It is hard to know where to start – and where to stop – when reflecting on the significance of structural violence, inequity and mistrust in relation to Ebola.  The outbreak is, we are told, the consequence of systematic ‘underdevelopment’, structural violence and global economic inequities. And yet, what this means in concrete terms varies across different contexts and is hard to pin down.

A recent series of papers from IDS on Ebola has attempted to draw out lessons to guide practical action to go beyond the immediate demands of an Ebola response and to start tackling the structural dynamics of inequality and violence that have fueled the spread of the disease.  Key points can be drawn from these papers on structural violence, inequity and mistrust.

Structural Violence

Structural violence is the systematic and continuous implementation of undemocratic policies and practice that makes it impossible for communities to escape the cycle of poverty. There are multiple forms of structural violence, historically:

• Transatlantic slave trade
• Colonial rule
• Post-colonial development reforms 
• Structural adjustment which hollowed out states, reduced public services, and encouraged state apathy in training health professionals and developing health capacity. 

And still, there are existing policies and practices with promises of sustainability and equality, which in fact seem to enhance inequality, including:

• Trade policies
• Aid arrangements
• Land reform 

The Ebola-infected countries are all particularly vulnerable to ill-health and disease, with high levels of exposure to infectious diseases and living conditions that enhance disease spread.  This is coupled with inadequate pay for government health workers; drug shortages; and distant, non-existent, or non-functioning clinics. This lack of health service is one form structural violence, alongside this are:

• The absence of schools, legislative oversight and state facilities in the Sierra Leone/Liberia border region
• The systematic exclusion of peri-urban residents from the benefits of urban life in the form of decent accommodation, water and sanitation, access to health services as well as legal and political procedures.

These structural exclusions deepen gendered fault lines as women experience health exclusions more intensely (in terms of childbirth and maternal mortality) and are more susceptible to Ebola (through their caring roles, health worker activities and mourning rituals associated with death) and enhance inequity.

Inequity

Top of the inequity list must be the global systems, markets and the corresponding social and political institutions that reinforce inequality across and between countries.  According to Elbe and Roemer-Mahler, the fact that the WHO can’t control its own budgets and fulfil its mandate is a reflection of the power of particular member states and donors; the lack of power amongst others; and a replication of the interests which dominate the global health agenda.

The Ebola crisis highlights the fact that the inequitable structure of these systems, markets and institutions restrict the ability and efforts of communities to benefit from their initiatives. Notably, while West African mining offers new investment opportunities and is viewed with optimism by the international business community, local communities have seen few of the highly-desired and expected impacts.  Instead of decent working conditions and pay, piped water and electricity, residents find that the transport network helps outsiders extract wealth, meaning that investment and profits do not actually reach local people, overlooking the livelihood needs of small-scale agrarian farmers and that unemployment remains high as job seekers flood into the area, bringing with them new socio-economic tensions, frustrations and inequalities.  As ecological, social and political dynamics are disturbed, so people and animals are dislocated from their homes and must adapt. 

Inequity is also experienced by residents in peri-urban west Africa, who live without water and sanitation in overcrowded contexts, are unable to engage in appropriate health and sanitary behaviours which limit the spread of disease, and are often the target of sanitising and control initiatives.  They are thus stigmatised as ‘the problem’, often for political not biomedical reasons, while having the least control over their environments and initiatives to address disease spread. 

Thus ‘development’ either in the form of rural intensification and industrialisation or urbanisation, has not brought about improved labour conditions, economic and social opportunities, reduced corruption, increased equity or improved public health and public services. Rather, it has juxtaposed rural and urban poverty with corporate wealth and power, and initiated new ecological and environmental uncertainties.  Such situations and uncertainties provoke and enhance mistrust.

Mistrust

Mistrust is everywhere where Ebola is.

In fact, many believed Ebola itself to be a government plot designed to eliminate political opposition, claim donor funding, and rid cities of poor people. Ebola was anything other than a virus undermining the essentials of life: dignity, humanity, and sociality.  This is because of the public’s deep scepticism and wariness of the Sierra Leonean, Guinean and Liberian states’ ability and willingness to transform state-society relationships.

This mistrust is also borne through experiences of failing and frail health systems in these countries.  Health promotion and the prevention of disease outbreaks requires people to believe that, when visiting hospitals, they will be provided with assistance that will help them to recover; that health workers are competent; that service providers will act in the patients’ interests; that systems function etc.   Indeed, a government’s legitimacy is premised on its ability to safeguard the public’s health.  Yet, this has not been the case in the Ebola epidemic where people have avoided formal provision of health services and resisted public health interventions. 

Responses to the Ebola outbreak, reminiscent of responses to war, have generated further suspicion and doubt, particularly the emphasis on military intervention, lock-downs, quarantines, aggressive control of people’s movements, closed borders and new stigmas for Ebola sufferers and survivors.  Such authoritarian and top-down initiatives cannot engender trust. 

Just as local populations have their own understandings of, and don’t trust hospitals and biomedical approaches; so medical response teams have their views of, and don’t trust ‘culture’, community institutions and local authority.   Oosterhoff and Wilkinson remind us that, in mistrusting ‘community’ and ‘culture’, the biomedical response places responsibility for disease transmission on individuals who are expected to reject ‘negative’ behaviours such as communal eating or burial traditions, while failing to provide sufficient resources to those same individuals to enable their ‘appropriate’ management of the disease. Essentially, this allocates disease responsibility to individuals without providing the wherewithal to make this feasible.

Embedded in both biomedical responses and ‘traditional’ institutions are valuable understandings about life, health and death.  Both perspectives recognise the massive burden Ebola places on its victims as well as on those who do not get ill.

While vaccines might one day be developed for Ebola, addressing these forms of structural violence, entrenched inequalities and widespread mistrust is essential for moving beyond this impasse; not just for West Africa and Ebola, but for transforming institutions critical for shaping everyday life and sustaining wellbeing of those living in historically impoverished regions of the world.