2.8.1 Key Findings from the Literature
The literature review for the thesis was formulated by extracting information from multiple themes found within the main research objective. These included a background to the context of western Uganda, understanding EVD emergence, amplification and response from a biological and clinical perspective as well from social, cultural and geopolitical perspectives. The key findings of the review are summarised in this concluding section around the concept of power, identified as the common thread running through each of the sections outlined above.
The first section outlines the historical and political context of Uganda from where the EVD outbreaks in this study emerged. This gave a brief snapshot of the historical sequence of authoritarian political order tolerated by Ugandans since the eighteenth century from the emergence of kingdoms, colonialism, post-independence dictatorships and a violent civil war. Although Uganda has enjoyed relative peace and economic stability for the past thirty years emerging as a single party ‘democracy’ it remains overshadowed by a global
capitalist system and external neoliberal policies that have resulted in growing inequalities since the ending of the cold war. The mass influx of refugees from eastern DRC into western Uganda is a consequence of war modes of production and expansive interests linked to Ugandan and Rwandan extractive and security interests. This post-Cold war political economy that guarantees access to cheap resources for global corporations whilst costing the lives of over three million Congolese people lies subordinated to a cultural epidemiology that defines and blames those same Congolese as refugees for their eating habits and subjecting the region to EVD outbreaks.
EVD is well documented from a biological perspective, however a comprehensive understanding of its biological form, clinical manifestations, and pathophysiology in
humans does not necessarily translate into cost-effective and common sense treatment being made available for the majority of Africans during outbreaks. Perceived as a threat to western public health and security, donor led interventions and financial support flows inwards in the form of responses that focus on containment and research for vaccine and innovative drug developments. The geopolitics of current response interventions are outlined against the history of ‘international’ health emerging from the development of northern institutions serving northern interests. An overview of contemporary global health diplomacy and the construction of ‘universal consensus’ among decision makers to support an increasingly securitised agenda is considered in view of the inequalities of health
interventions and outcomes during EVD outbreaks. The third section broadens the lens beyond the biomedical framework by capturing some of the cultural and social
perspectives around EVD outbreaks. The concept of ‘cultural epidemiology’ was supported for its consideration of anthropological perspectives. However, the role of anthropology in EVD epidemics has being confined within the limitations of offering a culturally determined explanation for EVD emergence and amplification but excluded from offering a critique of the larger structural forces underlying it. The determinants of war and conflicts that are commonly associated with EVD emergence and the role of unresolved poverty and weak health systems have remained subordinated to a behaviour blame narrative. Finally, local experiences from a limited number of studies are mostly descriptive and converge around human understandings through a psychological
perspective of human experience. Figure 2.1 summarises the multidisciplinary perspectives applied to current understandings of EVD identified from the literature.
Fig. 2.1 Interdisciplinary perspectives and concepts around Ebola Virus Disease
Ebola
Virus
Disease
Historical & Political Context of EVD Emergence A Biological Agent A Cultural Epidemiolog y Social Determinants of EVD Emergence Global Health & Geopolitics of EVD Local Experience s2.8.2 Gaps in the Literature
While collaborative work between international, national, and local teams to contain outbreaks of highly virulent pathogens at source remains important in developing
countries, an imbalance exists in the knowledge disseminated in the scientific literature and the narratives around EVD outbreaks that are dominated by inputs from the global north. The voices of those directly involved are seldom included.
This review of the literature reveals how EVD outbreaks have been well documented in terms of biological and epidemiological perspectives. Several studies make references to plausible underlying determinants but none actually explore these causalities analytically. For example, one abstract makes reference to how “Specific conditions in hospitals and communities in Africa facilitate the spread of the disease” (Baize, 2014, p.1418), but no further reference to the ‘specific conditions’ are mentioned in the main article. In another study in Guinea the author suggests that continued transmission of the virus was due to “localized resistance to EVD interventions, in addition to limited awareness and
acceptance, fear, mistrust and stigma”. However the author then goes on to claim that a reason for high transmission was due to high mobility in and out of the capital city by “patients seeking medical services not available elsewhere” (Rico et al., 2016. p.). Here limited access to health services contradicts the behaviour blame narrative but is
overlooked. The article makes no references to poverty, lack of health system
infrastructure or the fact that the West African countries affected are amongst the lowest on the human development index (UNDP, 2014). The literature around natural infection among wildlife make some references to the challenges that unbalance the ecosystem such as logging and deforestation but again a deeper exploration of these determinants remain absent (Formenty et al., 1999; Wolfe et al., 2005). According to Leach & Hewlett (2010) models looking at infectious disease emergence need to be dynamic, systemic, and critical. They need to track rapidly changing clinical, even molecular phenomena and then link them to the large-scale social forces that shape the contours of disease emergence. This broader exploration of the underlying determinants of EVD outbreaks has been mostly neglected to date (Dry & Leach, 2010).
What emerges from the review as a major gap is the lack of local voices in terms of interpretations and lived experiences throughout the events and their contribution to knowledge. While a few studies on previous EVD outbreaks in Uganda have explored local perspectives and lived experiences during EVD outbreaks, none have linked them to
the broader determinants that underlie their emergence or outcomes (Hewlett & Amola, 2003; Kinsman, 2012; Matua, 2014). In 2015, the Lancet invited a number of “respected global health practitioners to reflect on lessons learned from the West Africa outbreak, to explore the idea of global health security, and to offer suggestions for next steps”
(Heymann et al., 2015, p.). None of the authors hailed from the West African countries where the epidemic occurred, or from a country where Ebola had ever occurred in the past. Only one member originated from an African institution in South Africa, the New
Partnership for African Development (NEPAD), an institution that has been critiqued as a privileged strata of African elites that fit into existing global power relations (Taylor, 2003).
Inclusion of the perspectives of local health service providers working directly with infected persons and at risk of infection themselves could offer deeper insight into the role of how international responses were perceived and the long-term impacts, if any on the health system during and following the outbreak. An understanding of these perspectives could identify gaps and valuable lessons learned.
The challenge of managing and controlling EVD outbreaks from within impoverished communities in sub-Saharan Africa where they are most likely to occur provides a rich context for arguments from the biomedical, cultural and socio-political models of disease emergence in addition to the epidemiological and behaviour based narratives in situ.
Secondly, there is clearly a space in the literature for a deeper analysis to understanding the broader dynamics shaping the emergence of EVD outbreaks from local as well as national and global perspectives. This knowledge can be transferred to global and national policy makers in developing improved and sustainable response mechanisms into the future.
“Only through the concrete understanding of particular worlds of suffering and the way they are shaped by political economy and cultural change can we possibly come to terms with the complex human experiences that undermine health” Kleinman (1991).