Are some countries — and some political systems — more at risk for bad health and epidemics than others?
Economist Amartya Sen has famously argued that democracies don’t have famines. Here’s his reasoning: Famines result not from failed crops but from failures to distribute food. In functioning democracies, governments are accountable to the public — and therefore have more incentive to prevent catastrophic failures, such as famines, from occurring.
Is the same true for epidemics?
It’s certainly true that politics is related to the spread of disease. As Maryam Deloffre noted here at the Monkey Cage in her post on Zika last month, “political and economic factors like state incapacity and uneven development created conditions conducive to the spread of infectious disease.” During the 2014 Ebola outbreak, strong state capacity helped Nigeria avoid an outbreak, while Sierra Leone’s health system was completely overwhelmed by the disease.
But while political and economic factors do matter, they’re not the only factors. Political systems alone cannot predict where a disease will spread, or which country will be more or less susceptible to an epidemic.
For example, Brazil consistently ranks higher than Uganda on measures of government capacity and economic development. Yet Zika reached epidemic levels in Brazil while in Uganda, where the disease was first discovered, there have been only two recorded human cases in almost 70 years. Assuming that government capacity and economic development lead to better health outcomes obscures many of the ways in which politics and disease interact.
Case study: HIV/AIDS in Uganda and in South Africa
I researched the politics of AIDS in Africa to understand why Uganda was able to successfully control HIV, while South Africa failed. How did a poor, autocratic country with low institutional capacity turn the epidemic around? Why did the richer, more democratic country with the stronger health-care system do so poorly? The answers come at the intersection of politics, diseases and public discourse.
During the early days of HIV’s presence in Uganda, President Yoweri Museveni spoke about the disease every chance he had. He did so in a colloquial and accessible way, and Uganda’s decentralized structure of government helped Museveni spread his message quickly and widely.
We might think that decentralized government would make it harder for a president to spread a message. With more actors and more opportunities for opposition, it would seem that it would be more difficult to exert influence. But in Uganda, this structure is really just a tool of political patronage. With so many people dependent on Museveni for their political positions, public officials at every level quickly fell in line when the president decided to prioritize speaking about HIV.
As author and journalist Helen Epstein and others have argued, Museveni’s messaging helped reduce stigma, gave people a willingness to discuss HIV publicly and made it more likely that Ugandans would take actions — such as remaining faithful to one partner or getting tested — that slowed the spread of HIV.
South Africa, by contrast, handled the disease in almost the opposite manner. It is indeed a democracy. But South Africa’s political history led the government to reject any productive way of confronting the disease. One key reason was that the African National Congress (ANC), South Africa’s ruling party, employed a top-down, militaristic style of leadership, which emerged from its history in exile. One’s position within the party isn’t always based on merit or democratic principles; rather, it depends on political patronage and the ability to “work as part of a team.” That made questioning or criticizing a leader’s position extremely difficult.
And President Thabo Mbeki’s position was troubling. He asserted that HIV could not cause AIDS, and instead he directed attention to other factors, such as poverty and nutrition. This “AIDS denialism” gained significant traction in part because of his leadership — and in part because that message resonated with South Africans’ general mistrust of Western science and pharmaceutical companies. This confusion permitted the promotion of a slew of questionable homegrown solutions, and Mbeki encouraged popular conspiracy theories about the origin of AIDS.
Public health researchers have concluded that, as a result of Mbeki’s political decisions, almost 350,000 people died unnecessarily. Even now, South Africa has yet to have the same success with behavior change as Uganda has had.
In fact, when the Centers for Disease Control and Prevention recently recommended that Americans infected with the Zika virus either refrain from having sex or use a condom, South African opposition leader Helen Zille referred to her country’s poor history on HIV prevention by tweeting:
I wonder whether they will have more success at achieving behaviour change than we have had. I hope so. https://t.co/mN49N6fSQ0
— Helen Zille (@helenzille) February 6, 2016
Democracies can fail to stop epidemics, too, and poverty isn’t always the problem
Sometimes democracies can interfere with good public health policy. Electoral cycles influence what kinds of policies are pursued and when. And public pressure — the very thing that Sen argues makes democracies protective — isn’t always focused on protecting against future outbreaks. Sometimes other issues are more pressing. This creates what political scientist Per Strand has called a “governance dilemma” — spending money on HIV or other disease prevention can be politically costly.
It’s true that, as Deloffre noted, microcephaly cases in Zika-affected countries were “initially concentrated in the poorer and underdeveloped areas.” Being poor and having inadequate access to services often puts marginalized groups on the front lines of infectious diseases.
But the connection between poverty and disease is not always so simple. HIV also spread in Africa through networks of better-off, mobile and well-connected individuals. Two of the continent’s wealthiest countries — Botswana and South Africa — have some of the highest HIV rates in the world.
Politics, culture and economics can be as important as vectors and viruses — but it’s a complicated mix
Epidemics aren’t famines. Sometimes democracies can fail at public health while autocratic regimes succeed. Sometimes having access to resources will put populations at higher risk. Instead of assuming that some political or economic realities are better or worse than others, we need to recognize that political context and history matter in shaping policies and influencing public reaction to those policies.
In other words, political and economic factors interact with viruses and vectors in unpredictable ways to spread — or prevent — disease.
If the goal is to reduce the spread of infectious diseases, we need to do more than ask, “What worked there?” We need to ask, “Why did that work there when it did?” We need to better understand how disease epidemics interact with social and political realities. That’s how to find lessons that may help contain and control future outbreaks of disease.
Mark Daku is a postdoctoral fellow at the Montreal Health Equity Research Consortium at the Institute for Health and Social Policy at McGill University. His research is at the intersection of political science and epidemiology. Follow him on Twitter at @markdaku.