There’s been an interesting mini-debate over at the FCPA Blog about whether, or to what extent, corruption is partly responsible for the severity of the Ebola crisis in West Africa. Richard Cassin, the publisher and editor of the FCPA Blog, argued that it is. He made this argument initially in a post from this past August entitled “Ebola tragedy is also a story of graft.” He offered as evidence the following observations: (1) the WHO and other observers estimate that a very high percentage–perhaps up to 25%–of global spending on public health is lost to corruption; (2) the very high Ebola fatality rates in West Africa have been attributed in part to the lack of adequate intensive care facilities to administer the treatments; and (3) the countries hardest hit by the Ebola outbreak–Guinea, Liberia, Sierra Leone, and Nigeria–are reputed to be highly corrupt, as indicated by their very poor scores on Transparency International’s Corruption Perceptions Index.
Many critics who commented on Cassin’s initial post complained that the evidence offered did not in fact support the strong claim in the title that corruption has contributed significantly to the Ebola outbreak. In particular, the critics pointed out that: (1) the fact that a great deal of public health spending generally is lost to corruption does not actually tell us whether corruption was a major factor in the particular case of the Ebola outbreak, and (2) the low ranking of the affected countries on the CPI likewise–even if we concede that the CPI is a decent measure of actual corruption–does not indicate that corruption caused (in any significant way) the Ebola outbreak to be as lethal as it has been; at most it shows a correlation that might be explained by any number of other factors.
Cassin responded with a second post last month in which he rebutted the critics. He acknowledged that while one can never establish with “scientific certainty” that corruption has a causal effect on the severity of the Ebola outbreak, there is powerful circumstantial evidence that corruption is a “gateway” to this and other public health crises (as well as other problems like terrorism and crime), because it siphons off public resources. Cassin cites to a couple of research papers that purport to show that corruption in general has adverse impacts on public health, in particular because it adversely affects access to clean water and sanitation.
While I’m generally sympathetic to Cassin’s larger point, I think that the criticisms are fair ones. Here’s my take.
- First, the critics were right to take Cassin to task for emphasizing–in the initial post–the low CPI ranks of the hardest-hit countries as evidence that corruption was partly/largely to blame for the outbreak–and Cassin was right to back off of that aspect of the argument in his follow-up. Ebola is native to a part of the world that happens to have very high (perceived) corruption rates; we don’t have enough variation in corruption levels in the “hot zone” to make any inferences about how much of an impact corruption has had on the severity or lethality of the outbreak. And there’s obviously lots of room for what a statistician would call “omitted variable bias” — third factors that might affect both the disease burden and (perceived) corruption, like tropical climate or poverty. And to criticize this sort of inference isn’t to make unreasonable demands for “scientific certainty” — it’s to recognize that in a case like this, we can’t draw any meaningful inferences about the role that corruption played in the outbreak.
- Second, Cassin is on much stronger ground when he emphasizes the evidence that corruption has adverse impacts on public health by diverting money that’s supposed to be used for medicine, sanitation, clean water, and other health services and public goods. I agree with him that those problems are fairly well-established. (For more discussion of those and related points on this blog, see here, here, and here.) But I do think the critics are right to press Cassin on the fact that although there’s good evidence that corruption is generally bad for public health outcomes, there isn’t all that much in either of his posts establishing that corruption contributed specifically to the Ebola epidemic (either by creating conditions that were conducive to an Ebola outbreak, or by impeding the effectiveness of the response, or both). He does have one sentence in passing in the first post suggesting that West Africa lacks adequate intensive care facilities, but he doesn’t establish whether this is because the money for those facilities was stolen, or whether it’s because no investments in such facilities were made in the first place. And in the second post, Cassin hints that poor sanitary conditions and lack of access to clean water might have contributed to the Ebola outbreak, but he doesn’t come right out and say it — the paper he quotes appears to be about public health more generally — and I don’t know enough about Ebola to know whether that implied causal link is a plausible one.
So I guess my (tentative) position is that while there is indeed strong evidence that corruption contributes to public health problems generally, Cassin was perhaps arguing a bit too far beyond his evidence when he claimed (or strongly implied) that corruption was specifically a major contributing factor to the current Ebola crisis. It’s certainly plausible, given the general evidence he cites, that corruption may have contributed in some way, but there’s really nothing in either post that establishes any such link with any specificity.
By the way, one minor observation that tends to corroborate my take on this: One of the papers on the adverse impact of corruption on public health that Cassin showcases in his second post is by Professor Taryn Vian. Cassin’s post emphasized Professor Vian’s impressive credentials–but oddly neglected to mention that Professor Vian herself was one of the people who criticized Cassin’s first post, finding it to be “not  as factually based” as other FCPA Blog posts. I tend to agree with Professor Vian’s more nuanced assessment of the issue:
If there is any message about corruption which we can draw from the Ebola epidemic it is this: corruption is a public health risk factor. Corrupt practices in the health sector reduce the resources we have to respond to epidemics like Ebola. It also weakens public trust in government health systems, trust which we need to rely on in emergency situations. Anti-corruption strategies can strengthen public health systems and response networks so they are there when we need them.
That lesson is a fair one. But declaring, without more, that the “Ebola tragedy is also a story of graft” or that “graft [is] a gateway for Ebola” probably goes too far.
In my opinion the link between corruption and Ebola may exist but if so, it is a very remote one. There is no hard nor soft evidence (in any sort of the meaning) that such a link is associative and certainly not a causal one. Ebola did not appear now: it is now that it got the epidemic proportions. We would need to establish the causes of this epidemic in order to stipulate any link whatsoever and with whatever, including the corruption. So I would be cautious in making such statements that Cassin did. Needless to say, one can open a discussion of the links about the interplay among corruption, public health and development. One can also discuss possible links between the health responses to epidemics (see vaccination) and corruption but these are then examples of an instrumental profit driven abuse of a particular health situation/response through corruption as a mean to make a profit.
Corruption is arguably a “gateway”/risk factor for any crisis that requires a coordinated public response and that could be alleviated by better institutions. In that sense, I think Richard Cassin takes on too much in his analysis of systemic corruption and its effects on the Ebola response. But in narrower contexts, some evidence suggests that corruption does play a direct and causal role in the spread of the disease. A recent WSJ article (link below) describes how some victims’ families allegedly bribe body-retrieval teams to forge death certificates and release bodies for traditional washing and burial (as opposed to mandatory cremation). Obviously, improper handling of victims contributes significantly to the inability to contain Ebola. Even this article draws from conflicting reports and statements and lacks substantiation. But highlighting corruption in this scenario is both more likely to be accurate and more likely to have a beneficial impact on the response.
WSJ Article: http://online.wsj.com/articles/some-ebola-stricken-african-families-pay-bribes-for-fake-death-records-1413153854
Very interesting! I hadn’t seen that, and it certainly establishes a more direct link between corruption and Ebola than anything I’d seen previously. That said, you’re right to draw attention to the lack of substantiation in the article, and it’s also not clear how big of a contributing factor this is. But I agree that this evidence does suggest that corruption may be playing a role in Ebola crisis specifically, and not just public health generally.
One other thing to note here: Although in the public health context the usual concern is about resources being misappropriated (as Vian, Cassin, and others emphasize), the article you reference highlights a very different form of corruption, as well as the link between corruption, traditional practices, and health. Here the corruption is not for personal material gain, but rather to honor traditional funeral practices. That sort of corruption would presumably require a very different policy response than theft of public health resources.
While I agree that the evidence Cassin points to is too far removed to prove causation, I think it’s worth pointing out that the nature of the crisis as it currently stands makes it very unlikely that any solid, scientific evidence corroborating this theory will emerge soon. The crisis is still ongoing, and, according to the W.H.O.’s latest forecasts, may be spreading at a faster rate than ever in the next few months. Patients and their families who are quarantined are unlikely to report corruption while in isolation, and while I have no idea how much access media has to the most affected areas, lack of oversight could be especially dangerous where contagion is involved.
I obviously do not mean to suggest that we should assume causation merely because there is no evidence to prove otherwise. But perhaps reports like the one Elizabeth posted should signal more alarm that Cassin’s theory is indeed plausible. Recognizing that it may be some time before substantial evidence emerges, I could imagine that such a theory could be developed over time, even if it starts with articles that lack the highest degree of substantiation. The nature of the crisis may need to allow for some conjecture before the scholarship develops further.
One other quick response about this being a different kind of corruption: acknowledging my unfamiliarity with the traditional practices in Liberia, I’m not sure it’s entirely clear that accepting bribes is necessarily motivated by the officials’ respect for those practices. This type of bribery could just as easily be characterized as exploitation of those values as it could be respect for them. Again, it’s unlikely that any substantive proof will emerge soon, but this article certainly does increase my concern for this theory.
Both good points. On the first, to clarify, my (mild) criticim of Cassin’s posts is not that he’s wrong or that his hypothesis is implausible, but rather that — even taking into account the limits of evidence in a fast-developing situation and the impossibility of “scientific certainty” — anticorruption advocates need to be cautious about not over-claiming, and about what inferences we can and can’t draw from the available evidence. Perhaps that more general concern is what moved me to weigh in. On the second point, just to clarify, when I said that the sort of corruption Liz referenced was “not for personal material gain,” I meant gain for the bribe _giver_; for the bribe _taker_, I suspect that the motives are indeed personal gain for precisely the reasons you describe, though I wonder whether some health workers might be more susceptible to bribery in this situation because, in addition to the payoff, they can rationalize this as respectful of traditional practices (and perhaps convince themselves that the cremation mandate is excessive).
I agree that Cassin’s first post isn’t substantive enough to draw the link he wants to make. Though my knowledge of the Ebola crisis is pretty superficial, my understanding of the main contributing factors (lack of health infrastructure, government inaction, etc.) is that they aren’t directly a result of corruption.
I don’t necessarily see that much daylight between Cassin’s second post and the comments from Professor Vian, you, and Liz, though: in a broad sense, corruption contributes to difficulties with development/the economy and effective institutions, which, among other things, makes addressing health crises difficult, in addition to facilitating the development and spread of diseases like Ebola.
Cassin’s point that “[p]roving with a scientific certainty a correlation between corruption and Ebola isn’t possible” also overlooks the correlation/causation difference–even if a correlation did exist, corruption may correlate with (just to throw out an example–I’m not sure if this is true) poverty, which might be the more on-point facilitating factor with relation to Ebola’s spread. I suppose the comeback to that, though, is that corruption might contribute to poverty/lack of economic development (and Cassin even alludes to corruption not being the direct cause when he mentions corruption siphoning funds from public infrastructure and services), but even that idea once again circles back to your point that Cassin’s original claim may have been somewhat overstated.
Everyone has some great points. Two things to add to the conversation about corruption, poverty and Nigeria’s response.
I believe there has been significant research showing that corruption significantly hinders economic development, leaving more people in poverty. When people are poor, they tend to live in significantly smaller, more cramped spaces. Therefore, even when they know a family member is highly contagious, it would usually be impossible to put them in ‘isolation’ at home (by sending them to a separate bedroom, for example) if everyone is crammed into one room.
But regardless of the contribution of corruption to the spread of Ebola in the worst effected countries, Nigeria actually proves that high levels of corruption don’t NECESSARILY mean bad infectious disease control. Nigeria, with sky high levels of corruption, has done an excellent job stopping Ebola. In fact, the CDC has sent teams there to study what made their response so effective. If no new case emerges by Monday, the WHO will officially declare Nigeria Ebola free (they are already well past the 21 day incubation period).
It would be helpful to look at how the response in Nigeria differed from that in the other three countries and try to determine if corruption was at play there.
Yes, I wholeheartedly agree that poverty seems to have been a significant contributing factor. (There’s a discussion of that point in a post on the Quartz blog here: http://qz.com/280793/decades-of-corruption-have-left-african-nations-prey-to-ebola/. That post points out not only that poverty leads to crowding, but also that poverty and low agricultural productivity contribute to the reliance on “bushmeat” — fruit bats and the like — that contribute to the spread of the disease.
So in a very general sense, corruption did contribute to the Ebola crisis, insofar as it contributed generally to poverty. And everyone seems to be in general agreement that corruption is to blame for much of the misallocation of public health resources generally. But as for the stronger version of the thesis — that corruption is largely to blame, in a more direct sense, for the failure to respond adequately to this particular Ebola outbreak, I think the evidence is much more equivocal, as your point about Nigeria highlights.
That all makes sense. One minor side note on the bushmeat point because I’ve been hearing that a lot — The NY Times reported (http://www.nytimes.com/2014/09/06/health/ebola-immunity.html) that one of France’s leading ebola experts actually thinks “many rural villagers are ‘vaccinated’ by eating fruit gnawed on by bats and contaminated with their saliva.” So some types of foraging might actually be helpful in fighting the disease.
The NYT picked up the corruption-Ebola link today: http://kristof.blogs.nytimes.com/2014/10/16/step-one-to-fighting-ebola-start-with-corruption/.
This article does very little to address the causation issue. I just don’t think statements like “Corruption and Ebola are essentially the same hemorrhaging disease. If we cure corruption, we will have the healthy planet we all truly want and our children deserve” contribute much to a constructive discussion, especially when thousands are dying.
But I’m surprised that major news outlets have focused on this aspect of the Ebola tragedy and it will be interesting to see the impact such framing has on longer-term commitment to governance reform and health sector development in the worst-affected countries. As Sarah and Bea have noted, it is too soon to tell. My point is simply that: from an academic perspective, unsubstantiated claims have little value but, from a practical perspective, such claims can still draw important attention to a number of serious issues.
The article and comments make excellent points. In my opinion, the one to highlight is the connection between poverty and corruption. Access to healthcare is important and very difficult in developing countries. This has been highlighted in the United Nations Millennium Goals in attempting to improve statistics on a variety of healthcare risks. While these metrics have been improved, many goals will not be met by the 2015 deadline.
Ebola is a current health scare to the public awareness. While corruption is a factor in lack of care for sick individuals, it is not the only metric to consider. Developed countries are having difficulties tackling this disease once individuals are determined to be ill. While the majority of individuals who have contracted Ebola are concentrated in developing, often seen as corrupt, nations, other nations can still be at risk due to the global nature of travel. Developed nations should continue to be concerned about the corruption of these nations and the impact that may bring on the developed world.
The newly discussed links between Ebola and corruption should lead to the greater discussion of healthcare in developing countries. Improving overall access to healthcare would also aid in developing countries current fears of Ebola, whether warranted or not. AIDS continues to be an issue in developing countries, especially due to the expense of the medicines required to treat the disease. The healthcare risks in the third world are impacted by corruption. Bribes, lack of quality care, and the expenses are all part of the discussion.