Last week, Chris Blattman asked in his post, “Did the International Monetary Fund help make the Ebola crisis?” and his short answer was no. His post was in response to a paper (technically, a “comment”) published in a leading health journal, the Lancet Global Health.
Their basic argument: the IMF gives lip service to social services, but their insistence on financial austerity starved the health systems of Guinea, Sierra Leone, and Liberia, and the crisis is worse because of it.Unfortunately, this just doesn’t really make sense if you’re familiar with the governments in these places, local politics, or more generally how weak states actually work. I see more opinion than evidence. To me, it illustrates the perils of doing research from afar, and ignoring politics.
In lieu of what Blattman is calling opinion, we offer some evidence for why observers could argue that the IMF is partly to blame for the worst Ebola outbreak on record. In addition to reading the Lancet Global Health commentary cited by Blattman, we recommend five readings for folks to consider the argument that the IMF — and the international political economic context, more generally — helped shape the landscape in which Ebola emerged in West Africa last year. Like the Lancet commentary, the readings we recommend exhibit an awareness (not ignorance) of local politics. And because proximity to the research site appears to be of primary importance for Blattman, we include a few written by experts who draw their conclusions from research conducted ‘from near’ rather than ‘from afar.’
- “Anthropological Perspectives on Structural Adjustment and Public Health” is a review article by University of Washington anthropologists James Pfeiffer and Rachel Chapman; both have studied public health issues in Mozambique since the 1990s. Their comprehensive synthesis and detailed analysis of existing research by anthropologists examines the effects of programs supported by international financial institutions and neoliberal ideologies guiding government health financing decisions. Many of the accounts they describe are field-based inquiries in health services delivery in Latin America, sub-Saharan Africa and the former Soviet Union. Other accounts are drawn from economics, political science and epidemiology, reflecting their commitment to interdisciplinary scholarship.
- “The Deadly Ideas of Neoliberalism: How the IMF has Undermined Public Health and the Fight Against AIDS” is a book by Rick Rowden, who has worked for development NGOs for nearly a decade. We recommend, in particular, Part Three of Rowden’s book, which examines published research, official reports, conference declarations and parliamentary statements to document the failures of neoliberal reforms to improve health outcomes. In Part Three, Rowden “explains the ways in which… support for strengthening public health systems and health workforces is being blocked by the IMF’s fiscal and monetary policies and their associated budget restrictions and wage bill ceilings.”
- AIDS and Accusation is a medical anthropology classic by Harvard physician-anthropologist Paul Farmer. “AIDS and Accusation” combines ethnographic, historical and political-economic analysis to show how a dam-building project funded by the U.S. Agency for International Development and carried out under Haiti’s Duvalier regime displaced peasant farmers, shaped labor migration patterns and heightened migrants’ HIV risk. Although the book does not explicitly blame the IMF for Haiti’s woes, it shows how policies of yesteryear — from the trans-Atlantic slave trade, to indemnity and donor-funded development projects — can affect public health and the institutions put in place to address contemporary health problems.
- “Globalization, State Failure, and Collective Violence: The Case of Sierra Leone” is a peer-reviewed research article by political scientist Earl Conteh-Morgan. Conteh-Morgan traces pre-civil war popular discontent with the government of Sierra Leone, in part, to President Siaka Stevens’s (1971-1985) early resistance to IMF/World Bank policies and later adoption by President Joseph Saidu Momoh (1985-1992) to demonstrate how World Bank and IMF policies affected public-sector financing of social services. Conditions wrought by austerity measures nurtured widespread discontent and, later, state collapse. War severely affected delivery of health care by destroying health clinics, propelling flight of qualified clinicians, and limiting training and payment for new clinicians.
- “Rebuilding Human Resources for Health: A Case Study from Liberia” is a case published in 2011 by a team of researchers from Liberia’s Ministry of Health and Social Welfare (MOHSW) and the Clinton Foundation’s Health Access Initiative. From the article:
Even with better salaries for health workers, MOHSW’s ability to hire additional health workers was constrained by the dual challenge of limited resources and an employment ban in the public sector. The employment ban was one of the conditions Liberia agreed to in order to benefit from debt relief under the joint International Monetary Fund-World Bank Heavily Indebted Poor Country Initiative. It was revised in 2007 to allow the government a moderate increase in minimum wage but continues to keep salaries low and impacts the ability of the government to hire new civil servants.
In our own work — Benton’s book, “HIV Exceptionalism,”and Dionne’s article, “Local Demand for a Global Intervention” — we show, using the case of AIDS interventions in Africa, that local actors exert agency to make meaningful, high-impact decisions. But those same local actors are also constrained by donors’ misaligned funding and policy priorities: powerful Western agencies like PEPFAR, the Global Fund and UNAIDS often organize and fund their priorities with limited insights from the local communities that are their “intended beneficiaries.” This myopia is a feature, rather than a bug, of international funding for health; these days, there’s a premium for projects that are mobile, replicable and scalable. In other words, the projects typically supported by major donors are those that can be implemented anywhere and for anyone — with small tweaks, here and there.
Though we wouldn’t go so far as to say that the IMF is wholly to blame for the Ebola outbreak, the IMF and organizations like it have played an important role in creating a political environment in which the epidemic could emerge and become the deadliest on record. That is not to say that we are taking as Blattman writes, “a Western-centric view, where it’s our aid or financial policies that are responsible for the success or failure of poor countries,” nor, relatedly, do we think domestic governments are blameless in their actions and inactions leading up and responding to the outbreak. Rather, we argue that to ignore the effects of foreign aid and financial policies on local politics and social conditions is to miss an important part of the story — the transnational part of this story — that needs to be told.
In a commentary to be published in April in the African Studies Review, we argue that the legacies of the trans-Atlantic slave trade, colonialism and, yes, structural adjustment programs have helped to shape the political, social and economic environment in which Ebola thrives as much as they shape the response to the crisis itself. Though our commentary goes into greater detail than this blog post, it leaves open questions about the extent to which specific policies and practices will matter most in curbing the epidemic.
It is still too early to make definitive statements about who is to blame, especially since the end of the West African Ebola outbreak is not yet on the horizon. Nonetheless, there’s something to be learned from the experience of earlier epidemics and responses, and that record suggests that the IMF and organizations like it are — at least partly — blameworthy.
Adia Benton is assistant professor of anthropology at Brown University. Her book, “HIV Exceptionalism: Development through Disease in Sierra Leone” is due out next month. Follow her on Twitter at @Ethnography911.