A little while back I did a short post expressing skepticism about some claims that corruption was a significant contributor to the Ebola outbreak in West Africa. I agree that insofar as corruption diverts resources from public health and sanitation, or leads to undersupply of necessary medicines and supplies, it is likely to worsen both the frequency and magnitude of public health problems. But I was more skeptical that there was any direct evidence that the admittedly rampant corruption in places like Liberia, Sierra Leone, and Nigeria was a major contributor to that particular public health crisis.
Last month I was fortunate enough to moderate a panel on corruption and public health at the World Bank’s International Corruption Hunters Alliance meeting, and the presentations at that panel have altered my thinking about this issue somewhat. More generally, several of the presenters from countries hit hard by Ebola — including Commissioner Joseph Kamara of Sierra Leone’s Anti-Corruption Commission and Commissioner Aba Hamilton-Dolo of the Liberian Anti-Corruption Commission — made a convincing case that corruption has been, if not a primary cause, then at least a significant contributor to the extent and severity of the Ebola outbreak. Of course, there is still relatively little direct evidence, and it’s reasonable to wonder whether commissioners on anti-corruption commissions may be likely to overestimate the significance of their particular issue area for the most pressing immediate crisis facing their nations. Nonetheless, they did make a plausible case that corruption, while perhaps not a direct contributor to the outbreak, has significantly impeded the response.
On this point, Commissioner Hamilton-Dolo emphasized an important argument that I hadn’t really paid enough attention to, even though I quoted Professor Taryn Vian making essentially the same point in my earlier post: in addition to the squandering of public health resources, corruption may also impede the effective response to public health crises by undermining trust in government. The argument, as I understand it, goes something like this:
In the midst of a public health crisis, the government needs to issue instructions–very rapidly–and people need to follow them: quarantine orders, evacuation orders, instructions about what to do and what to avoid in order to prevent the spread of a disease like Ebola, etc. The degree to which people are willing to comply with these instructions depends, at least in part, on how much people have confidence in their government, how much they trust it, and how much they view its commands as legitimate. Particularly in the midst of a public health crisis like the Ebola outbreak, it is simply not possible for the government–especially in a high-population, relatively low-capacity state–to coerce compliance within the necessary timeframes. However, corruption (or, more accurately, the perception of widespread corruption) erodes trust in government; this is true even for forms of corruption that have nothing directly to do with public health, or the reliability of government health directives. The claim, as I understand it, is that the perception of widespread government corruption–rampant bribery, embezzlement, favoritism, conflict-of-interest, and the like–causes a generally negative, untrusting attitude toward the government, and that as a consequence, when in the midst of a public health crisis the government says “Do this, don’t do that, etc.”, people are more likely to simply ignore the government instructions, particularly if they seem burdensome.
Is this right? It certainly seems plausible to me. And there is a fairly extensive academic literature establishing a strong negative correlation between perceived corruption and trust in, or perceived legitimacy of, the government. (For some examples, see here, here, and here.) There is, of course, an obvious problem with disentangling causation: it’s quite possible that lack of trust in government may worsen corruption, as well as the other way around. But the link is at least plausible. I’m less familiar with the literature on responses to public health emergencies, but I wouldn’t be surprised if there were evidence suggesting that people are less likely to follow inconvenient or burdensome instructions from the government, or to take government health warnings seriously, if the government is perceived generally as less legitimate and trustworthy.
All that said, I haven’t seen any research that directly and convincingly establishes a link between general perceptions of dishonesty/corruption in government and propensity to ignore government public health instructions or advice. And I certainly don’t know of any evidence, other than Commissioner Hamilton-Dolo’s personal (and presumably well-informed) observations, that this phenomenon impeded the effectiveness of the response to Ebola in the recent West African outbreak. Perhaps some of our readers out there, with more knowledge about these issues than I have, might weigh in on both the plausibility and substantive significance of this hypothesis?
I would agree with all the points you make but would argue that the lack of trust in government can go even further than disregarding some of their instructions. Al Jazeera reported back in August that the lack of trust was so bad that some people who had not yet seen the disease first hand believed that the government had invented it. “The outbreak has exposed a lack of trust that many Liberians have in their government. Despite numerous efforts to inform the public about Ebola’s presence during the early stages of the outbreak, ordinary citizens echoed theories that the disease was a fabrication by officials as part of a conspiracy to milk foreign donors for money.”
It would make sense that public health emergencies have a tipping point beyond which corruption is a huge hindrance. There is a difference between thinking that government employees want to skim some extra money and believing they are callously indifferent to the lives of the public. In societies where the government is so corrupt that people believe the latter, mounting an effective government-led public health campaign would logically be near impossible.
Wow, I didn’t realize the problem was so extreme. Thanks for bringing that report to my attention. This, I suppose naturally raises the question of what can be done when trust in government is so badly eroded that the people don’t believe anything the government says. I suspect when it gets that bad, the issue isn’t really so much corruption anymore (though that may be a contributing factor), but rather suggests the need for some kind of comprehensive political reform. Easy to say — no idea how to do it.
Separately, Blair Glencorse (of Accountability Labs) made the same point Sarah raises in his article last August: “A group of Liberians explained to us recently that they think Ebola is a ploy by the government to steal even more money from Western donors.”
Thanks very much for sharing this link. It’s a very helpful, though also quite depressing, assessment of the situation.
One question I do have, though: How widespread is the view in Liberia that the Ebola outbreak is a wholesale fabrication by the government? Both the link you provide and the Al Jazeera story Sarah linked to in the earlier comment seemed to rely on a handful of anecdotes. I very much doubt we’re going to have anything as systematic as an opinion poll on this in a country like Liberia in the midst of a crisis, but I did want to pause and ask if we have any evidence that the views noted in each of these stories are widely held. After all, every country in the world has some crackpot conspiracy theorists: In the US after 9/11 (and still today) there are people who think the US government itself brought down the Twin Towers.
That’s not to say the main point isn’t valid. Even if only a small minority actually think Ebola is totally made up, the lack of trust in the government may still be a significant obstacle to an effective public health response. But I still wondered if we have any sense of how pervasive these particularly extreme beliefs are.
I would imagine the same mechanisms to be in play when it comes to vaccines against meassels etc.. I’m not well-read within that litterature but there must be a large body of research. I only know collegue of mine found social capital/generalized trust to be strongly correlated with complying with vaccine reccomendations when looking at the 2009 birdflue pandemic:
Back to Ebola, and to the qestion of causality. Its plausible that it run in both directions, reinforcing eachother. Corruption > Low trust > Low state capacity > corruption and so on… It’ll will be interesting to see if there will be a flip side of the Ebola outbreakes in Liberia, Guinea and/or Sierra Leone. If in the end the crisis will have created a higher capacity, at least in the health sector, generating a somewhat higher trust in general.
I’m not at all surprised that citizens in those countries see everything “their” (?!) ruling elites do as a driven by the hidden agendas of maximising their wealth and consolidating their power. After all, citizens have probably seen very little visible evidence that these elites pursue any other goals.
Example: Tajikistan became the first country in the world to ban the sale of conventional lightbulbs. Was this because (a) its rulers developed a sudden interest in energy efficiency, or (b) because the president’s daughter had secured the monopoly on the import of energy-efficient light bulbs? You choose.
So if the Tajik government – after years of shamelessly looting the health system – told you to evacuate due to an outbreak of disease, would you assume that (a) they suddenly took an interest in your health, or (b) had come up with a new money making scheme? You choose.
In highly corrupt countries, I think it’s perfectly rational to see everything through a “money-grabbing elite” conspiracy lens unless and until proven otherwise. The alternative is to use a “public service” assumption as your starting point, which to me seems completely at odds with the evidence you encounter every day of living there. That’s an empirical stance, not a moralistic one.