The number of cases of covid-19 — the newly named coronavirus — has topped 70,000 globally, with over 1,800 deaths. The World Health Organization declared a Public Health Emergency of International Concern on Jan. 30, citing the lack of scientific knowledge about the new virus, as well as the need to increase preparation in “vulnerable countries and regions.”
Trust matters for public health
Studies on race and health in the United States and global immunization campaigns indicate that trust is an all-important element. Without trust, people tend not to heed health information or follow treatment advice. Distrust of public health institutions meant people avoided health-care centers during West Africa’s 2014-2016 Ebola outbreak, for instance.
Corruption within public services deepens people’s suspicions of government health actions, and it undermines health-care access. When new diseases such as Ebola in West Africa or covid-19 emerge, a lack of scientific knowledge or patient personal experience also can undermine confidence in health-care institutions.
As my research in Ghana shows, patients may question medical approaches to health issues with “unseen” causes such as mental health disorders. A lack of confidence in public health services is one reason people with chronic conditions such as mental health disorders delay seeking care.
Trust can depend on who delivers the health message
Surveys show that people in Africa tend to place greater confidence in traditional or religious leaders than government officials. This pattern could present a challenge with covid-19, if distrust leads citizens to discount public health authorities.
Experience suggests that the potential for the virus to spread will be much higher if community leaders are not part of the public health response. In the West Africa Ebola outbreak, cases began to decline when religious leaders and village chiefs started to educate people about social distancing and bringing the sick to Ebola treatment units.
Trust in outside organizations also matters
In Africa, where donors provide sizable amounts of health funding and the WHO plays a significant role in providing technical assistance and support, trust in these organizations can affect health responses. Trust relates to past actions — and many African health officials may be somewhat circumspect about the WHO’s capacity, given its perceived foot-dragging on the Ebola outbreak in 2014.
After that outbreak, donors called for pandemic preparedness. They devised multiple programs like the World Bank’s Pandemic Emergency Financing Facility. Yet their limited financial commitments to these programs undermined trust among health experts and policymakers. The bank’s delayed release of financing for the 2019 Ebola outbreak in the Democratic Republic of Congo brought criticisms. Some African politicians question whether the global health security agenda is most concerned with protecting people in high-income countries from diseases that originate abroad.
Years of donor-promoted market-based reforms that cut public health budgets and capped salaries — as well as a focus on disease-specific programs like those for AIDS — have meant less funding for primary health care. The resulting staff shortages, facility overcrowding, medication shortages and poor patient care in most African public health systems exacerbate people’s unwillingness to rely on available medical services.
African leaders and citizens prioritize conditions such as malaria, tuberculosis, child health and AIDS in policymaking and budget allocations. Politicians must decide how to use limited resources, and they tend to respond to diseases that affect many — and are relatively easy to treat. This enables them to claim credit, which may increase overall trust in government.
Spending money on a possible future outbreak, in contrast, has little political payoff. As one official told me, “After all, such an outbreak may never occur.” The focus on short-term political benefits also limits treatment for diabetes, hypertension and mental health disorders that affect millions across the continent but receive limited attention or resources.
Governments are under pressure to be vigilant
If an outbreak occurs and governments are not prepared, however, there will be political backlash. Surveys across 32 countries indicate that health, education and employment are African citizens’ top priorities.
Africans want their governments to be responsive to their needs. In addition, African leaders have to consider how donors might react if they are slow to respond to pandemics. In Tanzania in 2019, the WHO reported a possible Ebola case in the country, which the government denied. When Tanzania refused to share patient laboratory results, the United States and the WHO issued strong criticisms.
This example illustrates how power undergirds global health. Through resources, the United States and the WHO exert the power in helping African countries be prepared for covid-19. But power also affects how we see health issues and whose expertise we value. As my colleagues and I argue, power means that issues with nascent scientific knowledge, limited advocacy and no strong government backer — such as mental health — gain little attention. Similar forms of invisible power — evident in negative portrayals of Africa in the global media and Western societies — promote the idea that African countries are not up to the task of covid-19. Global collaboration rooted in African knowledge can challenge such views.
As Emma-Louise Anderson and I find in our research on AIDS programs in Zambia and Malawi, even when constrained by aid dependence or diplomacy, African health professionals have considerable capacity to shape health programs in locally relevant ways. For the coronavirus, African health authorities have tested and reported possible cases to the WHO. The Africa Centers for Disease Control and Prevention, created after the West African Ebola outbreak, is emerging as a regional leader with the interest and capacity for cooperative responses to outbreaks. And its efforts to build national public health institutions benefit public health beyond disease outbreaks.
As global institutions prepare for what inevitably may be more covid-19 cases in Africa, recognizing the ability of African community groups and governments to act will be key to a successful — and collaborative — response.