In Zimbabwe, the government recently declared a cholera emergency in the capital, Harare, after at least 20 people died and 2,000 fell ill. The response to these and other public health crises in Africa points to the need for action by multiple authorities.
Our research shows that while the WHO has a highly visible role in responding to such crises, Africans with a direct stake in promoting health (“stakeholders”) have significant power to shape health outcomes.
Over the span of a decade, we interviewed almost 250 government officials and community leaders working on AIDS, Ebola, noncommunicable diseases such as diabetes, and epidemic control. We spoke with people in Liberia, Ghana, Nigeria, Zambia, Tanzania, Uganda, Burkina Faso, Togo and the United States.
In Liberia, our research explored community actions during that country’s 2014-2015 Ebola outbreak. In Burkina Faso, Nigeria and Togo, the work questioned how the West African Health Organization (WAHO) responded to the outbreak.
Local actions can have big outcomes
Africans are not passive participants in the presence of global health organizations such as the WHO — but have the power to affect health outcomes through what may seem to be small activities. Our research shows that religious leaders, traditional healers and community activists take on specific tasks, such as educating people about outbreaks, mobilizing their followers to help the sick and providing medicine and initial treatments.
As religion and global development scholar Katherine Marshall points out, they are often first responders in health outbreaks, because they live in the community and know the inhabitants. These leaders also may act as intermediaries between community members who may be critical of outsiders and global health experts who may not understand local customs or belief systems. In Congo, for instance, the WHO has turned to local religious leaders and village chiefs to gain access to rebel-controlled territories.
Local leaders do more than negotiate. They explain health issues in ways the local population can understand. Here’s an example — several Zambian pastors told their followers that AIDS treatment is a “gift from God,” an explanation that made people with HIV want to take their medications faithfully. In Liberia, church leaders framed Ebola as “the devil” that needed to be combated with hospital care for the ill and prayer for healing and protection.
And these players are finding their way onto the global stage
African stakeholders also demonstrate far broader power on health issues. For example, a number of African presidents made highly publicized speeches at the United Nations on AIDS in 2001 — and to the global media on Ebola in 2014. These statements made it hard for powerful states to ignore these crises.
African countries have organized health responses themselves, not waiting for international assistance. Before the WHO’s intervention in the West African Ebola outbreak, WAHO, within two days of Guinea and Sierra Leone declaring an Ebola an epidemic, contributed $12 million toward regional intervention. WAHO supported the rapid repair of health-care facilities in Sierra Leone.
WAHO also supported teams who traced the contacts of infected people in Guinea, Liberia and Sierra Leone. And WAHO provided essential supplies: 14 ambulances, 2,000 infrared thermometers, 200 disinfecting products and 1,000 safety boxes for the transport of vitamins and supplements in areas with infected people.
These actions often occur in contexts that are highly dependent on foreign assistance. Congo, for example, gets 39 percent of its health money from donors. Approximately 70 percent of WAHO operational funding comes from external partners.
Despite this dependence, African stakeholders have managed to make the aid work on their terms. They have pushed back against health policies they think are not appropriate in their cultural or religious contexts. For example, Liberian religious and traditional church leaders successfully demanded the end of the cremation of Ebola-infected bodies.
Traditional healers in Burkina Faso and Togo have sought scientific evidence about the efficacy of their therapies. They also received training on intellectual property rights to ensure they can maintain control over traditional remedies in the face of pressure from pharmaceutical companies.
What gives stakeholders power in health responses?
Research indicates that local populations need to “trust the messenger” before they adopt health behaviors such as immunizing children. In surveys conducted in 36 African countries by Afrobarometer, a nonpartisan research network, the majority of respondents in all countries said that they trusted traditional leaders “somewhat” or “a lot.” A high level of trust makes these leaders effective health messengers. Our research indicates that when there is limited information — such as an Ebola outbreak — people rely heavily on these leaders to help them understand events and respond.
However, trust is not absolute. Research on African pastors and the AIDS epidemic in Uganda indicates that trust declines when populations perceive that local intermediaries are economically benefiting from global health programs. Distrust of governments in West Africa made people less likely to listen to public health messages — and this amplified the influence of community leaders.
Trust also takes place within a specific historical context. Though trust across religious and ethnic lines improved in Liberia after its war years (1989-2005), it was less apparent in areas most affected by Ebola. This fragile trust meant that people turned to their own ethnic and religious leaders for information.
In a similar situation, long-term conflict in eastern Congo has made local authorities indispensable for combating violence. But village chiefs, community leaders and religious officials have not always protected populations — and the local population’s trust may have eroded. In such contexts, leaders themselves may be not be effective health messengers.
These can be front-line health-care messengers
Even though none of our fieldwork was conducted in a country with a protracted war such as the one in Congo, our findings on stakeholder power and trust have wide applicability. We acknowledge the challenges of coordination and adequate resources in health crises such as the current Ebola outbreak in Congo, but our findings suggest that improving the health of local populations requires knowledge about how African players affect outcomes.
Emmanuel Balogun is assistant professor of international relations at Webster University and author of “Convergence and Agency in West Africa: Region-Building in ECOWAS” (Routledge, forthcoming 2019). Twitter: @EA_Balogun
Amy S. Patterson is professor of politics at University of the South, and author of “Africa in Global Health Governance: Domestic Politics and International Structures” (Johns Hopkins University Press, 2018).