October 27th 2014

Accidents waiting to happen: the failure to address the social determinants of health

Guest blogger Susanna Mitchell discusses the social determinants of health and questions if ignoring health system inadequacies in developing areas could result in uncontrollable global pandemics?

It is no coincidence that Guinea, Sierra Leone and Liberia, the countries where the Ebola virus has taken off with such vigour, are three of the poorest nations in the world. Nor is the total inadequacy of their health systems news to us – we have known about these terrible shortfalls for decades. Nonetheless, now that we are hastening forward to prevent the spread of an epidemic that we perceive threatens rich Western countries directly, it might be salutary to remind ourselves about some of the statistics that have been available to us for so long. Even viewed through the lens of narrow self-interest, and quite apart from the humanitarian ethics that should inform our actions, it must surely be clear to us now that neglecting the issue of the social determinants of health is a costly and dangerous mistake that may all too easily expose the whole globe to an uncontrollable pandemic.

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Guinea, where the epidemic started, has a population of 11.7 million, and according to the World Bank indicators for 2014, a GNI per capita of $460 in 2013. It has a poverty headcount ratio (at $1.25 a day) of 40.9% of the population. Life expectancy is 56, and the under-fives mortality rate is a shocking 101 per 1,000 – compare the UK 5, and the US 7. The literacy rate is 25%, nearly half a million children are out of primary school, and of those who do enrol only 61% complete. The maternal mortality rate per 100,000 live births was 650 (compare UK 8, US 28). The birth rate is 5 per woman, and only 6% of married women between 15 and 49 use contraception. Fatally, as far as the transmission of communicable disease is concerned, access to improved sanitation (which includes flush/pour flush  (to piped sewer system, septic tank, pit latrine), ventilated improved pit (VIP) latrine, pit latrine with slab, and composting toilet)  stands at 19% of the population.

The population of Sierra Leone is smaller, currently standing at just over 6 million, and the GNI per capita is $680. But this slightly higher average is unfortunately not reflected in the poverty indicators. Rather, the poverty headcount, at $1.25 per day, is 56.6%, and life expectancy stands at 46 (the lowest in the world). The under-five mortality rate is 161 – that is, between one and two in ten children die before their 5th birthday (this is the second highest ratio in the world – Angola with 167 being the most tragic). The maternal mortality rate per 100,000 in 2013 was 1,100, with a birth rate of just under 5 per woman, and 11% of those between 15 and 49 using contraception.  In 2012 the literacy rate was 44%, with 72% of children completing primary education. The access to improved sanitation is 13%, while as far as healthcare goes, there are an estimated one to two doctors per 100,000 of the population. In fact, in the World Bank’s tables, which are based on number of doctors per 1,000 population, Sierra Leone and Liberia both appear as 0.0 doctors per 1,000, and Guinea at 0.1.

Liberia, with 4.3 million people, has the smallest population of the three countries in question and, at the time of writing, the highest number of confirmed Ebola cases (4,249).   GNI per capita was $460 in 2013, and the poverty headcount at $1.25 a day was 83.8 in 2007 (latest figures available). Life expectancy in 2012 was 60, and the under-fives mortality rate was 71 per 1,000. Maternal mortality rate per 100,000 was 640, again with a birth rate of just under 5 per woman.  No figures are available for the literacy rate, but in 2011 over 389,000 children were out of primary school, with a primary completion rate for those who were enrolled of 65%. Access to adequate sanitation is 17%.  The WB’s statistics do not give the percentage of doctors to population, but according to the Journal of the American Medical Association, there are just 51 doctors for the 4.3 million inhabitants, and the country has only 620 hospital beds.

Malaria, TB, Diarrhoea and pneumonia are endemic in all these regions. WHO estimated that in 2012 there were an estimated 207 million cases of malaria, and that the disease killed 1300 children under five every day, 90% of them in Sub Saharan Africa. In 2013, 9 million people fell ill with TB, and without proper treatment up to two thirds of these will die. Over 95% of cases and deaths are in developing countries, and Africa carried the greatest proportion of new cases per population with 280 cases per 100 000 in 2013[1] Pneumonia can be prevented by immunisation, adequate nutrition and by addressing environmental factors, but in fact it also remains a global scourge, and is the leading cause of death in children, killing an estimated 1.1 million under-fives every year – more than AIDS, malaria and tuberculosis combined[2]. Diarrhoea, with nearly 1.7 billion global cases every year, is the second leading cause of under-fives death, and is also preventable – but prevention entails access to safe drinking water, improved sanitation, education about the spread of infection and rotavirus vaccination.[3]   At the moment, there is no prospect of achieving such precautionary measures in Guinea, Liberia or Sierra Leone, and the lack of structures, equipment and personnel to combat these diseases at the same time lays the their populations open to the uncontrollable spread of other deadly viruses with the capacity to spread far beyond the borders of their countries of origin.

A number of valiant NGOs have been attempting to address some of these issues for many years, but until now rich nations have offered multiple reasons for failing to take targeted action substantially to improve the dire and disturbing statistics detailed above.  Raging civil wars, coups and corrupt governance, and broken or absent institutions have prevailed in all three countries, and have supplied very plausible excuses for inaction –  but these explanations have been revealed as the pretence that they are by the current international consensus that the world should, and can, provide equipment, skilled staff, and systems finance and advice to combat Ebola. Despite the UN’s proposed trust fund so far failing dismally to realise the $1bn it declares is needed, individual countries are weighing in with equipment and skilled staff. The United States leads the field with a pledge of nearly $142 million in USAID for humanitarian activities in Guinea, Liberia, and Sierra Leone to include construction and support of treatment units, critical training for health care workers, and social messaging and mobilization. It is also sending 3,000 troops to Liberia to assist with healthcare logistics and has committed to building 17 new health care facilities in the region with 100 beds each, and to training up to 500 health care providers per week.[4]. [5]

International donors such as the World Bank and IMF have pledged to provide over $400 million and $130 million respectively, China has committed 174 doctors to Sierra Leone and $37 million in assistance to West Africa, while Cuba has pledged 165 doctors set to arrive in Sierra Leone this month, with an additional 296 going to Guinea and Liberia.

Other countries continue to join the effort. In the UK, where the Commons’ International Development Committee report recently claimed that government aid cuts made before the Ebola outbreak began may have made the situation worse[6], the government has just made a £125m pledge to contain, control and defeat Ebola,[7] and is supplying vehicles, beds, personnel and supplies for the construction and operation of a planned 92-bed treatment centre in Sierra Leone.  In addition to treatment facilities, DFID is also supporting WHO to train more than 120 health care workers per week in Sierra Leone, and has called for partners to staff, manage, and operate four new medical centres.

This assistance is certainly essential to save lives and attempt to limit the spread of infection in the stricken countries, but not only is the international response too little, it is being extended far too late. Like many countries in Africa, Guinea, Liberia and Sierra Leone have inadequate healthcare and educational systems, and appalling sickness and mortality rates, and we have long been well aware of this – while as far as Ebola goes, we have recognised the virus for over forty years. The problem has simply been that no R &D effort has been devoted to producing a vaccine against what has previously been seen as a purely African disease, since there seemed little hope of such a vaccine making money for the pharmaceutical producer. It is only now that Ebola is perceived, rightly or wrongly, to be threatening rich Western countries, that leading companies, led by Johnson & Johnson in the US and GlaxoSmithKline in the UK, are planning to work together to develop the necessary immunisation.

It is now critically important that the three afflicted economies are given increased help to recover after the Ebola emergency is over. The crisis has further destroyed already minimal healthcare systems, hospitals have closed and scarce medical staff have died in the epidemic. Children have been orphaned and family structures broken. But in addition, the epidemic has had devastating effects on other aspects of the economy. Formal and informal trade has been adversely affected by mobility constraints and closed borders; tourism has totally dried up; agriculture has been disrupted and food prices have soared; investor confidence has dropped and foreign firms have suspended operations and repatriated workers; the fiscal balance will worsen as the reduction in economic activity causes a fall in tax revenue and government expenditures rise to meet emergency and post-emergency needs.

All this will make a terrible impact on human welfare. Previous to the epidemic, growth in Liberia and Sierra Leone had been exceptionally high (Liberia  11.3%  and Sierra Leone  20.1% for 2013)[8] , and although much of this growth was due to mining and extractive industry and little of the benefit filtered down to the poor, there is no doubt that the sharp reduction expected will have a disastrous effect on their wellbeing.    A recent World Bank Group Study forecasts the impact of the epidemic on the three countries and the rest of West Africa under both a swift containment and a prolonged persistence scenario of the disease. See the table below.

World Bank Press Release of Report on effects of Ebola epidemic, October 8th 2014. xcdsd

This human tragedy should be seen as a wakeup call to the international community. We live in an immensely rich world where the persistence of abject poverty and its terrible outcome is morally unacceptable and very largely preventable. Even if we discard humanitarian concerns – which we surely should not – it must now be clear that such inequality and suffering is economically inefficient and globally perilous.

The current crisis has shown that we can move swiftly when we feel ourselves under threat. Let us now learn from this horrifying lesson and make sure that the disaster does not recur again.

Susanna Mitchell


[1] http://www.who.int/mediacentre/factsheets/fs104/en/
[2] http://www.who.int/mediacentre/factsheets/fs331/en/
[3] http://www.who.int/mediacentre/factsheets/fs330/en/
[4] http://www.usaid.gov/ebola/fy15/fs03
[5] See http://www.voanews.com/content/us-troops-help-liberia-combat-ebola-/2465887.html
[6] The committee’s chair, Liberal Democrat deputy leader Sir Malcolm Bruce, said: “The scale of the Ebola crisis now unfolding in Sierra Leone and Liberia may well be connected to declining levels of international support for health system improvements in what remain two of the poorest and least developed countries in the world.
[7] http://www.bbc.co.uk/news/uk-29450320
[8] World Bank Indicators 2014

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