PERSPECTIVE| FES SENEGAL Strategies for Combating Ebola? Comprehensive development needed! ANNETTE LOHMANN November 2014 n The Ebola crisis is exposing structural deficits in development that go far beyond a health crisis: the health crisis is threatening to become a food crisis as well as an economic and social crisis. All this shows that infectious diseases are inseparably interwoven with fundamental issues relating to political, social and economic development as well as properly functioning statehood. Not Ebola is the fundamental problem, but rather deficits in development, brutally exposed by the disease and which in turn are massively reinforcing the impact of Ebola. n Developing countries and the international(donor) community must tackle structural problems early on in a resolute and determined manner. Only if sustainable, inclusive health-care systems can be established providing at least basic security for everyone, the state assumes the role of providing public goods and reasonable, socially just distributed economic growth is achieved can shocks such as the one caused by the outbreak of Ebola in West Africa be significantly mitigated – and become less of a global threat. n It is not enough to focus on a few(rather more developed) countries in sub-Saharan Africa, as this fails to realise that development in less internationally salient countries is also in the direct interest of the international community.

ANNETTE LOHMANN| STRATEGIES FOR COMBATING EBOLA? Ebola or Ebola Fever is a viral disease. It attacks both primates as well as humans. The disease cropped up for the first time in the present-day Democratic Republic of the Congo and in the Sudan in the 1970s. It is named after the Congolese river Ebola. The virus is transmitted by bodily fluids; the incubation period is up to 21 days. No approved medication is available to treat it, nor is there any vaccination to prevent it available at present. In many cases of infection the disease is fatal. Ebola has become a global challenge. Borders are being closed out of fear all over Africa, the USA and Canada have in part imposed drastic restrictions on travel into their countries from countries affected, in particular for medical personnel. Even in countries in West Africa that have not been affected, information and awareness campaigns are taking place, while travel, economic and conference activities are being scaled down massively on the whole. Four cases and one fatality in the USA to date have unleashed public hysteria there. Without wanting to compare numbers of fatalities or play things down: these drastic measures cannot be explained by the pure numbers involved in the spread of Ebola at present. According to the World Health Organization(WHO), there had been more than 15,000 cases and over 5,000 fatalities in West Africa by the middle of November 2014, most of them in Liberia. By way of comparison: 1.6 million people in the world died of AIDS in 2012, while there were around 2.3 million new infections. According to the WHO, in the same year 627,000 people died of malaria, most of them in Africa. 1.3 million people died of tuberculosis in the world in 2012 as well, according to the WHO. While the world is witnessing the spread of Ebola in West Africa with bated breath, Ghana and in particular the capital Accra is at the same time grappling with a massive outbreak of cholera, with 24,000 infected persons and almost 200 fatalities by the middle of October 2014, according to the WHO – and health care in hospitals in a deplorable condition there. The number of cases of cholera and tuberculosis in Cameroon is soaring at present as well – without this receiving any coverage in the international press or any crisis-support measures being taken. Nor do the channels of transmission justify this panic. Ebola is not transmitted through the air, for instance – in contrast, e.g. to the avian flu – but rather through the exchange of(extremely small quantities) of bodily fluids(or the consumption of infected game). This explains why in Conakry, Guinea many physicians and hospital staff have been infected. They are having to bear the brunt of the consequences of insufficient equipment in hospitals and overwork resulting in carelessness. In addition, they are often confronted with infected family members who are afraid of being treated by a physician wearing protective clothing. Let us not be mistaken: the current Ebola crisis in West Africa has taken on unparalleled dimensions, plunging the countries affected into a serious crisis. Apocalyptic projections are being ventured suggesting that this already-dramatic situation can deteriorate into something many times worse. But the Ebola crisis is above all exposing gaping structural deficits in development that go far above and beyond a health crisis. When people became aware that Ebola had broken out in Guinea at the end of March 2014(the actual outbreak took place as far back as the end of 2013), but then seemed to be receding in the ensuing months, the governments of Guinea, Liberia and Sierra Leone as well as the international community did not see any cause for resolute, rapid action, thereby underestimating the situation drastically. Insufficient capacities on the part of the WHO, which has been weakened by cutbacks in funding from the international community, as well as the countries affected, which are among the poorest in the world and have woefully inadequate health systems, prevented rapid, effective and efficient containment. The second wave of infections thus caught decision-makers unprepared. The virus was moreover carried into additional countries in West Africa by travellers: cases of Ebola appeared in the most heavily populated country of Africa in July 2014 – in the Nigerian city of Lagos, with 20 cases and eight fatalities being confirmed there by the beginning of November 2014. Further spread of the decease has been checked in the meantime thanks to a comparatively better health system and the resolute reaction of the authorities there. There have been six fatalities involving Ebola in Mali as of the middle of November. 1

ANNETTE LOHMANN| STRATEGIES FOR COMBATING EBOLA? The first and to date only Ebola case in Senegal was at the end of August 2014. The infected person was a student who had illegally travelled there from Guinea. Reports about attempts to cross the border illegally as a result of comparatively good medical treatment possibilities in Dakar are multiplying. Already at present, the tourist sector is registering a significant decline in numbers, and the epidemic is having a major impact on regional and international conferences – an important source of income for Dakar. Senegal has been officially declared free of Ebola once again since 17 October 2014. There was a(renewed) Ebola outbreak in the Democratic Republic of the Congo at the end of August, although another strain of the virus was responsible there. 66 cases had been confirmed by the middle of November 2014, 49 of them fatal. There are indications that the further spread of the disease has been successfully contained in the meantime because cases can be better isolated there than in West Africa and the government is well versed in infectious diseases. In other places the situation has taken on dramatic proportions. The inability of Liberia’s health system to cope with the situation is one prominent example. Before the outbreak, there was one physician per 100,000 inhabitants in a population of 4.4 million. According to the UN, this ratio has worsened considerably as a result of medical personnel becoming infected. An air lift was set up between Dakar and Liberia’s capital Monrovia as well as Sierra Leone and Guinea for this reason in autumn 2014 with the aid inter alia of the American military and German armed forces to help transport aid material as well as material for the construction of health clinics and quarantine stations. Deficits in public health care have not only been exposed by the inability to cope with Ebola. They have also become visible with regard to secondary effects. People who are suffering from illnesses other than Ebola no longer receive care because the infrastructure is already overwhelmed, or they no longer go to hospitals out of fear of infection. As a result, a simple malaria infection, widespread at present due to the rainy season and which under normal circumstances can be treated relatively easily, can become life-threatening. The Ebola crisis is also negatively affecting the general supply situation. Over the long term, in the view of experts, people in all countries hit by Ebola will require food aid. Agriculture in Liberia, Sierra Leone and Guinea is suffering immensely, according to a warning issued by the UN Food and Agriculture Organization(FAO). Fields cannot be tended because many people, among them peasant-farmers, have been placed under quarantine and roadblocks set up. Traders have left the areas affected and(interregional) trade is suffering. This especially goes for»small-scale border trade«, i.e. primarily informal commerce, which provides a living for hundreds of thousands of people. According to the World Food Programme(WFP), approximately 200,000 people in Guinea, Liberia and Sierra Leone food insecure at present(due to the spread of Ebola up to October 2014). If the spread of Ebola slows down by January 2015 – as forecasted by health experts – approximately 750,000 people from the three countries would be affected by food insecurity by March 2015. To top it all off, gloomy forecasts have also been issued with regard to future economic development. Growth forecasts for Liberia have been adjusted downwards by the World Bank from 5.9 to 2.5 percent, and for Guinea by more than two per cent from 4.5 to 2.4 percent. This might still sound like solid economic growth, but it is deceiving. What would appear on the surface to be high growth rates of 5 percent and more in sub-Saharan Africa are frequently negated by ongoing population growth rates. For true economic development to take place, higher rates would be necessary which are not based on the export of raw materials. There has been no industrialisation of West Africa with creation of value chains, which would help avoid vulnerability to price fluctuations for raw materials. Production losses in Guinea, Liberia and Sierra Leone have accumulated to an estimated USD 359 million(Euro 290 million) in 2014. In addition to the direct effects being suffered by the three countries most affected, all of West Africa is at least indirectly affected by Ebola.»Ebola has stigmatised our countries,« according to John Dramani Mahama, President of the regional organisation ECOWAS.»Nations that depend on tourism, that have registered no case of Ebola, are suffering from the cancellation of vis2

ANNETTE LOHMANN| STRATEGIES FOR COMBATING EBOLA? its«. On top of it all, Africa is once again being perceived as a continent gripped by crisis – and hence stigmatised as a victim and recipient of aid. This not only reinforces clichés – it also impedes a constructive analysis of the role and responsibility of African actors. The actual problem: insufficient development The danger is looming that the health crisis will turn into a food crisis or an economic and social crisis. All this underscores that infectious diseases are inextricably interwoven with fundamental issues relating to political, social and economic development and properly functioning statehood. Not Ebola is the fundamental problem, but rather deficits in development, brutally exposed by the disease and which in turn are massively reinforcing the impact of Ebola. What is needed is long-term, stronger development cooperation – above and beyond urgently necessary aid on a massive scale for the fight against Ebola. One key deficit in development that has now become apparent is the ailing public health system, which is often chronically underfunded. According to the World Bank, per capita expenditure on health in 2012 was between$ 32 in Guinea and$ 96 in Sierra Leone. By way of comparison: in the same year per capita expenditure on health in Germany was$ 4,683. The health system in many countries of the Global South can only be propped up with subsidies from international donors. Public health has thus become a mirror image of the level of development in a country. Added to this is the fact that, although there are government social security systems including health insurance in place, in most cases only formally employed persons have access to these systems, which are often rudimentary at best. The overwhelming majority of employees in sub-Saharan Africa, however, are informally employed and thus left to fend for themselves or rely on traditional family networks. Even less serious illnesses pose a massive threat to entire families. There is a lack of national health systems with funding based on the principle of solidarity which provide and guarantee at least basic care for everyone – independently of the type of employment. This also illustrates that health has in the meantime become a global public good requiring long-term and sustainable commitment both by the international community as well as governments of the individual countries. The American economist and special advisor to the Millennium Development Goals, Jeffrey D. Sachs, recently rightly called for»basic health care to be provided in every slum and in every rural community« in order to achieve universal health care and thus help the poorest countries( Eine Antwort auf Ebola – was ist zu tun, um weltweite Epidemien in den Griff zu bekommen? http://www.ipg-journal.de/kommentar/artikel/ eine-antwort-auf-ebola-544/). The Social Protection Floor Initiative(SPF) of the International Labour Organization(ILO) from 2009 proposed for the first time social security programmes for all citizens, including in poor countries, thus taking into account the exclusion of many people from social protection there. This recommendation acknowledges the fact that a minimum degree of social protection is a basic precondition for growth, employment and hence development. Some newly industrialising and developing countries such as Brazil, Thailand and Burkina Faso have in the meantime begun to implement the principles underlying the SPF. This strategy offers the possibility of economic and social stabilisation and development. It warrants further attention, implementation and international support. Prevention of a crisis such as the present one or appropriate crisis management requires a minimum level of functioning statehood. Thus the closure of borders, which on the surface appears to make sense, is an indication of the helplessness of governments rather than any convincing, adequate strategy. At the same time, purportedly closed national borders are permeable and not sufficiently patrolled – the effort to seal off borders is undermined by many illegal border crossings. Nor can the economies of many countries afford to close borders. They lack the sturdy foundations to make them resilient against external shocks such as the Ebola crisis. This economic weakness also acts as a constraint on the development of a strong state. Effectively functioning statehood goes even further, however: only when a state is able to make sufficient public goods available – and is also perceived as the agent of these in the eyes of the population – can citizens develop trust and confidence and a minimum collective feeling of community based on solidarity. Traditional 3

ANNETTE LOHMANN| STRATEGIES FOR COMBATING EBOLA? large-family structures frequently serve as a substitute. At present governments of countries are losing the confidence of the population, however, as the inability of the state to cope is all too apparent. This is especially problematic because old conflicts are threatening to break out again in the countries primarily affected. And finally: countries like Guinea, Liberia and Sierra Leone are poor and struggling to cope with many challenges. Resources are nevertheless frequently squandered as a result of mismanagement and endemic corruption in the state and society, while existing potential is not being leveraged. In order to be able to confront the development deficits identified here, reasonable economic growth must be achieved. In spite of positive trends in economic development in many states in sub-Saharan Africa, the hope that a general improvement in living conditions would come about for the majority of the population is only infrequently met. What on the surface appears to be a high level of economic growth often does not lead to any perceptible economic and social development or it dissipates without any impact(»jobless growth«), casting doubt on narratives like»Africa Rising« or the»Lions on the Move«. The absence of redistribution and mechanisms for social protection – especially for the large informal sector – translates into high social risks and uncertainties for a large share of the population. A minimum of social participation is just as remote for a majority of society as is political participation. The exclusion of the majority of the population from social progress precludes any sustainability of political transformation processes. Democracy must»deliver« in this respect while ensuring just participation. Otherwise political progress will always remain unstable and vulnerable to setbacks. Finally, the task is to confront the insufficient level of education in sections of the population with sensitive information and educational work. People in West Africa are being confronted with the Ebola virus for the first time and uncertainty is rampant. At the same time, traditional rituals(such as burials, for example) are helping spread the virus. Work convincing and informing people, frequently being performed by helpers at the risk of their lives at present, deserves major recognition. Furthermore, the foundations for information and awareness-raising on issues of health and hygiene have to be created for the period following the crisis. Development is also in the interest of the international community Guinea, Liberia and Sierra Leone are among the poorest and least developed countries in the world. For a long period of time they were nevertheless not a priority in international development cooperation. The Ebola crisis has sparked major international attention towards these countries which, however, is coming(too) late and might not be sufficient. To prevent a repetition of such a scenario, developing countries and the international(donor) community must combat structural problems early on and in a forthright manner. Only if sustainable, inclusive health-care systems can be established providing at least basic security for everyone, the state assumes the role of providing public goods and reasonable, socially just distributed economic growth is achieved can shocks such as the one caused by the outbreak of Ebola in West Africa be significantly mitigated – and become less of a global threat. A political focus on a few(more developed) countries in sub-Saharan Africa, as proposed by some observers or political actors, is not enough here and fails to realise that development in internationally less salient countries is also in the direct interest of the international community. African states and their representatives need to assume their share of responsibility to this end as well. In addition to short-term crisis measures to combat Ebola, the task is furthermore to resolutely combat illnesses such as AIDS, malaria and tuberculosis and to invest in prevention and vaccinations. Healthcare must be recognised as a priority public good – coupled with political, social and economic reforms. The Ebola crisis in West Africa offers an opportunity to contribute to a stabilisation of the region over the long-term through a comprehensive, sustainable policy. 4

About the author Annette Lohmann is the director of the Friedrich-Ebert-Stiftung office in Dakar, Senegal. Before this she headed the FES office in Bamako, Mali. She worked in the Middle East Department of the FES in Berlin from 2007 to 2010. From 2005 to 2007 she served as representative of the FES in the Working Group for Peace and Development(FriEnt). Imprint Friedrich-Ebert-Stiftung| Africa Department Hiroshimastr. 17| 10785 Berlin| Germany In charge: Manfred Öhm, Head of the Africa Department Tel.:+49-30-26935-7440| fax:+49-30-26935-9217 http://www.fes.de/afrika Orders: caroline.lemmer@fes.de Commercial use of media issued by the Friedrich-Ebert-Stiftung(FES) is not allowed without the written consent of the FES. The views expressed in this publication are not necessarily those of the Friedrich-Ebert-Stiftung or of the institution for which the author works. ISBN 978-3-95861-032-3