context provided above, we should expect that ordinary people navigating an epidemic would be suspicious of the motives and directives not just of their governments, but also of local agents implementing health interventions on behalf of their governments. It should not be surprising that these suspicions could further antagonism toward governments.

Citizens’ fears of Ebola go beyond suspicion of government motives to rational assessments of the intersection of the poor health systems serving them and the deadly nature of Ebola itself. The fatality rate of Ebola can be as high as 90 percent when access to effective supportive therapies—replacement of electrolytes and fluids, blood transfusions, and other forms of intensive palliative care—is limited. The cumulative negative legacy of war and SAPs on health care provision was acute at the outset of the outbreak: there was too little expertise for managing Ebola cases, and there were too few hospital beds, supplies, and personnel to provide intensive care for the increasing number of seriously ill patients. In settings already experiencing a health worker shortage, the 2014 outbreak made a bad situation worse. By the end of 2014, six hundred and sixty health workers had been infected in Guinea, Liberia, and Sierra Leone, of whom three hundred and seventy-five died (WHO 2014a).

Early response to the Ebola outbreak relied largely on the heroic efforts of local health workers and burial teams, who were poorly supported by their governments. In Sierra Leone and Liberia, in fact, these workers went on strike when their employers failed to pay them or provide the appropriate gear and equipment (Fofana Reference Fofana2014c; Agence France-Presse Reference Agence2014a).

Evaluations of domestic government responses to the epidemic have mostly been critical. To their credit, all three countries, early in the epidemic, activated their national emergency response committees, drafted Ebola response plans, and carried out needs assessments (WHO 2014b). However, action on those plans was sluggish or weak, largely due to the governments’ limited experience with the disease and subsequent underestimation of the epidemic’s potential (Fofana Reference Fofana2014b; Nossiter Reference Nossiter2014). For example, by April 2014 Guinea President Alpha Condé claimed that the disease was under control and publicly criticized Médecins Sans Frontières (MSF, or Doctors Without Borders) for issuing dire warnings about the outbreak. It was not until August—at which point five hundred Guineans had been infected—that President Condé began attempts to tackle the problem in earnest (Nossiter Reference Nossiter2014).^{Footnote 5}

More aggressive domestic government responses were mostly inadequate and no more effective at curbing transmission of Ebola. In June, for example, Liberian President Ellen Johnson Sirleaf declared that her government would prosecute anyone “reported to be holding suspected Ebola cases in homes or prayer houses” (Sirleaf Reference Sirleaf2014), and Sierra Leone’s President Ernest Bai Koroma made a similar statement shortly thereafter (Fofana Reference Fofana2014b). But these threats of prosecution—echoing those used during epidemics in the colonial period—were largely ineffectual. Worse yet were actual uses of force. One of the best known failed domestic responses was the ten-day quarantine in West Point, a densely populated informal settlement in Liberia’s capital, Monrovia. During the quarantine, Liberian security forces clashed with neighborhood residents, injuring several and killing a teenager (Epstein Reference Epstein2014).

Some contend that other government-supported interventions were more effective. Sierra Leone implemented a three-day ose-to-ose (house-to-house) outreach and lockdown in late September, during which more than twenty thousand field workers visited homes to identify new cases and provide health education. While many observers were initially skeptical of the initiative, the effort and scale of its reach were generally praised (O’Carroll Reference O’Carroll2014). Swiss scientists argued, however, that while the initiative may have helped to identify infected individuals, the stay-at-home period was too short to significantly interrupt transmission (Agence France Presse Reference Agence2014b).^{Footnote 6}

Another problem—and an enduring legacy of SAPs and their emphasis on health care provision by nongovernment actors—was the heavy reliance in the three countries on aid organizations to provide patient care, particularly early on in the outbreak. Most prominent was MSF, which quickly opened several isolation units and sent sixty health care workers to the area even before the initial reported cases were confirmed to be Ebola (Sack et al. Reference Sack2014). However, by late June MSF officials reported that the outbreak was out of control and that they had exhausted all their available resources. At that point they implored domestic governments and the international community to supply more resources (Doctors Without Borders 2014), but these early dire proclamations were generally dismissed by local governments and the World Health Organization (Fofana Reference Fofana2014a; Nossiter Reference Nossiter2014; Youde Reference Youde2015).

Yet another major challenge was the large number of actors responding to the outbreak and a lack of clarity in regard to who should lead the effort. The cross-border nature of the outbreak required coordination among multiple organizations, including the local ministries of health of Liberia, Guinea, and Sierra Leone, the World Health Organization, MSF, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF, bilateral aid agencies, and other nongovernmental and aid organizations. The World Health Organization (WHO), the United Nations’ directing and coordinating authority for health, is responsible for providing leadership on global health, giving technical support to countries, and monitoring and assessing health trends. But though the WHO was the unquestioned leader in international health immediately after World War II, other organizations—intergovernmental bodies as well as private corporations, philanthropic organizations, and civil society groups—have expanded their mandates to cover global health issues, and new health organizations have emerged, severely restricting the WHO’s ability to be a leading voice (Brown, Cueto, & Fee Reference Brown, Cueto and Fee2006; Youde Reference Youde2012). Nonetheless, many looked to the WHO to lead and coordinate the response to the outbreak.

Global health analysts have characterized the WHO response as “woefully inadequate” (Youde Reference Youde2015) and plainly a “failure” (Busby & Grépin Reference Busby and Grépin2015). In an internal draft document in October 2014, the WHO blamed staff members in Africa for initially bungling the response to Ebola, describing many of them as “politically-motivated appointments” and noting numerous complaints about WHO officials in West Africa (Ahissou & Cheng Reference Ahissou and Cheng2014). But the organization’s slow and out-of-touch response was also the product of a much more basic logistical problem—the fact that a global health agency headquartered in Geneva, Switzerland, was tasked with leading the response to an epidemic in West Africa. A report in the Washington Post on the failure of the global response captured the essence of this dynamic: “Officials hold faraway strategy sessions about fighting emerging diseases and bioterrorism even as front-line doctors and nurses don’t have enough latex gloves, protective gowns, rehydrating fluid or workers to carry bodies to the morgue” (Sun et al. Reference Sun2014). Even in the limited sphere of “coordination,” the WHO failed: the Africa regional office rebuffed collaboration with the CDC, and WHO officials disputed claims by MSF that the epidemic was out of control (Youde Reference Youde2015).

The WHO response was also terribly slow. It was not until July 2 that the organization convened a meeting to bring together local ministries of health and other partners to discuss a collective response (WHO 2014c), and a subregional outbreak coordinating center was not established until mid July (in Conakry) (Youde Reference Youde2014). It was not until August that the WHO declared the 2014 Ebola outbreak a Public Health Emergency of International Concern (WHO 2014d); this was five months after the first cases were reported to the WHO, and by this time 1,779 people had become infected, 961 had died (WHO 2014e), the outbreak had spread to Nigeria, and two American aid workers infected in Liberia had been evacuated to the United States (see timeline). In November an election was held to change the leadership in the WHO Africa regional office, but by then the U.N. had already taken more direct charge of the control efforts (Ahissou & Cheng Reference Ahissou and Cheng2014).

Timeline of West African 2014 Ebola Outbreak

In September U.N. Secretary General Ban Ki-Moon announced during an emergency meeting of the U.N. Security Council the creation of the U.N.’s first-ever emergency health mission, the United Nations Mission for Ebola Emergency Response (UNMEER). In his remarks, the secretary general stated that the WHO had the necessary “strategic perspective” but lacked “a very strong logistics and operational capacity” (U.N. Security Council 2014a). Rather than increasing the capacity of the WHO to respond effectively, U.N. officials insisted upon this parallel effort. Particularly interesting was the rhetoric supporting UNMEER’s creation, which invoked international security concerns above other motivations; the resolution adopted at the end of the emergency meeting stated that “the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security” (U.N. Security Council 2014b). The security paradigm—and particularly one in which threats from West Africa were spreading to the West—therefore colored U.S. and European responses to the crisis.^{Footnote 7}

Colonial legacies are obvious in the organization of Ebola response. While general assistance in each of the countries has been multinational, military assistance has been delivered along old colonial lines, with the United States sending aid to Liberia and the United Kingdom assisting Sierra Leone. A fraught decolonizing relationship between Guinea and France, by comparison, appears to have limited France’s response to the outbreak in Guinea; a visit to the affected region by French President François Hollande did not take place until late November 2014 and by the end of 2014 the French government had only begun to sketch a coordinated response.