And, sadly, this is not an isolated report. Drew Hinshaw from the Wall Street Journal wrote about a heartbreaking scenario from Sergeant Kollie Town, Liberia in August:
Rubber gloves were nearly as scarce as doctors in this part of rural Liberia, so Melvin Korkor would swaddle his hands in plastic grocery bags to deliver babies. His staff didn’t bother even with those when a woman in her 30s stopped by complaining of a headache. Five nurses, a lab technician,then a local woman who was helping out cared for her with their bare hands. Within weeks, all of them died. The woman with a headache, they learned too late, had Ebola.
There is a particular irony to the story of missing gloves in Liberia, as the country is also home to the “largest single natural rubber operation in the world”, Firestone Natural Rubber Company. Although Liberian rubber is mainly used in car tyres, the company says it also supplies rubber to companies manufacturing “vital medical components”, such as the latex gloves desperately needed in health facilities in the region.
The lack of gloves is a reiteration of inequalities in Africa, but this time refracted through the contemporary configurations of “global health”. How can it be that after decades of unprecedented financial investments in healthcare in developing nations, and in particular on the African continent, health facilities are still missing the most basic supplies?
In recent decades and with the help of the United Nations’s Millennium Development Goals (MDGs), health initiatives have received unprecedented attention and funding, and many advances have been made. However, together with the MDGs came a particular framing of health and health interventions.
The MDGs name HIV and malaria and “other diseases”, as well as malnutrition, child mortality and maternal health, as priorities – and this has real-life consequences for policy and funding decisions. HIV, malaria and tuberculosis still receive the biggest share of the funding.
All MDGs have clear numerical aims. For example: “reduce child mortality by two-thirds between 1990 and 2015”. This clear-cut numerical focus has strong effects on performance, as it renders health and progress measureable and accountable. So it is assumed this keeps momentum going and funders on board.
However, it has also meant that we have in recent years overwhelmingly focused on specific single–disease interventions. The rationale behind this is exemplified by a statement from Melinda Gates in 2007, when she introduced the Gates Foundation’s focus on malaria eradication:
And because we can’t fix the whole healthcare system in all of Africa … the only way to end death from malaria is to end malaria.
For many, these highly focused interventions and technological fixes was – and continues to be – pragmatic. The promise is that with the appropriate tools and benchmarks, progress can be measured and the messy realities of international politics and local infrastructures circumvented for more effective results.
This has led to a proliferation of such highly focused projects, many of them hybrids involving international donors, NGOs, public-private ventures, research and data collection enterprises. Social studies of global health have shown that this has led to a fragmentation of healthcare provision, which in turn has resulted in massive uncertainties for patients.
Under the label of evidence-based medicine, new intervention strategies and technologies are trialed, scaled-up and then all too often handed over to ministries of health that lack the financial and operational means to sustain the interventions, even if they don’t lack the expertise.
West Africa’s Ebola epidemic painfully shows that this patchy logic of highly focused and time-bound projects has significant shortcomings. Healthcare infrastructures cannot be circumvented when one aims to improve healthcare sustainably. Well-functioning infrastructures are flexible and adaptive. They are able to change gear and respond to shifting disease landscapes. Just like the harvesting of rubber and the production of gloves, they are rooted in history and configured in specific political economies.
Many global health initiatives seem to be based on an impoverished understanding of health and wellbeing. We assume we know which diseases and ailments are relevant and crucial to address. Ebola teaches us that we are well advised not to work from this bold assumption. A humble version of Socrates’ classic: “I know that I know nothing” seems to be a better guide to navigating complex and rapidly shifting disease landscapes.
The lack of gloves, personal protective equipment and skilled personnel in West Africa’s health facilities is not only a result of war or weak states, but also of the current logic of developing global health. It presents us with an urgent call for change in global health approaches and logic.
This modified version of an article that was first published in Somatosphere: http://somatosphere.net/2014/10/rubber-gloves-global-health.html