In this chapter, various participants offered diverse perspectives on health challenges facing communities in politically unstable countries and regions. They described how local circumstances affect global health risks, including challenges within countries with differing public and private health system infrastructures, and considered directions governance might take to span these political spheres, including accountability and community involvement.
Communities in fragile states often lack local health governance and capacity to recognize, report, and respond to infectious outbreaks, creating critical gaps in the global risk framework. Engaging such communities to address infectious disease threats will require context-specific messages and attention to high levels of preventable mortality common in such settings, according to speaker Paul Wise of Stanford University. Revising or replacing the architecture of relationships between the World Health Organization (WHO), the United Nations (UN), and other international agencies and their major funders will not significantly improve health governance in fragile states, Wise stated. Rather, he argued, “the exercise of power will need to be played out on the ground in some of the poorest places on Earth,” and it must recognize and address the provision of public goods
in these communities, including the question of legitimacy, which can be judged by how governance is achieved and how policies perform. He noted that in some states at particularly high risk for infectious disease emergence and transmission, governance does not adequately address community needs and can be actively predatory.
Mukesh Kapila of the University of Manchester criticized the viewing of governance predominantly through the lens of power. “I couldn’t but reflect from my experiences in 30 years working for the United Nations, the Red Cross, and WHO that that’s what has gotten us into the mess that we are in,” he stated. “The exercising of power actually isn’t going to take us anywhere at all. In fact, what we need to do is to give up power, and the more power you give up, the more influence you gain,” he insisted. Characterizing the West African Ebola crisis as a failure of trust, Kapila argued that “a proper paradigm for global health governance would be about the amount of trust there is between the governed and the governors.” Global health governance unlinked to national and local health governance is not sustainable, he said. While Wise thought that governance is always related to the exercise of power, he acknowledged, WHO’s power and how it is distributed and respected is a question of trust and deep legitimacy.
Where legitimacy is weak, governments lose informational authority, Wise continued. This situation tends to delay community mobilization to address disease threats, regardless of capability or public interest. It is important to note, however, that weak governance does not equal weak communities, as they can often be some of the most resilient. But when there is a divide between the communities and those that govern them, and interests and motivations are not aligned, the gaps that are created can lead to tragedy—as seen during the Ebola epidemic in southeast Guinea, when health workers, journalists, and volunteers seeking to assist communities were attacked, resulting in eight deaths, he said. Although this incident was interpreted in the Western press as stemming from ignorance or superstition, its real cause was political, Wise explained. This occurred in an area that had experienced more than three decades of assaults from a hostile national government, whom the health workers seemed to represent. In order to combat this active evasion of government authority by communities, governments often turn to coercive tactics, including examples like attempting to quarantine the Liberian community of West Point using state authority. This may seem to work at the outset, but it will not be a sustainable or effective solution.
Wise also described a second component of governance for public goods in fragile states—institutional design—as comprising formal procedures and accountability and formal relationships with international and nonstate actors such as the International Health Regulations (IHR). These elements interact with mechanisms of legitimacy, and also with a third component of
public good provision: technical requirements for infectious disease surveillance and outbreak response. In order to transform technical interventions into political currency, three requirements must be met, he said: people must perceive that an infectious outbreak poses a real threat, they must believe that the technical strategy can mitigate that threat, and they must consider implementation of the strategy a responsibility of the state.
These relationships create a virtuous cycle when a technical intervention effectively mitigates a perceived threat, Wise explained. The evidence of mitigation increases state legitimacy, which improves the capability of the health strategy to work as it was designed, he continued. This political currency, which is explicit in counterinsurgency doctrine, is related to, but distinct from, the use of military logistic capability (e.g., logistical assets). However, he added, it is important to recognize that the process of transformation from technical strategies into political currency exposes the health sector to political assault and threatens the neutrality1 of health workers and health services—as has occurred with tragic consequences for polio eradication workers in Pakistan.
Combining Diverse Disciplines
Technical characteristics influence institutional governance requirements as each intervention places a distinct burden on governance, Wise stated. As a result, local health governance tends to be heterogeneous. Wise acknowledged that security and governance in parts of the world that are most concerning cannot be fixed easily. However, he argued, because governance capacity is heterogeneous, and each intervention places different demands on governance, strategic governance reforms can be designed to meet specific technical requirements. These reforms must not only address issues of infectious disease surveillance and response, but must also address local public health needs, he added. It would be peculiar, if not perverse, to try to implement governance reforms in places with extremely high young child and maternal mortality, and have the reforms be confined to outbreak surveillance and response, he observed, because the former problem is ongoing and typically a priority for those communities suffering, and the latter is intermittent if not rare. Mechanisms should be considered that can simultaneously advance local health priorities while reducing outbreak risk, Wise stated.
The pursuit of strategic governance reform will require a new set of integrated health and governance strategies drawing on “combinations
1“Neutrality is not the same thing as being apolitical,” Wise asserted. “Neutrality is an active process and to be neutral demands a deep understanding of the local political dynamics. . . . There is no room to be apolitical here.”
of diverse disciplines who have never spoken to each other, such as political science, global security, and maternal and child health,” and expanding well beyond the purview of complex humanitarian emergencies, Wise said. He also urged the creation of a new taxonomy of strategic governance health interventions, which support good governance as well as cost effectiveness through integrating political and technical considerations. It will be that kind of integrated approach that will best ensure that policies, programs, and recommendations prove both effective and just, he concluded.
“Today no one has the power to do anything,” Kapila asserted. “No one has a monopoly of knowledge—not even academies of science or World Health Organizations—and the problems are too big for anyone to do command and control.” Instead, he said, what is needed is leadership based on passion and basic public health humanitarian values that bring the world together for a common cause, rather than a structured systematic approach, which can quickly become outdated. That shared knowledge is the legacy of Ebola and all the other failures to address health and humanitarian crises.
Mark Heywood, of Section27, South Africa, noted that the people of Africa, who constitute about one-tenth of the world’s population, bear nearly one-quarter of the global disease burden. He described major health challenges including HIV/AIDS, which kills approximately 180,000 people annually, despite the fact antiretroviral treatment now reaches up to 3 million Africans. Registered deaths from tuberculosis number 80,000 per year and include an unknown number of multidrug-resistant cases. Thus, the issue of health risk in Africa is local as well as international, he said. Of South Africa’s insufficient 74,000 community health care workers, 40,000 are being integrated into the country’s health system, Heywood reported, and each earns a monthly wage of about $100. While this framework is not a strong basis for building effective health systems, it can play a role in disease identification, he pointed out. At the same time, tuberculosis, the leading cause of death in South Africa, infects an estimated 80 percent of the population—many of whom remain unaware of the disease that kills them.
While Ebola has given this issue of infectious disease risk greater visibility, it has had a long salience, as several speakers and participants had already observed, and Heywood asked if the political will to truly tackle this risk was sufficient. If mitigating and managing health risk is not a priority, he declared, the root causes of these risks will fester while their symptoms—in the form of epidemics—continue to be managed. Well before the West African Ebola crisis, he said, “we knew that weak health systems
failed to identify microbial threats, and that epidemics further weaken such systems,” but the momentum to break this current cycle is lacking. In Africa, despite instances of improved health outcomes such as declining rates of infant mortality, there has been a general weakening of health systems, Heywood asserted. He noted the weakening of public state health systems and growth of private systems as a contributor to this decline.
Strong, Accessible Primary Health Care
The rapidly growing private market for health care often works against the interests of the public provision and management of health care. In South Africa, just 17 percent of private health care costs for the population equals 100 percent of public health care spending. In sub-Saharan Africa, more than 50 percent of all expenditures on health are out of pocket, primarily for private health care, driven by the poor quality of public health care systems. However, despite consumer belief to the contrary, private health care generally underperforms compared to public health care, particularly with regard to addressing HIV/AIDS.
Ann Marie Kimball of Chatham House remarked that much of the discussion during this series of Global Health Risk Framework workshops had focused on the chronic health care deficits that set the context for the Ebola crisis. While primary care should be functioning as a first line of alert and notification in disease detection, she said, many solutions propose international command-and-control functions that would seem to be fairly late interventions. Heywood observed that community health care has long been a programmatic issue in health, recalling that a significant community health care workforce was built up in response to HIV/AIDS to manage patients and the deceased, provide home-based care, and support the search for treatment. However, that community-based primary care workforce could have played a far wider role, he argued, such as taking on other aspects of preventive care and disease surveillance. Instead, investment in that health workforce has receded along with the perceived threat of HIV/ AIDS, highlighting the sustainability challenges when solutions to broad health challenges are disease specific.
Heywood also highlighted other contributors to the decline of health systems in recent years, including issues such as population movement, weakening of democracy in some locations, and overall government corruption. These contributors illuminate the persistent need for community engagement and mobilization, as well as government accountability in order for global health strategies to be successfully implemented. Long
before the current Syrian refugee crisis, Africa has experienced multiple episodes of mass migrations from conflict zones over many years, he said. As many as 2 million undocumented Zimbabwean migrants currently reside in South Africa—people whose health needs and care are neither assessed nor supported. Additionally, the weakening of democracy and the closing political space for civil society has become an added challenge. Users of health care systems are increasingly excluded from governance, he noted, widening the gap between those who govern and those who are governed.
Heywood explained that, over the past 3 years, more than 60 countries have drafted or passed laws that curtail nongovernmental organization (NGO) activity, including in the field of health. Meanwhile, the growing influence of major powers such as China and Russia in African countries has worrisome implications for the future of democracy, human rights, accountability, and transparency—and, thereby, the legitimacy of health governance as Wise discussed previously. Adding to the worries of foreign power influence and curtailed NGO activity on the ground, corruption also impedes the management of health systems at local, provincial, national, and global levels. Within South Africa, Heywood noted, corruption-related losses to health care (both public and private) amount to approximately $2 billion per year, and the country’s national health laboratory services currently risk collapse due to mismanagement. Examining all of these contributors holistically, it is not difficult to see the adverse implications for many health systems throughout the world when good governance—legitimacy, institutional design, and salient technical interventions—is not practiced and the communities which these health systems are designed to serve are cut off from decision making.
A Need for Community Mobilization
Viewing the response to Ebola through the lens of HIV/AIDS, Heywood advised a return to mobilized communities setting agendas and driving responses and mitigating risks that can be carried into the risk framework. To do this, he added, would require giving users of health care systems far greater input, agency, and power than they currently possess—and allowing them to maintain it beyond any individual crisis. Infectious disease outbreaks should be seen as parts of a continuum of vulnerability and risk, which requires a continuum of response and engagement to try to build responses, he urged.
“We pay a lot of lip service to community mobilization, but what role actually is assigned to communities?” Heywood asked. “How do we start speaking of communities as partners rather than looking at communities as victims?” To begin to answer these questions, two tasks must be tackled—the near-term process of establishing a risk framework, and the long-term
process of addressing the root causes that make communities vulnerable to infectious outbreaks—and this cannot be done without the active participation of those community members. He advised identifying strong communities that persist in the face of weak governance and leveraging their strengths for others.
Directing Government Accountability
For WHO to mean something in communities within fragile states, it must be accountable to the world’s people, Heywood insisted. We should be asking how to bring the moral and political authority of WHO back into play in relation to people’s needs, and in relation to people’s risks. Duchin of Seattle–King County Public Health and the University of Washington pointed out the importance of developing a governance framework that addresses the potential for significant political upheaval, and Wise advised that awareness of political dynamics must somehow be integrated into health intervention programs from their inception. Duchin also expressed concern that many African colleagues—key stakeholders in this process—were not part of this workshop discussion, again highlighting the gap between the governed and those that govern.
Lessons learned regarding command-and-control capabilities from emergency responses to complex humanitarian emergencies are to some extent informative, Wise said. However, they are based on an acute response that typically lasts weeks, after which the average survivor stays at a United Nations High Commissioner for Refugees camp for 20 years. Governance need not be confined to infectious disease, Wise observed, but should be accountable to the people that are being served. However, infectious outbreaks cross borders and, therefore, arouse the interest of powerful Organisation for Economic Co-operation and Development countries, which can create challenges between priorities—especially when bilateral donors become involved.