Kim Yi Dionne, Laura Seay, and Erin McDaniel have written an insightful piece over at the Monkey Cage. A question they raise that caught my eye was “Is a largely military response appropriate for a public health epidemic?” I am currently teaching a class on the International Politics of Africa, and since we have talked at length about both the Ebola outbreak, intervention, and regional military establishments, this is definitely a timely question worth discussing.
My take is that appropriate or not, a military response had become effectively unavoidable. Though they rightly point out that the Liberian health systems and state institutions have not collapsed, it would be impossible to overstate how weak they are. I vaguely remember an account from Joseph McCormick and Susan Fisher-Hoch’s book Level 4: Virus Hunters of the CDC in which McCormick is in Sierra Leone responding to a Lassa outbreak. Government ministers were astounded to hear of the CDC budget, which was larger than the budget for the entire country.
Some basic numbers can further illuminate the severity of the challenge for the region’s governments. I’ll begin with doctors. The World Bank reports data for physicians per 1000 people. The world average is around 1.5, and virtually all of West Africa is a mere fraction of this. Just over half of the 23 states with a rate of .1 or less (one physician per 10,000 people) are in West Africa. Liberia’s rate of .014 is second worse for recorded states and with a population of 4.3 million would give it around 60 physicians nationwide. This is on par with news reports covering the outbreak. Similar in population and size to Liberia, my (under-developed by US standards) home state of Kentucky has over 13,000 licensed physicians. Give Kentucky a mark 3.02 on the measure.
Sierra Leone ranks at .022, Guinea at .100. Worsening this is the nature of Ebola. Clinical symptoms can be indistinguishable from endemic diseases that can’t be transmitted person-to-person such as malaria. When outbreaks begin health professionals have little reason to suspect a pathogen so dangerous and rare. By the time a diagnosis is made the local medical staff has already suffered casualties. I’ll point to the recent unrelated outbreak in the northern Democratic Republic of the Congo, not far from the first documented outbreak in 1976.
According to the information given to the WHO and provided to media, here’s how it spread: The first person to contract Ebola in the Democratic Republic of Congo was a pregnant woman who butchered a bush animal given to her by her husband. She was taken to a clinic after she started displaying symptoms of Ebola virus disease and died on Aug. 11 of a hemorrhagic fever, that at the time, was not yet identified as Ebola. The woman died, and was dealt with by health care workers.
In a country with such low numbers of trained medical staff, every death matters. Beyond medical infrastructure, security will be an increasing concern. Attacks, though described as isolated incidents, illustrate potential hazards and could worsen as governments continue to attempt to enforce quarantines and there are more medical personnel on the ground and traveling to newer areas. MSF have seen its personnel attacked. So, too, has the Red Cross. The same can be said about multiple clinics, from which infected patients have had to flee. It's not quite the smallpox episode of ER or families fleeing quarantines in movies like Outbreak or Contagion. In a region with precious few clinics and medical personnel, it is absolutely critical to provide adequate security for the resources that are present. Not just for the lives of the staff, and not simply to preserve precious resources, but also to demonstrate that clinics are safe venues to which patients can go without fear of violence.
Safety simply cannot be guaranteed with local resources. The Liberian military is also undermanned, as are a preponderance of African armies. The US contingent being sent to the region is itself 50% larger than the Liberian military, which also lacks air capabilities. The Kentucky Air National Guard possess both more air power and more personnel than Liberia’s armed forces, while the Kentucky Army National Guard has around 4x as much personnel. We certainly do not question the ability of the National Guard to respond to crises such wildfires, blizzards, ice storms, or as seen with my hometown of Falmouth, KY in 1997, floods. An epidemic poses different challenges but the core functions of controlling movements, providing security, and providing transport and communications are certainly crucial.
Below are descriptive data that illustrate just how stretched thin the Liberian military would be attempting to either enforce a quarantine or to otherwise help maintain security. I’ll begin with people per soldier. Though a cursory measure, we could think of this as accounting for how many people each soldier would be responsible for defending. Non-African states see a median value of 215 people for each soldier. The median African state is nearly 3 times as high, at just over 600. Liberia is in a league in its own at just under 2000 people per soldier.
We see similar dynamics if considering geographical area. In this case, think of how much territory a soldier would be responsible for defending on average. Non-African states see a median value of 2.6 square kilometers per soldier. The median African state is 6x higher this go-around, at 15, while Liberia is again is demonstrably understaffed at 50 square kilometers per soldier.
Other Africa Liberia USA
People per Soldier 215 601 1958 198
Kilometers per Soldier 2.6 15.2 54.4 6.2
Obviously, the Liberian government cannot and is not attempting to lock down an entire country, and nor should they. Looking at security in this manner is also obviously quite crude. However, the state is remarkably understaffed in both healthcare and security, a particularly unfortunate scenario given current needs. Foreign assistance is essential, and the region—which shares many of the traits in terms of weak medical and military establishments—simply lacks the capacity to address the challenge.
If nothing else let’s hope this case acts as a signal to the international community that health crises involving communicable diseases are not simply the problem of a far off state that may be of little strategic relevance. Infectious disease is a global concern.
This is also (yet another) sign that the international community needs to make general healthcare a larger priority. The original outbreak on the Ebola River in the northern Congo was ultimately slowed due in part to the simple effort of Dr. Bill Close to bring protective gear (rubber gloves and rubber aprons) to the local medical personnel. Proactive, rather than reactive, efforts at humanitarian assistance could help avoid the necessity of military intervention in future cases.