FRED LOGEVALL: Well, good afternoon to one and all. And I want to welcome you to this event, which is going to be focusing on the impact of the Ebola pandemic. My name is Fred Logevall, and I am a faculty member in the History Department here at Cornell. I'm also serving as vice provost for international affairs. And I'm here, really, in my capacity as director of the Mario Einaudi Center for International Studies.
A particular welcome to our guests, who will be introduced in a moment. And I want to just make a couple of points before we begin. Obviously, the subject matter of our session this afternoon is a most serious one. We have currently, I believe, 13,268 total cases of Ebola. This is according to the most recent statistics, at least that I've seen, from the World Health Organization. The virus has reached some eight countries, I believe, to this point.
And I think there's a broad consensus, certainly among experts, that the pandemic has brought immense damage, not only to the health and social welfare of the affected countries, needless to say, but also to the mining, agriculture, and service industries globally, as investors evacuate foreign workers, as borders close, and international flights are suspended, in some cases, canceled. And the political repercussions, I don't have to say to any of you, have been very large indeed.
So it's, we think, an opportune moment to come together in this room with a panel of experts to talk about these implications. And it's an honor for me to have an opportunity to welcome all of you and to just say a few words. I want to say in addition that this is an event that is jointly organized by the Institute for African Development and the Einaudi Center, that it's part of the Einaudi Center's Roundtable Discussion Series that features experts in international affairs who can address topics that are of great international consequence. And it's also part of our Einaudi Center Foreign Policy Forum.
We have received very grateful support, I want to indicate, from the Bartels family. So this roundtable series really wouldn't be possible without the support that the Bartels, who have been so generous to the Einaudi Center in so many different ways and to Cornell as well, that we wouldn't be able to do this without what the Bartels family has brought.
We have, as I indicated, a very distinguished panel here to talk about this. And I want to invite now-- it's my great pleasure to invite to you Cornell Professor Muna Ndulo, who's a distinguished professor in the law school here at Cornell. And he is also the director of the Institute for African Development.
Muna is going to moderate today's event. We're going to be going, I believe, until 6 o'clock. Muna is very much in charge. And he is now going to introduce the event and also introduce our panel members. Muna.
MUNA NDULO: Thank you.
Thank you very much, Fred. Thank you for coming and for finding time to be with us. I know how busy you are. So thanks.
I would like to join Fred in welcoming you to this roundtable on social, economic, and political impacts of the Ebola epidemic. As has been mentioned, the roundtable is organized by the Mario Einaudi Center for International Studies in corroboration with the Institute for African Development.
We have four eminently qualified persons to address the issues presented by this topic. But before we proceed, I would like to make a few remarks and also first begin by thanking Ms. Heike Michelsen and Ms. Jackie [? Saya ?] for organizing this event. They worked very hard to make this event possible, so thank you.
Now I would also like to make a few observations about the topic that we are going to be dealing with today. The Economist, in one of its recent reports, reports that, in September 1976, a scientist in Antwerp received two [INAUDIBLE] out of Yambuku, a district in what was then called Zaire. It was two samples from a man who was fatally ill.
The scientist discovered they were dealing with a deadly unknown virus. They named the virus Ebola after the river in the Yambuku district in the Congo where this sample had come from. Now between 1976 and 2014, there'd been actually 20 Ebola epidemics, each in a small village or town. These epidemics claimed a total of 300 lives. And these epidemics were contained fairly quickly.
One of the questions, of course, that arises today is whether the international community ignored lessons they should have learned on the way these communities dealt with today's epidemics. Today's crisis is of a different order. It has stricken three countries, Guinea, Liberia, and Sierra Leone, with a combined population of 20 million. It has killed over 4,500 people. And cases have been reported spread by medical personnel in several other countries, including the US, Nigeria, Spain, Switzerland.
On August 8, the World Health Organization declared Ebola an international public health emergency. [INAUDIBLE] accorded to the most severe acute public health emergency in modern times.
Following onto this, I think, we should try and focus on some of the issues that actually this whole crisis presents. As was mentioned, the crisis, in terms of the challenges, cuts across disciplines. As [INAUDIBLE] recently observed in front of an audience of a thousand scientists, he paraphrased Georges Clemenceau's famous quip that war is too important to be left to generals. And he suggested that health is too important to be left to health practitioners alone.
Like in most responses to humanitarian disasters that are mounted by the international community, the Ebola response is focused too narrowly on the technical aspects, one can argue, of containing a problem and too little on the underlying social and political reasons why the problem has been allowed to fester in the first place. [INAUDIBLE] also shown us that fear and suspicion has spread faster than the virus. The South African ambassador to the US, Mr. Rasool, recently remarked that there were no Ebola cases reported in South Africa and the country is 3,000 miles from the nearest outbreak. Much farther, I must say, than New York is from the area.
He remarked, ironically, it's not the epidemic of Ebola that is a problem for him in terms of South Africa. It is an epidemic of ignorance. That is the problem.
The fearmongering about the disease threatens to reverse decades of progress for Africa's image. Naive perceptions about Africa have resurfaced. Ebola has brought back the fears and fantasies about Africa. However, have also learned that Ebola affects everything, as the provost mentioned, jobs, food production. People keep away from fields and markets.
So to lead us in this discussion, as has been mentioned, we have four eminently qualified persons to speak on this subject. Each panelist will speak for 20 minutes. And then we will open up the discussion to the audience. I would like to introduce the four panelists.
The first speaker will be Professor Chinua Akukwe. He's a professor of global preventive and community health at George Washington University School of Public Health and Health Sciences. I think I'll leave the rest of his bio, as you have the bio with you. Very extensive experience with the subject at hand.
And then after him, the next speaker will be Professor Nathaniel Hupert. He is a primary care physician and a researcher in public health response logistics at Weill Cornell Medical College in New York.
And after him, he'll be followed by Mr. John Panzer. He's senior sector manager of the World Bank in the international trade department. And last but not least will be Professor Nick van de Walle from the Government Department at Cornell University. So I invite the first speaker, Professor Akukwe, to give us his presentation.
CHINUA AKUKWE: Thanks. Good evening, everybody. Good evening, everybody. See, I came all the way from Washington, did a red-eye this morning. So you should pardon me if I need to hear that you guys are awake with me.
You know, the good thing about being the third or fourth speaker is that Muna and Fred have already said a lot of what I had wanted to say. So what I'm going to do is simply, in the interest of time, to make some key highlights about Ebola.
If you look at this slide, whatever numbers that you've heard-- 13,000, 4,800 deaths-- just remember that they represent only about 1/3 of actual cases. Both WHO and CDC have confirmed that, whatever we are talking about today, we are simply discussing less than 1/3 of cases. A lot of individuals living with Ebola, not knowing, to the system in Liberia, Guinea, and Sierra Leone.
The other thing is that any city with an international airport is at risk of importing Ebola. This is from WHO. And then finally, that issue of, there is no known cure. This is what everybody keeps asking me, especially when I address predominantly African-American or African audience. Is there any discrimination?
Since I left medical school nearly 30 years ago and up to today, there is no known cure for Ebola. It's more supportive clinical care.
Why is the current epidemic so different? This is a very common question that I get. The first thing is that, for the first time in my living memory of getting involved in public health, an infection or an outbreak was going on for nearly four months and it was not detected, either by national authorities or by WHO.
The other thing is that more than 300 Ebola cases are linked to the funeral of a single infected traditional healer in Sierra Leone. In fact, most people believe that more than 50% of current infection today are traceable to this funeral for this prominent traditional ruler.
The other thing is that, for the first time, sort of outbreaks around the edges of tropical rainforest, you now have outbreaks in congested urban centers and swamps. And that's one of the reasons why Liberia is particularly hard hit. Because the slum-- I used to think that slums were bad in Nigeria or Kenya, but the one in Liberia, you cannot describe it. It is indescribable.
The other thing is that this is the first time that a lot of health care workers have been infected and more than half of them have died. Never used to happen in previous epidemics for various reasons.
Then the final thing is that, for some reason that I still don't understand, citizens of Liberia, Sierra Leone, and Guinea did not believe or respond to frantic calls or messages from their government about how to avoid contracting Ebola. Some people have speculated that this is a symptom of disconnect between governments in these three countries and their population. Because it took them more than six, seven, eight weeks to really understand that we have a serious problem.
What are we hearing now from those in the three affected countries, from WHO, from CDC? There are signs that it's beginning to slow down. But I was telling Jackie outside that I'm not sure whether it's slowing down because there are a lot of people that are not known to the system. But WHO and CDC say that it's slowing down.
And then, of course, the mass Ebola epidemic and hysteria is beginning to die down. I remember last week during the congressional elections, are different names for Ebola depending on which part of the United States had "Ubola," "Ibola," had "Ubola." Depending on whichever accent that people running for congressional elections, they were talking about Ebola.
So that [INAUDIBLE], at least this week, had a mass-- say that the epidemic in the US and Europe is slowing down. And of course, there's more emphatic international response.
And something that has gratified many of us working in Africa is that Africans are beginning to respond. Two days ago, the African Union announced that there will be setting up an Ebola fund of more than $750 million, mostly funded by African businesses.
What are the significant challenges? Now this, for me, is the take-home message of what I'm talking about this evening. The six C's that have always plagued health care systems in Africa are now more magnified with Ebola. There's a problem of coordination, collaboration, clinic care, contact tracing, who will pay for cost of operations, and how do you connect with at-risk populations? And the other big elephant in the room is, how do you keep the rest of Africa Ebola free?
We're talking about these three countries. You have Ivory Coast, you have Nigeria, you have South Africa, and so on. Kenya. How do you keep them from having Ebola?
The other thing. This is what I had spoken about for when I gave my testimony to Congress is that, we're talking about Ebola because there's virtually no health care system in the three countries. And there is no hope that, in the next five years, we're going to have any reasonable health care system in those countries. So part of the significant challenge is, how do you rebuild health care systems in Africa?
Then the hard-hit countries, the three hard-hit countries, despite the personal integrity of their top political leaders, we know that they are facing trouble because of Ebola. And one of the things that a lot of people are speculating is that, once the Ebola ends, whether there are a lot of citizens of these countries are going to ask for serious change in their level of governance. Because they believe that their government has not done enough at this point in time. And I think Professor Muna talked about international stigma, which is something that is becoming a major, major problem.
So in concluding, Guinea, Liberia, and Sierra Leone. We don't know what will happen, even at the end of Ebola. That is the truth, if you're in public health. We don't know what will happen.
Then the neighboring countries, the rest of Africa, and the entire world, how are you going to make sure that you contain the epidemic in these three countries and eventually end the outbreak? So one of the things that is very, very important is that there's really a need to strengthen disease epidemic response mechanisms globally. And also strengthen health systems in Africa. And I think, if we do that, that will be the ultimate response to Ebola. Thank you so much.
MUNA NDULO: Thank you. Thank you very much. So our next speaker is Professor Hupert.
NATHANIEL HUPERT: Thank you. I have no PowerPoint slides, which is kind of strange for a medical doctor because we typically-- I was trained to read my slides to the people who are reading my slides. And I enjoy the opportunity not to do that.
So thank you very much for having me here. And I want to build off of what you just saw. But first, I need to just preface, for those of you who haven't read the bio. So my role, despite being a primary care physician, has actually been since 2008 to provide the federal government with a little bit of interpretive experience in terms of trying to understand what the mathematical modeling community is saying about infectious disease outbreaks.
So what does that mean? Well, since 2008, I've worked both with the Centers for Disease Control and now, in Washington, with an office called the Office of the Assistant Secretary for Preparedness and Response. In the very, very small units that try to either develop mathematical models to predict what may happen, or to read, as they emerge in the scientific literature, the models that other academic groups around the world have been producing to try to make sure that the policymakers in this country have a better picture of what's going on.
And I just wanted to take my brief time here, and I'd be happy to change topic if this is not something that is going to be part of the larger discussion. But I wanted to just take a moment to explain the role of modeling in outbreaks like the Ebola and previously, as many of you remember, the 2009 global pandemic of influenza. Because there are really interesting scientific advances that have happened, even over the last 10 years, that have helped us understand outbreaks like this.
But there are also huge challenges in the use of these models. And in the interplay between academic groups that make the models, the policymakers who have to interpret them, and then the reality on the ground, which is often, in this case, literally thousands of miles away. But often, worlds away from the graduate students and the mathematicians who are hard at work trying to understand something in a very theoretical perspective.
So as many of you know, the big week for mathematical modeling in this outbreak was the week when the Centers for Disease Control released its Morbidity and Mortality Weekly Report that said, first, that the maximum number of cases could be 1.4 million by January. And second, that if we could achieve 70% isolation of cases, that we would have a very different picture on the ground, a much more favorable and potentially more containable picture.
So this really took fire, and it absolutely dominated the press coverage. The same week, the World Health Organization group released a very critical paper in the New England Journal, which is essentially the most prominent medical journal in the world, where they very carefully laid out the results of weeks of study of several hundred cases and refrained from making a projection too far in the future.
So I've got some colleagues in the audience who I would like to acknowledge. Peter Jackson is the head of the systems dynamics program at the Operations Research School. And his graduate student, Claire Zelner, who's working with us on these issues.
So Peter and I were just looking at those New England Journal slides again today. And what you see is that they give confidence bounds on their estimate of what will happen even a couple of weeks into the future that essentially go from here to here. And what that means is, we have no confidence in where this is going to go. Which is a very honest thing to say but doesn't play well in the media, frankly. It's much more dramatic to make a statement about a big number and then try to back that up.
Now what does this mean? Well, this means that policymakers were faced with a serious conundrum, because the science didn't really help at that point. And we could go into many reasons why the science didn't help. Part of it, as was mentioned, is that it's very difficult to get a lot of data out of the areas, the three countries, parts of the three countries where the epidemic is going on.
So, for example, just getting back to this critical issue of, is it on the downturn or is it on the upturn? One of the things that people have seen in the newspapers is that there are large treatment facilities that were just built in a rush that are partly empty in areas in Montserrado County around Monrovia. And it's easy to interpret this in many different ways.
One way would be that there is a downturn in cases. The other way is that, because it was a severe rainy season, that patients who were coming into the main part of the populated area of Montserrado County are not traveling because they can't travel.
So these are problems that are very difficult to translate into projections. And yet what models have been used for is making these large-scale projections and then attempting to modify the large-scale projection.
What we've been working on is the issue of how many beds are required. So this is one of the things that a couple of faculty at Operations Research here at Cornell and I have been working on. And that's a very tricky thing to try to get a handle on, partly because, what drives the number of beds that are required? Well, the number of cases. And we are unclear about how many cases are actually going to appear in the coming weeks, months, and certainly over the course of the next year.
So we're stuck in that, on the one hand, we rely on data that may not accurately represent what's going on on the ground. On the other hand-- and this is from my particular perspective as someone who tries to translate these models for federal policymakers-- there is a need to stand up in front of the cameras and make a decision about what this government or other governments will do. And that need doesn't go away, even if the data is poor and the modelers say, we're not really sure.
So into that potential void, you get a lot of modelers who use a certain amount of data and come up with a projection and then try to defend that projection. And some modelers who stay quiet during this time and wait for more information to come. But the latter group, even though they might be more scientifically appropriate, don't really help the policymakers who have to make decisions.
So what we're faced with is a very complex situation in which the decisions that are made then are looked at several weeks or months after they're made in light of the new data. And so now we can look back and say, somehow we made a decision to establish 17 100-bed hospitals, we being the United States government, the Department of Defense. That rolled out very slowly because of logistical concerns. And right now, this week, we've actually opened up one 25-bed unit in Monrovia that's designed to treat infected health care workers. As was mentioned, health care workers have borne a tremendous brunt in this outbreak.
The other 17 facilities are partially under construction. Some are still planned. And actually, you can go to various websites now and see where they're going to be created.
There is, I think, a legitimate question of whether they'll serve the purpose that they were designed to meet, which is to accept an overwhelming number of cases that were projected very early on in the epidemic. If they weren't, then we're faced with a very interesting issue. Can this huge investment in health care infrastructure actually serve to help to recreate the health care infrastructure that was destroyed during the civil wars in two of these nations? And can it also be integrated into the routine health care provided in those countries and in those regions?
I am not sure that those were considerations that were really given a lot of thought when the decision was made to create these. So this highlights a very interesting logistical problem, which is that the urgency with which the logistical decision was made was not pushed forward by the preexisting and, some would argue, even more overwhelming health needs of these three countries, which predated the Ebola outbreak. It was pushed forward by the acuteness of the Ebola outbreak and by the WHO declaration of emergency and by the sense of threat that this seemed to pose to the rest of the world.
Eventually, the Ebola outbreak will be brought under control. And then the question is, how does this large investment actually become a long-term investment? So perhaps we can come back to that later. So let me just stop my comments there and pass the mic along.
MUNA NDULO: Thank you very much.
Our next speaker is John Panzer. His topic.
JOHN PANZER: Thank you. Good afternoon. I don't have a PowerPoint, but I want to stand because I'm very short. If I sit there, I cannot see you. And especially if I put you to sleep, I don't know that I'm doing that. So this way I can calibrate my presentation.
So my name is John Panzer. I'm a director in the Macro and Fiscal Management Global Practice of the World Bank. Part of my work covers Africa. And as you may know, the World Bank has been quite engaged and involved in Ebola, but not only on the health side but also on trying to assess the economic impact and help countries address those. So my presentation is going to focus on that, on the economic impact of Ebola, and to some extent on the social impact as well.
By economic impact, we mean principally the effects on productive activity, incomes of the people, poverty, and on government finances. Of course, this is not to say that we are heartless economists and that this takes preeminence over the tragedy of death and human toll that is taking place in these countries. But of course, if these countries and these societies are to move forward from this tragedy, addressing the economic impact is essential and is of the highest magnitude.
When thinking about this, I think it's good to think a little bit or put in perspective, what are these countries and where are they coming from? Sierra Leone, Liberia, and Guinea are some of the poorest of the poorest countries in the world. If you look at a ranking of income per capita and our latest data ranks 189 countries in the world, these three countries rank 166, 174, 184. I mean, it's the bottom. It's the poorest of the poor.
If you look at the United Nations Human Development Index that takes into consideration other aspects that are broader than income per capita, out of 191 countries in the world, ranked, they are 179, 183, 187. So these are countries that are extremely poor and extremely fragile. And I'm sure a professor that will follow me will be able to link some of that with what is actually happening and why this is the first time we see some crisis of this magnitude develop.
At the same time that these countries are very poor, they were in a very positive trajectory. After years of civil war and very prolonged dictatorships in some of these countries, they're coming forward. They have been able to stabilize their economies, attract quite a bit of foreign direct investment. Granted, a lot of it-- most of it-- for mining, but also some for commercial agriculture, large-scale projects to generate electricity and sell them regionally.
So these countries were really moving in the right direction, growing at very fast rates, mostly because of the rebound from the years of civil war and because of very strong foreign direct investment. And even in a country like Sierra Leone, they were expecting that income per capita could double over the next seven years. They were growing at more than 15% per year before this crisis hit them.
There was also some improvement in governance. I don't want to oversell that. There are huge challenges there. But there was some improvement in governance.
And you can see, for example, that tax collection, which is one area one can use, tax collections as a proportion of the size of the economy had been consistently growing. And they do not fall way behind what you see in other countries that are also poor but have better developed governance systems than they had.
So this Ebola crisis hit them probably at the-- well, it's never a good moment, but probably at the worst possible moment, as these countries were coming out from these years of crisis. And its costs have been enormous.
When you see numbers in the press, if you care to see them, sometimes these numbers don't look so big because these economies are very small. Professor Ndulo said-- I think it was him who said-- that the population of these countries is 20 million. Well, that's, say, 15 times lower than the population of the United States. Say it's 300 million or something.
But the combined size of these economies is more than 1,000 times smaller than the size of the economy of the United States. So that gives you a sense.
And the economic cost has been huge because Ebola has caused what we call aversion behavior. Aversion behavior is this fear of association because of fear of contagion. So normally, when you try to measure the health cost of a health crisis, a lot of people measure it through, say, the cost of the health care, the cost of the productivity of the labor laws from people that do not go into the labor market because they are sick, or the cost that is imposed on society because families of these people cannot go to work.
But this is much different. This is just fear of association because of fear of contagion, which leads people to not go to the workplace. It leads farmers not to go sow the land. It makes small businesses close. It makes people fear to associate in markets. And it makes, for example, those that provide transportation be fearful that they can get contagious. And therefore, this aversion behavior brings practically the economy to a halt.
We monitored data in these countries. We were lucky enough that the World Bank has offices and economies working in all these countries. And in Liberia, for example, in the month of August, cement sales dropped by 60% compared to the same month in previous years. And cement is a great indicator of economic activity. Petrol and diesel sales fell by almost the same amount, between 40% and 50%, during this same period of time.
Data is very hard to get, so we've also faced the same problems that you face on trying to model the epidem-- epidemiol-- I won't say it-- what you're trying to model on the economic side. But we've done our best, and the numbers are staggering.
Let me say a couple of little anecdotal things. We're kind of lucky in the sense that the World Bank was conducting with the government a household survey at the beginning of 2014, and we had been able to interview about 4,000 people. Of those 4,000 people, 2,400 had cell phones. So during the month of October, we tried to contact all those 2,400 people, call them, to ask them how they were doing after Ebola. And we only managed to get hold of 650 of them. So it's not a very representative sample, so people are very wary that I say anything about this.
But to give you an idea. For those that work in agriculture, 25% were no longer working in agriculture. But at the same time, 66% of those 25% said that somebody in their family was still working. Of those that are self-employed-- and this is very important, because in these very poor countries, informality is very large and a lot of entrepreneurial activity takes place through self-employment, you know. And 56% of businesses of those that declared themselves self-employed-- and they're tiny, tiny, tiny business people-- were no longer operating.
These, plus the data we have on cement sales, petrol, our interviews with hotels and so forth, allowed us to make quite decent, I think, estimates for the economic impact of Ebola for this particular year. And for this particular year, 2014, considering that the impact will only take place for half of the year since the first half of the year was fine.
The results are staggering. Basically, these economies will have half or more-- at most, they will have half their rates of economic growth they would have had had this Ebola crisis not taken place. So to give you an example, in Liberia, had this crisis not taken place, we were expecting Liberia's economy to grow at 6% this year, 2014. Now, I think that it's going to be lucky if the economy grows at 1 and 1/2% during 2014. Considering that the economy was growing at a rate of 6% during the first half of the year, you can imagine the size of the contraction that is happening now in order to bring this down.
This has enormous implications, not only on the ability of people to work and have jobs and so forth, but also on the ability of governments to function and provide services. When your economy contracts at this magnitude, you cannot collect taxes because the economic activity is depressed, let alone that it is hard to do it. And at the same time as these governments have faced enormous demands and pressures and needs to increase expenditures, not only in health, but in security, quarantine, hazard pay for health workers, death benefits for health workers' family, and so forth.
The fiscal impact that these countries are facing is huge, and it's growing. Our latest estimate the World Bank issued, I think it's the only publication with numbers that's out there, at the beginning of October. And at that time, we were expecting that the fiscal impact in these countries would be about 5% of GDP. That means 5% of the goods and services. That's a size equivalent to 5% of the size of the whole economy, goods and services produced, this year. This is as large as all the foreign aid that is coming to these countries.
So this crisis has created a fiscal impact that is at least as large as all the foreign aid that was expected to come to this country. If something like this would happen in the United States, we would be talking about fiscal impact in the order of $700 billion, $800 billion. It would be something unthinkable of. And this is what these countries proportionally are facing.
Have we seen the worst? I mean, I think that's a very interesting question which, of course, I do not have the answer. But what we see is that, in the domestic economy, things are starting to stabilize. I think somebody calls this habituation. I mean, initially, OK. You're not going to go to the field. You might get the disease. It's unsafe. But eventually you have to make ends meet. And people are learning to live with this situation.
And we see it in some very clear economic indicators. For example, gasoline sales are back to their initial levels, although diesel isn't. We think diesel is still low because a lot of large projects are not taking place.
What does maintain these economies besides this habituation of the population has been also that some large foreign investments are still going on. Mining is holding up. Some large plantation and agriculture is holding up. What is not happening is that all investments that were taking place, those, basically, have been stopped as foreign workers don't come to these countries.
So the bottom line is that we see that there is some habituation, there's some stabilization of the situation. And of course, the hope is that, if this crisis is contained in the next three months or next six months, then you can have a real rebound of the economy. Because there are some underlying strengths that we see there still happening.
Regional impacts. I think that's of very, very big concern. I mean, these countries are small, their economies are small. There are 20 million people. West Africa, as Professor said, West Africa has a much larger population and an economy of 700 billion people. Nigeria alone has an economy of $500 billion a year. These countries altogether have an economy of $14 billion a year.
So any expansion of this crisis to larger countries and countries with larger economies would, frankly, be catastrophic. So far, we haven't seen that. And despite the fact that there is also a lot of pressures for us to come and say, what is the regional impact? Give us the numbers. We hear that Chinese tourists are not going to South Africa.
Frankly, so far the impact is limited because we don't see aversion behavior in any of the neighboring countries. And the little aversion behavior that you see is from foreigners that are scared to travel to these countries for tourism. But none of these countries have a tourism industry to start with.
So our expectation-- it's not our expectation. Our hope is that the countries and the international community can help bring this crisis to an end in the next three or four months. If that doesn't happen and the numbers roll out and we don't know what band will be, but it could be from 100,000 to, they say, millions. Whatever it is, if it's large enough, it's very hard to think that Ebola will not propagate to neighboring countries. It's very, very difficult to imagine that scenario.
I mean, that scenario, and if aversion behavior takes place, we can estimate very, very large economic losses for the West Africa region. I'm not even talking about the rest of Africa.
So to conclude, a couple of things. First, the economic and social costs of Ebola in these three countries are enormous. Yet they still pale in comparison with what could happen if this crisis is not brought to an end in the next three months. There is a lot of work to be done if the crisis is contained to rebuild confidence and security in this country, provide financing to businesses that have been decapitalized and devastated, safety nets that those impoverish, and support to governments so they can go back to the business of providing services to their people and keep on the improvement path they were at. So that's the task ahead. Thank you.
MUNA NDULO: Our next speaker is Professor Nick van de Walle.
NICOLAS VAN DE WALLE: Well, thank you. And thank you all for coming. And thank you to the Einaudi Center and the Institute of African Development for organizing this event, for which there was obviously an unmet demand. I was at one of the faculty meetings to talk about this kind of programming, and there were several questions in the room at the time about whether there was demand on campus for something on public health issues in Africa. And I think you're testimony to the fact that there is.
So when I first started to think about what I wanted to say today, I googled the political effect of Ebola. And I think the first 50 stories in the news part of Google that emerged were all focused on the US and on the effect of the epidemic on the US election.
Muna suggested I should talk about the political implications of the crisis since I'm a political scientist. And I don't want to talk about the political implications on the US. And I will resist talking about the US election.
But to start out, I think the fearmongering and ill-informed hysteria that's been in this campaign season, a hallmark of the US reaction, does have implications for politics within Africa, as I will suggest. And no doubt much of Africa, and not at all just Liberia, Sierra Leone, and Guinea. Two weeks ago I was at a conference in South Africa, and I can tell you that, since I've come back, four or five people have recoiled from me when they found out I was. And I said, look, South Africa is far away from where the epidemic is.
But so, I think this epidemic of fear has not contaminated Western Europe nearly as much. But I don't think there's any doubt that there will be fewer tourists, more obstacles for citizens of all of Africa to come to the US, and probably some long-term damage to the reputation of Africa that is deplorable. But it seems to me almost inevitable.
So how does one think of the political implications? Well, the first thing to say is that it's very hard to say because, as the previous speakers have suggested, we really don't know where this epidemic will go. And as a political scientist, I really don't have much of a take on that. Although, as I will suggest, I think one can make probably political science-y kind of predictions.
The first place, I think, to start is to look at the AIDS epidemic. And there was a kind of cottage industry of articles in the political science literature about what the AIDS epidemic would do to southern Africa. And the logic of this literature was basically that the epidemic would shorten the time horizons of citizens who would be much more likely to tolerate risk and to tolerate risky behavior. And this was widely viewed as increasing the risks of political instability in the region.
I don't think this literature reads very well a decade later, frankly. It seems a bit hysterical. And on the whole, the AIDS epidemic did not have dramatic political effects on how politics is practiced in southern Africa.
And so this is in part because societies, African societies, just as all societies, are pretty resilient. And the historical legacies that create how countries do politics are pretty strong. And it takes more than just a little epidemic to really upset them.
I think there are some interesting lessons from the AIDS epidemic. And the first one I would suggest is that the nature of the illness affects the nature of the politics around that illness. Let me give you one example.
The key thing about AIDS and the key way in which it's really different from Ebola was the very long dormant period of the disease. So people could walk around for 10 years not knowing that they had AIDS. Sorry, they could walk around for a long time now knowing that they had AIDS, and then they could know they were HIV positive but not be symptomatic for many, many years.
And that very much shaped the response and the politics around AIDS. Among other things, in countries like southern Africa, HIV-positive citizens became one of the best organized and vocal lobby for public health efforts. I suspect that, if you find out that you have Ebola, the last thing on your mind will be to look for other Ebola sufferers and organize an NGO. You know?
And so I think that's fundamentally a real difference about the disease. I think also, it fundamentally is why I do not think we will reach the kinds of numbers for Ebola that existed for AIDS, in which the fact that there was this long dormant period meant that it was very, very much harder to stop the disease before, in some cases, a third of the adult population was affected.
The other thing is that, pretty quickly, there was a treatment for HIV/AIDS that would maybe not solve the disease completely but would keep it at bay, OK? And that meant that there was a real premium and a real debate about what to do in terms of public health terms. I would argue that the primary public health discussion around Ebola now is, there's a long-term strategy to maybe develop effective vaccine or effective medicines. But the main strategy is one of containment. And that too, I think, will shape the politics and the course of the disease.
So let me say basically two general categories of political effects that one can talk about. One, as the last speaker spoke about, the economic effect and suggested that there is a dramatic economic effect. Let me go further. And here, another difference with the AIDS epidemic.
Southern Africa has much stronger state structures, much stronger public health systems, much more literate populations, more urban populations and, on the whole, much more legitimate political systems. Botswana is a democracy. South Africa is a democracy. Botswana is a longstanding democracy. South Africa has probably the strongest political institutions on the continent.
West Africa, on the other hand, is a region tottering on the edges of chaos and has been for a long time. Now one hesitates to generalize about a region that encompasses 20-odd countries and is probably larger than the continental US.
But nonetheless, these countries that were hit directly were just coming out of civil war. The Central African Republic is in the process of falling into civil war. There's a very precarious situation in Mali right now. Burkina Faso has just had a military coup. Niger has had a succession of coups in recent years.
There's an Islamic threat in the region that has destabilized states. Several states in the region have been really gangrened by the international trade of drugs, with state officials being clearly bought by the Latin American cartels, and so on.
So it is the weakest region, subregion, in Africa with the highest risk of political instability. And it's hard to think-- and let me also add that the price of oil is collapsing. And the rosy numbers over the last decade for the region are in part due to these high oil numbers, which are now going to decline in something like eight or nine countries of the region.
So I think that the economic shock will be quite severe. And these are not politically stable countries, for the most part. So I think that does have political implications.
Secondly-- and I don't want to talk too long-- but the role of the state. The epidemic is in a very real sense a political failure since it highlights, really, the failure of these states to provide decent health to their citizens and to be responsive in a public health manner to this kind of crisis.
Now there are a couple ways of thinking about the implications of this for politics and in the long term. The comment I've just made about the subregion suggests that this may affect the political legitimacy of regimes in the region. Where there's a real cleavage between a state elite, which has been very complacent about spending on social services and has very often viewed social services such as health as something that donors do but that is not a core function of government.
And it's very clear from public protests all over the region that states don't have much legitimacy. This could further weaken that legitimacy, as I've just said.
Secondly, we see that the epidemic has already been used by several governments, most notably the government of Liberia, to limit political freedoms. So Liberia has imposed a press ban. Now the government's argument was that the press is sometimes irresponsible with rumors and stuff like that. And I can vouch for the irresponsibility of the West African press. But still, it's scary when governments start to do that.
Governments are likely to be less forthright and more oppressive to certain marginal populations. We haven't really talked about the gender dimension of this epidemic. But my sense is that more women than men have been affected by it. Something like 60% of the victims have been women.
And one can assume that, as governments decide who they're going to treat and what kind of strategies that they're going to pursue, that more marginal, weaker elements of society are almost necessarily going to be affected more adversely. And I think it's true, but we haven't really seen much on the gender dimension. I think we should see more.
Thirdly on how this affects the state is that we've seen, really, the emergence of an NGO sector. It's really striking how the heroes of a lot of the stories about reaction to the crisis have neither been the donors-- WHO has really taken a pounding in terms of bad publicity-- and it's not been the governments. Even Ellen Sirleaf Johnson no longer seems like the kind of heroine that she'd become in the eyes a lot of the Western press. On the other hand, Doctors Without Borders has emerged as-- its reputation if anything enhanced by this crisis.
Now finally, to end on a positive light, is the long-term optimistic view, which I would call the Charles Tilly view. Now for some of you who don't know, Charles Tilly was a historian who famously said the state made war and war made the state, talking about Western Europe.
And his argument was that external threats and threats to the state had strengthened the state throughout history. And that the strong states of Western Europe had emerged thanks to years of conflict. Now, of course, this is also how the 1,000 or so little kingdoms that existed at the end of the Roman Empire became 50 states. The other 950 disappeared. But this war process was good for the state.
And this has been used in the recent past to say that external threats and internal threats are actually good for states because they rise to the challenge and they increase their capacities. I think this is probably true in southern Africa. The threat of AIDS. I don't know I would say it strengthened the state, but it certainly strengthened the ability of the state to do public health.
And so maybe in the long run, this is the jolt that these very relatively complacent West African governments will need to build up capacity to provide better services to their citizens. And I'll stop on that hopeful note. Thank you.
MUNA NDULO: Thank you very much to our panelists. I think you agree with me that they've talked on all the aspects of the problem, political aspect, health, and economic. So now we invite the participation of the audience. Question or comments. Yes, please.
AUDIENCE: I enjoyed the presentations very much, and I think we've learned a lot. One thing that I have been missing that I have not heard from the panelists is, what lessons, if any, can we get from this [INAUDIBLE]? And if I read the press, WHO maintained that they could have done a much better job had it been for greater support over time from the donors. Particularly the US [INAUDIBLE] had not been paid.
I think, I don't know the extent to which this is correct or not. But it seems to me that we have to learn from this terrible episode. And the world community has to be much better prepared in the future to contain such an epidemic at the outset. And I was wondering if the panelists did have some suggestions about how to better prepare ourselves to fight such an epidemic early on and contain it.
MUNA NDULO: I was going to ask you to hold. We can have at least three questions. Yes, please.
RAFAH: My name is Rafah. And I want to say that I'm from Liberia. I guess I'm from Liberia, I would say, [INAUDIBLE]. And every day I stay here [INAUDIBLE] back home because I am committed here of 5,000 residents. So Dr. [INAUDIBLE] every day has to be in touch.
And I was intentionally coming to this for the discussion. I was intentionally [INAUDIBLE] asking me these questions. Because I think, firstly, what is going to be achieved is that it allows people to see Ebola or good things that Africa [INAUDIBLE]
But I have [INAUDIBLE] for whom the funds are provided because many of those information I think quite those who represent [INAUDIBLE] on the ground. For example, we talk about the views [INAUDIBLE] Liberia may be to the present of slums, in the slums, [INAUDIBLE]. And I think they did [INAUDIBLE] they committed our [INAUDIBLE] committees in which many persons infected with Ebola with national committees. There [INAUDIBLE] allow us to [INAUDIBLE].
MUNA NDULO: You're still [INAUDIBLE].
RAFAH: Yeah. I'm try to [INAUDIBLE]. I'll do my best. We have [INAUDIBLE] we have [INAUDIBLE] we have [INAUDIBLE] we have many other [INAUDIBLE] was affected. [INAUDIBLE] The next one is Ebola [INAUDIBLE] live in America.
MUNA NDULO: Could you get to the question, please? Because we have limited time.
RAFAH: [INAUDIBLE] people come and treat us [INAUDIBLE] We have to try to [INAUDIBLE] In Africa, in Liberia, people live this [INAUDIBLE] community and care for each other.
MUNA NDULO: I think I will cut you now because we really have limited time and we need other people to come in. And I think the panel has caught the gist of what you are saying. Please, try to be brief so that we can get as many people as possible. Yes, please.
AUDIENCE: I have two quick questions. The first is just a clarification. When you said that AIDS formed a way for-- helps the state form their public health response, was that a response to African state or to the US state?
NICOLAS VAN DE WALLE: African.
AUDIENCE: All right. And the second broader question. Why does the panel think that this particular hemorrhagic fever has been so devastating to the economy and has led to a response when there's quite a few other hemorrhagic fevers that have a higher death toll rate and are endemic in Africa?
MUNA NDULO: OK, so I think we've got three questions. We'll come the next round and ask the panel to respond.
CHINUA AKUKWE: You start.
MUNA NDULO: Who wants to go first?
NATHANIEL HUPERT: So thank you for your questions. Let me just take a brief stab at the first question, which is, how can we be better prepared? What I tried to allude to was that a lot of the scientific effort to figure out what's going on is very much reactive to the events. We have a large number of academic groups both here in the United States and around the world who are funded by the United States government to provide mathematical modeling for outbreaks.
What's interesting is that, as some of you probably read, there was a group from Indiana of physicians who went to the JFK Hospital in West Africa over a year ago to start a partnership with their Emergency Department. They wrote about this in the New England Journal, a very moving piece about the head of the Emergency Department who wound up dying of Ebola. When they asked him over a year ago, after they completed their hazard vulnerability analysis, which is a technical term for trying to figure out what the risks to the operation of the hospital are, and they listed things like intermittent electricity, poor quality of the water, et cetera.
When they asked him what he thought the biggest risk to the hospital was-- and this was well before the start of the outbreak-- he said, I'm worried about an outbreak of a hemorrhagic fever here, because we don't have the infrastructure to contain it. So wouldn't it have been interesting if some of those modeling groups had tried thinking about the economic, social, and infrastructural weaknesses around the world and tried a mathematical exercise of putting Ebola down in various vulnerable countries in the world. I'm sure that, if that had happened, we would have seen interesting results.
Whether those results would have moved us to strengthen the infrastructures that were clearly in need of strengthening, I'm not sure. But I think your point is that we have perhaps new ways of strengthening our preparedness. And from the certain perspective that I look at this, I would absolutely agree with you. I think it will be a challenge, maybe less of a challenge now, but a challenge to have these groups see those potentially much less attention-grabbing and headline-grabbing approaches be integrated into policymaking.
MUNA NDULO: Do you have comments--
CHINUA AKUKWE: Yes. Yes. In terms of-- excuse me-- lessons learned, I think that's a very important question. I think there are a couple of lessons that are already learned by everybody.
First one is that WHO is now reorganizing the way it responds to epidemics. Lot, of course, unknown about problems over 15 years for various reasons. And I think the second lesson is that national governments, based on what happened in Nigeria and Senegal, where the governments were able to reach their citizens, perhaps for the first time in many, many years.
A lot of people are studying to see how was it that governments of Senegal and Nigeria were able to mobilize their citizens to respond. And I think the other thing that we're also learning is that community response. And I think our friend from Liberia has a reasonable point in what he's saying.
The importance of strong community response is one of the things that we also learned. And then, of course, the idea that you need to rebuild health systems. Right now there is an outbreak of another hemorrhagic fever, Lassa fever, in northern part of Sierra Leone. And another one going on in northern part of Nigeria. So if you don't have a strong health system, you're not able to deal with some of these outbreaks.
MUNA NDULO: [INAUDIBLE] please.
JOHN PANZER: Yeah. I would like to put things in a little bit in context. And of course, after a crisis like this, the response is you need to strengthen health systems. But the life in these countries-- and if you're the minister of finance-- is very tough. The whole budget of the government of Liberia, including after all the aid that comes into the country, is $500 million a year.
Professor here tells me, because I asked him, the budget of this university for one year is $3 billion. So your budget at Cornell is six times-- operating?
NICOLAS VAN DE WALLE: Yeah, yeah, yeah.
JOHN PANZER: I may be wrong. But just-- I may be wrong. Just put this in perspective.
NICOLAS VAN DE WALLE: Yeah. That includes the medical school.
JOHN PANZER: It includes the medical school, Doctor. OK. So you can imagine, OK, what are we talking about? So the life of a minister of finance is, do I provide electricity so that people can get to work and get out of poverty by being productive? Or do I provide health systems so the probability of an event like this, if it happens, it doesn't wipe out the economy? These are very tough choices.
But to answer your question, sir, because I think it is very relevant. We see that, in this interconnected world, there are now public bads. So Ebola is a public bad. Something that starts in a rural area between Guinea, Liberia, and Sierra Leone countries that-- even I worked 20 years in the World Bank. Until I worked in Africa, I didn't know where exactly they were.
A thing that happens in a village there suddenly has implications for the whole world and could have enormous costs. So there's got to be a system in which the world community can address these public bads before they become too costly for everybody. That's good business.
The second is, I think we have to develop some mechanisms through which you can very quickly react to it, financial mechanisms. And those are not in place. And I think one lesson from this event is that global leaders will have to get together and decide to set aside some money to address these public bads.
NICOLAS VAN DE WALLE: I don't want to repeat anything that's already been said. The question of why this epidemic and why not some other hemorrhagic fever, I think, is a good question. My sense is that this is the first one where very early in the outbreaks there were cases in cities. And thus it was much harder to contain.
But nonetheless, this has been an accident waiting to happen since, as was said, the possibility of such an outbreak. I mean, there have been a dozen Hollywood movies about it in the last 30 years. And this comes at a time in which health has gotten something like a quarter to a third of all foreign aid to the region. And you know, I think the bottom line is that aid is good for certain things. For example, it's good at vaccines or--
But it's not good at creating public health systems. Or it hasn't been good so far. And that's, I think, that's the striking implication of this, is just how weak the public health system in Liberia is.
He was talking about the size of the budget. I saw recently that Liberia, before this crisis hit, had 55 doctors in the country.
MUNA NDULO: So next round we have here. Yes, please.
AUDIENCE: Thank you. [INAUDIBLE]
NICOLAS VAN DE WALLE: That's got a student.
MUNA NDULO: You can go first. We'll take the student.
AUDIENCE: I have a comment and a question. To me, I feel like the Ebola-- the toll that Ebola has taken in these African countries is symptomatic of the serious governance in many parts of Africa.
And in the case of Nigeria, for instance, there's a lot of [INAUDIBLE] government. I believe it's receiving way too much accolades for how they have handled Ebola. And what people are not focusing on is the fact that Ebola got to Nigeria through the first-class cabin. It came through a very affluent man. And so the whole population that was impacted were the affluent, middle class, upper-middle class. So it was very easy to contain it.
So if Ebola got into Nigeria through the masses, through the land border, it would have been a totally different situation. So I wonder, to what extent is a crisis like Ebola should be a way to change the paradigm in terms of the way aid is given to Africa? So instead of giving African governments money that we know that they are going to misuse and embezzle, why don't these countries who make infrastructure to the countries? So give us hospitals, give us roads. Don't give the governments money because it's not [INAUDIBLE]. Thank you.
MUNA NDULO: So yes, please. We'll come to all of it. Yes, please.
AUDIENCE: I had a question about the statistics. I was wondering, is there testing that is used by health care workers to diagnose patients? Or if diagnosis is on the basis of symptoms you know. Thank you very much.
MUNA NDULO: Thank you. Yes, please.
AUDIENCE: Quickly and to the point. The gender. I'm glad you mentioned a link. I regret that it wasn't addressed properly.
Women have been [INAUDIBLE] caregivers [INAUDIBLE] So if you want to have an impact, how do you address the different information?
Another point is the site habituation. What is done? I'm from [INAUDIBLE] in West Africa. [INAUDIBLE] has border with Liberia and Guinea. So their tradition was that, if I must say that if you're sick now, but the point I'm making is there's no time for an operation. There are certain things besides habituation. You don't go back to business as usual just because of [INAUDIBLE] So what is done with that?
And finally, there is poor infrastructure where you've got infrastructure. This was [INAUDIBLE] African government. But there were issues in [INAUDIBLE]. Briefly, one last story.
Recently I was in a discussion with a former IMF officer who is an African and who was reporting his own terrible experience as a young and energetic and optimistic way to Africa. And he had this team telling [INAUDIBLE] where is the man working? To cut, education cut, task cut.
So many of the infrastructure in Africa where [INAUDIBLE] even [INAUDIBLE] countries where there was some responsibility. And I disagree with the unique-- it's like every West African country. We're going to say that it's difficult to [INAUDIBLE].
So the health care facilities in Africa would indicate not only because of the conflict and a terrible situation. But I think that also because of policies of international financial institutions. So I hope you can address those.
MUNA NDULO: Yes, please. We're about-- I think we'll take no other questions because we're running out of time and we need to give a response on that. Yes, please.
AUDIENCE: I had an honor to work in a Nigerian [INAUDIBLE] At that time it was a post-war [INAUDIBLE] was FBIS. I didn't see a lot of [INAUDIBLE] infrastructure. It was very bad and still is.
But I do know a lot of international focus on these political things. And they were worse. While they ignored the infrastructure, they ignored the poverty. And I'm wondering why this disease was not contained in the first place but an emergency. Why the focus was not given-- undivided attention was not given at that time, but now everybody is out crying.
MUNA NDULO: At the back.
AUDIENCE: Hi. Thank you. In the interests of time, I'll make this question quick. My question is for Mr. van de Walle.
So other questions in this round have been about infrastructure. But back on July 19 of 2012, Jane Perlez, while writing for The New York Times, mentioned that China had recently invested $20 billion into Africa. So does China necessarily have a greater interest in trying to stop this Ebola outbreak from spreading to the rest of Africa in order to have a return on their investment?
And to follow up on this as well, Mr. Akukwe, on the slide [INAUDIBLE] your recitation, you stated that you don't think that there's any of these African countries that can manage simultaneously if there was a gigantic outbreak in the country. And Mr. Panzer, you talked about how these are some of the poorest countries in the entire world.
Now Mr. Van de Walle again, in your presentation you talked about how war can m make countries stronger, but you said sometimes it results in the long run. So will these countries really have the long run to become stronger without having terrorist groups such as Boko Haram go into the country and really take over these governments, seeing their inability to prevent this Ebola outbreak and control the spread?
MUNA NDULO: So any other very, very brief question because [INAUDIBLE] Very, very brief, please. Yes, please.
AUDIENCE: I'm [INAUDIBLE] endeavors that the Ebola epidemic has given [INAUDIBLE]?
MUNA NDULO: OK. We've got to go to the back. You've had your hand up. Very brief, please.
AUDIENCE: OK. Can this [INAUDIBLE] each of these countries need? [INAUDIBLE] very bare need of feeding these people in these small towns, in these small villages. Because one of the things is that they go and eat bush meat. And that many of these [INAUDIBLE]
So given the crisis [INAUDIBLE] and given the dire need of them here, if some of these individuals could hear some that is taken for granted, how do we stop hunting in this sense?
MUNA NDULO: I think we've given a chance to everybody. Anybody else? Yes. Here. Please. Give me brief.
AUDIENCE: Just a quick [INAUDIBLE] question. The reason I asked about the [INAUDIBLE] process [INAUDIBLE] is because, from my knowledge, I understand that doctors diagnose based on symptoms alone. And I thought that [INAUDIBLE] because there are so many diseases in West Africa that have similar symptoms, Ebola, cholera and malaria. And it's rainy season, which is prime time for these diseases. So if it's not based on testing, then I--
MUNA NDULO: OK. The last.
AUDIENCE: Yeah. It is a similar question but focused on the staph diseases that which educated and [INAUDIBLE] tend to neglect but which are not diseases. And try to create mortality and morbidity for [INAUDIBLE] outbreak.
MUNA NDULO: So I'll let the panel decide which questions they answer and choose a theme.
NATHANIEL HUPERT: I can give a very brief answer too about the--
So let me just give a very brief answer about the diagnosis. And I know this from working with staff at the Kenema General Hospital in Kenema, Sierra Leone. In the hospital there, they test for three things. One is malaria, one is Lassa fever, and the other is Ebola. The malaria and Lassa fever tests are rapid tests. The Ebola is a PCR, polymerase chain reaction test, that at the time that I was working closely with them had to be motorcycled over to a lab that wasn't on site. And now there's a lot of activity trying to get on site, essentially labs on a chip.
But at no time, at least when I was working with them, were they only making symptomatic diagnoses. And I think that that's pretty much universal throughout the three countries. Some of the earliest and most impactful investments were these mobile labs. One from China, one from the Navy, and a couple of others. And UNICEF is now on the ground trying to get better telephonic systems for results coming out of these labs.
CHINUA AKUKWE: Yeah.
MUNA NDULO: Yes, sir.
CHINUA AKUKWE: Yes. I want to assure you that I'm not aware of any clinical diagnoses of Ebola. I'm not aware of it, and I haven't seen it. And one of the problems you're having in some rural parts of Liberia, [INAUDIBLE] they're not about to have these rapid response mechanisms from their laboratory services. And that's why the US government and international agencies are trying to ramp that up.
On the issue of governance, we can stay here till end of next week just talking about governance. But we all know that everything in Africa eventually boils down to governance.
Gender is very, very important. Gender, especially in Liberia and Sierra Leone. The majority of people who are dying are caregivers, women. And it's my understanding that a UN mission now based in Accra are developing a new strategy to make sure that they are about to reach the women who are family caregivers.
Cultural aspects. I'm glad that you mentioned that. Funeral ceremonies are killing people in these three countries. And I remember in Nigeria, once Ebola came to town, even my own tribal area, Igbo, like to bury people and not allow anybody to bring back any corpse from any part of West Africa. So I think eventually, every country will have to take very drastic action to make sure that you end the spread of disease.
Finally, on disease response. The failure of Ebola at the national, local, and international level was a breakdown in disease response mechanism. And we are being assured now that that will not happen again, at least from WHO.
JOHN PANZER: Well, I just want to second this point that, ultimately, it all boils down to governance. There's no other way where a society becomes 186 out of 191 in the world in terms of economy or human development if you don't have a severe problem of governance. And it's almost a tautology. So that's the core problem.
The issue is, this crisis, this Ebola happened in the countries that were probably least prepared to deal with it. And the reality is, when you are that poor, it's very hard to provide health, to build health-- building health systems is very complex. It's a lot more difficult than providing a vaccine. It's very complex. It requires a lot of the C's that Professor mentioned.
And many of these countries are very, very far from that. As to the macro issues of the IMF and so forth. That's a very old, old narrative. Whether true or not, it's certainly not the narrative of today. But ultimately, countries, just like people, need to deal with the resources they have to provide the services. And if somebody gives the bad news, that doesn't mean that that person is culprit for that situation.
NICOLAS VAN DE WALLE: Yeah, I mean, whatever the effect of structural adjustment was in West Africa in the '80s, the truth is that spending and statistics on education and health are considerably better in most of these countries than they were before the onset of structural adjustment. So one can imagine an alternative universe in which some of these countries like Liberia would not have had civil wars and would have had much more effective investments in public health. But it's hard to think through a counterfactual very rigorously.
I do think, I mean, I did not know that the budget of Liberia was only $500 million. To give you a sense of that, I think that the US last year gave $120 million in foreign aid to Liberia. So I don't know how much of that gets tabulated in the ODA, in the aid statistics.
The point I would make is that it's clear that the efforts-- there have been real efforts in an area like public health over the course of the last 20 years in many of these countries. But almost by definition, it has not been a particularly effective effort. Albeit, it's a very hard environment in which to work. But as someone said, the aid to Nigeria is often ineffective and the modalities, the type of aid that a country like Nigeria gets, should change. I'm not sure.
But there's no doubt, there is no doubt that countries are usually better served if they're doing things on their own and if there's the will and the desire to solve things like public health. I mean, you don't have to be super rich to say, oh, we only have 50 doctors. We should train more doctors. That's not rocket science, and it doesn't require billions of dollars in budgets.
It requires just a number of scholarships every year. And even the poorest countries in the world could afford that. So I think in general, the situation where you rely on foreign aid for your efforts in an area like public health generally means that you're not going to perform as well as if everything was motivated locally and organically within the society itself.
AUDIENCE: Thank you.
MUNA NDULO: Well, I think we've come to the end of our proceedings. So please join me in thanking the panel.
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The Einaudi Center for International Studies partnered with the Institute for African Development (IAD) Nov. 10, 2014 in discussing the impact the Ebola pandemic is having on the most affected countries and the African continent as a whole.
Speakers: Muna Ndulo, Nicolas van de Walle; Chinua Akukwe; John Panzer and Nathaniel Hupert.