An ounce of prevention is worth a pound of cure, but the Ebola crisis shows this lesson is still lost on the institutions that control the global public health agenda.
By the time West Africa’s Ebola outbreak has run its course, as many as 20,000 lives will be extinguished. But not by the disease alone; people are dying from neglect: neglect by the intergovernmental bodies that were their last lifeline; neglect by the bureaucratized international aid and financial institutions that have by turns enchained and abandoned the Global South.
The weight of Ebola on the hardest-hit countries, Liberia, Guinea and Sierra Leone, has now left those at the front lines of the epidemic facing unprecedented pressure, laboring around the clock to fill the resource gaps that enable the virus to thrive.
Facilities often lack the most basic protective gear. David Boys, deputy general secretary of Public Services International (PSI), a union federation representing 20 million public workers, says via e-mail: “the current level of resources is totally inadequate, staff are not trained to handle this type of infection.” Amid institutionalized impoverishment, “Many health workers are not being paid their wages, and those wages are too low to begin with.”
The occupational hazards of this care labor sows an ethical crisis: doctors and nurses are being forced to choose between protecting their own lives, and providing the care to which they are professionally committed. Back in July, Baryou Wallace of the Collaborating Civil Society & Trade Union Institutions of Liberia warned of a fatal lack of coordination in the government response, complaining publicly that the health ministry “cannot find the time to discuss with health workers leaders about a way of resolving the crisis, so that together we can all join the fight against the Ebola disease.” Today, it is both tragic and understandable that critical personnel in Liberia and Sierra Leone have been pushed to strike in desperation.
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At the embattled John F. Kennedy hospital in Monrovia earlier this month, spokesperson John Tugbeh told The Guardian that workers had decided to stop work until provided standard protective suits: “From the beginning of the Ebola outbreak we have not had any protective equipment to work with. As result, so many doctors got infected by the virus.… We need proper equipment to work with [and] we need better pay because we are going to risk our lives.”
This risk was not inevitable. The current epidemic reflects the historical scars left by pervasive poverty, conflict, corruption, and dependency on volatile foreign aid regimes. An underlying crisis is the “brain drain” of doctors and other critical personnel who have left for better-paying jobs in richer countries. Liberia has a population of 4 million but “only 200 doctors and 1,500 nurses, most of whom are in and around the capital of Monrovia,” according to Academics Without Borders.
The hazards now facing the medical workers who have remained reflects the shortsightedness and mismanagement of the World Health Organization (WHO). According to The New York Times, during the financial crisis, WHO sliced some $1 billion from its already strapped budget, leaving the agency at the mercy of “[t]he whims of donor countries, foundations and individuals [who] greatly influenced the WHO’s agenda, with gifts, often to advance specific causes, far surpassing dues from member nations, which account for only 20 percent of its budget.”
The infrastructure capacity needed to check Ebola’s spread is further strained by the migration of the outbreak into remote, under-resourced villages, while dense cities are overwhelmed by contagion. Meanwhile, other chronic issues, such as malaria, are being left to fester while Ebola consumes precious resources. And some earnest ongoing efforts by officials to strengthen the regional hospital infrastructure have now been shattered by the outbreak.
The violent clashes in Monrovia and the lockdown of Sierra Leone show that corrosive mistrust and tension between communities and government has sparked a secondary crisis of social strife and alienation.
The Western media have added insult to injury by training a lurid lens on the outbreak and drawing on racist tropes of backward, irrational mobs. Left outside the frame are the deeper, structural humanitarian issues that stoke public panics.
Evoking facile stereotypes of Africa as a primitive basket case ignores the enduring influence of colonization, which lives on in the form of multinational extractive industries and foreign aid dependency, and the current piecemeal crisis response from the chief donors, France, Britain and the United States.
The labor movement has been one of the few voices that has decisively communicated the plight of the local health workers at the core of the response. PSI has launched a global campaign to push for an infusion of personal protective equipment for health workers. In addition to calling for more emergency assistance from overseas, the group has pledged to “[w]ork with national governments to ensure appropriate social protection systems are in place, including for the families of workers killed in the line of duty.”
For the workforce, Boys says, international labor groups should support local unions’ efforts to secure equitable collective bargaining agreements and in the long term, apply “pressure for appropriate health policies and budgets to ensure universal health coverage.”
The grim prognosis for regional healthcare under Ebola’s shadow can only be addressed proactively, according to Lawrence Gostin, faculty director of Georgetown’s O’Neill Institute for National & Global Health Law. In a recent Lancet commentary, he asks, “[W]hat could states and the international community do to prevent the next epidemic? The answer is not untested drugs, mass quarantines, or even humanitarian relief. If the real reasons the outbreak turned into a tragedy of these proportions are human resource shortages and fragile health systems, the solution is to fix these inherent structural deficiencies.”
A first step would be a $100 million workforce “contingency fund”—which the WHO sought previously but never materialized. As a global reserve for emergency care and for building long-term infrastructure, such a fund, Gostin argues, would provide the resources to “rebuild broken trust, with the returns of longer, healthier lives and economic development far exceeding the costs.”
Ebola’s monstrous spread and the sluggish global response reflect the warped priorities of unsustainable, inequitable global healthcare institutions. By listening to workers, however, officials and international agencies can start to build more resilient systems, through democratic engagement, rather than spasms of charity. Doctors and nurses know what it takes to protect their communities, because they cannot abandon their posts. They stand firm, even as the world turns away.
To get involved with the labor movement’s Ebola aid effort, check out the fundraising campaign launched by National Nurses United to provide personal protective equipment for healthcare workers in the affected region.
