By Tanisha M. Fazal for ISN
Is there a two-way connection between Ebola outbreaks and civil war? Tanisha Fazal thinks so. If the current crisis is undermining the already precarious infrastructures of fragile, violence-prone states, and if past Ebola outbreaks are anything to go by, then the nations now being assaulted by the virus are indeed headed for trouble.
As the Ebola crisis may (or may not) be reaching a containment phase, it is critical to consider what conditions may have enabled its outbreak. Epidemiologists are hard at work identifying mutations and transmissions. What they may miss, however, is a troubling connection between civil war and Ebola.
Of the 32 sub-Saharan African states to have experienced internal armed conflict since 1976, nearly a third have also experienced Ebola outbreaks. If we were to look at a map of where in sub-Saharan Africa Ebola has struck since it was first identified in 1976, the virus might appear to be tracking ongoing and recent civil wars in the Democratic Republic of Congo (1976), Gabon (1996), Uganda (2000), Gabon again (2001), Congo (2002) to today’s outbreak in West Africa. Civil war enables the spread of disease – especially viruses as stubborn as Ebola – by destroying physical and personal infrastructure.
The destruction of infrastructure after civil war
For example, prior to the start of over a decade of civil war in Liberia, there were 293 clinics in country. By the end of the civil war over 80 percent of these clinics had been looted or damaged. According to one report, Liberia had 237 physicians in country in 1989, 89 by 1998, and fewer than 20 in 2003. With assistance, this number had climbed significantly by 2013, but was still well short of the public health infrastructure that would be needed to identify and contain an Ebola outbreak. Sierra Leone’s medical infrastructure was similarly devastated by civil war. A 2008 survey of Sierra Leonean hospitals found that most had either no or interrupted oxygen and electricity and half had no running water. Only one hospital had more than one native surgeon.
Other infrastructure, such as roads, also suffered during the war. According to USAID, the destruction of Liberia’s transportation infrastructure during the civil war was so severe that Liberia went from being a net exporter of rice to importing nearly all of its rice, because transportation routes from the capital to rural areas were severed . Stop signs and traffic lights were destroyed in the war. Sierra Leone also saw a significant drop in usable roads as a result of its civil war.
The destruction of interpersonal trust is as important in understanding the spread of disease as the ravaging of public infrastructure. Trust in government typically falls after civil war. One study found that Ugandan social capital decreased markedly after the civil war ended, while ethnic cleavages increased. Similar results have been found inNepaland theBalkans (on the other hand, another study found that Sierra Leoneans who had been victimized during the civil war were more politically active than those who had not been victimized). Interpersonal trust is much more difficult to measure than physical infrastructure, and research on this topic in post-conflict environments is evolving. It may be, for example, that ethnic and/or territorial civil wars are more likely to leave a legacy of mistrust than other types of civil wars. But even if civil war can produce surprising levels of postwar political participation, it should also produce high levels of wariness amongst the population – particularly when it comes to strangers.
Distrust of health care workers in ongoing and post-conflict zones is evident in the challenges faced by polio immunization campaigns inPakistan and Nigeria, where aid workers have been gunned down by militants in recent years. Aid and health care workers are frequently targeted in conflict and post-conflict zones, including Afghanistan, South Sudan, and the Central African Republic. These incidents further degrade already faltering health care systems.
Poor infrastructure and the spread of Ebola
With outbreaks like the ongoing Ebola crisis in West Africa, these background conditions quickly come to the foreground. A lack of good roads prevents health care workers from entering affected regions. To be sure, poor transportation infrastructure could hinder or help an outbreak; patients will have a harder time getting medical assistance, but the difficulty of getting to certain areas might also facilitate containment. Rather than celebrating bad roads that condemn entire villages, however, a better solution would be to have both good roads and good medical resources available. Moreover, even though poor roads hinder access to rural areas, what has been most dangerous about this outbreak is the presence of Ebola in large West African cities.
A lack of hospitals, clinics, and medical personnel prevents the afflicted from receiving the care they require. Compounding these problems are cultural beliefs that do not include the germ theory of disease. Add to the mix local norms ofhugging, touching dead bodies at funerals, and faith healing, and you have multiple new networks of transmission.
The lack of social trust after civil war further aggravates attempts to contain and treat the disease. Aid workers and health facilities have been threatened and attacked on multiple occasions during this Ebola outbreak. These incidents include attacks on an Ebola facility and the homes of Ebola victims in Liberia, threats against Red Cross workers in Sierra Leone, and the murder of eight health workers in Guinea. This additional dangerto health care workers already taking on the risky job of caring for Ebola patients in countries with minimal public health infrastructure has almost certainly depressed the number of medical volunteers to address this outbreak.
Health care workers in personal protective equipment that resembles spacesuits are likely to be extremely frightening, especially in cultures where the germ theory of disease is not widely accepted and thus there is no obvious explanation for the use of this equipment. To hand over a loved one, or even bodily fluids, under these conditions is as understandably terrifying as it may be medically necessary. In retrospect, recent attacks on health care workers are perhaps unsurprising. Individuals who do not believe in the germ theory of disease will almost surely hold some other theory of transmission. In post-conflict societies, this theory might be one that blames former enemies. Unknown aid workers – strangers – coming to your door to offer care could therefore be very suspect.
It is difficult to know whether and to what extent additional resources for health care could have mitigated the effects of this outbreak. Scientists still do not know enough about the origins of Ebola to have prevented its recurrence. Moreover, it presents similarly to Lassa fever, another hemorrhagic virus, and is also mutating very quickly. But what we do know is that health aid accounted for a mere three to six percent (on average) of post-conflict aid to Liberia and Sierra Leone through 2010. Increasing this percentage may be a first step to preventing, or at least mitigating, future outbreaks.
Ebola and future civil wars?
The Ebola outbreak has captured international attention, especially so when the virus travelled to North America and Western Europe. But it is by no means the only infectious disease that can spread rapidly and fatally, particularly during and after civil war. HIV/AIDS, malaria, and tuberculosis are already prevalent in Africa and also require constant monitoring. Previous research has suggested that improving a country’s health infrastructure post-conflict can increase government legitimacy and economic development . Investment in such infrastructure may also be critical to preventing global pandemics. Thus, wealthy governments should be extremely interested in making such investments; it is in their national interest to do so.
Just as the destruction of public and personal infrastructure in civil war enabled the spread of Ebola, the current outbreak has ravaged the already-precarious health infrastructure of affected countries. Another danger to guard against today is the possibility of renewed civil war. Projections for economic development as well asconfidence in government in Sierra Leone, Liberia, and Guinea are dangerously low, and the Director-General of the World Health Organization has suggested that these outbreaks could lead to state failure or collapse. In addition to providing emergency relief, then, the international community must commit, along with the governments of Sierra Leone, Liberia, and Guinea, to rebuilding a public health infrastructure that can contain the disease both medically and politically. Failure to do so could lead to as many indirect as direct future victims of Ebola.