By Stuti Srivastava
That health is a fundamental human right is inherently guaranteed. However, equitable access to healthcare - in both local and global contexts, remains a distant dream given the racial, regional, gendered, and class-based barriers that have been and continue to be perpetuated by colonialism.
The inequality/disease relationship is a form of violence enacted through cultures and rationalities. (Nguyen and Peschard, 2003) The social determinants of health, as mentioned above, both embody and aggravate health inequalities. Disease and its prevalence must be understood as a form of violence that is based on social hierarchy, one that can be seen easily in the differential infection or mortality rates within varying social groups during global disease outbreaks such as the AIDS epidemic, Zika, Ebola, or most recently, COVID-19.
Social understandings of bodies affect health access and perpetuate inequalities. For example, the belief that poor bodies are naturally more resistant to infectious diseases such as COVID-19 than richer bodies, or cultural myths and expectations, such as women must bear the pain of periods and childbirth in the natural grace of femininity, make certain groups more vulnerable to exposure to disease and late or inadequate medical help.
Social inequalities persist not just locally but also globally. Some bodies are more important than other bodies, made so by practices of politics and international interaction. Inequality in capitalist societies creates and sustains health disparities (McKeown 1979; Navarro 1976). Differential access to healthcare that prevails in developed countries where class differences affect how healthcare is available to people and thence effects spread of disease is repeated in newer, developing nations where extreme structural adjustment and capitalist reform is forced onto them and earlier structures of education, healthcare and welfare are either never introduced, or are rapidly introduced in order to embody neoliberal agendas of developed nations. This reflects the gap between the importance given to bodies, where the poor and marginalised body becomes dispensable, while the rich, white, heterosexual, male body remains more important to the state and international order.
Ebola in an Unequal International Order
The Ebola epidemic reveals a lot about global health inequalities, both in a racial as well as class context. The roots of the spread of the disease lie in a failure on the part of international organizations and developed nations to understand the vulnerability of the countries it stemmed in, and a lack of care and intervention exhibited until the virus reached the First World countries of Europe and the USA. Ebola’s emergence and impact are grounded in the legacy of colonialism and its creation of enduring inequalities within African nations and globally. (Ali et al, 2016)
Ebola’s emergence and spread was not an issue warranting global concern before it reached European countries. Until then, it was a racialized, exoticized disease affecting the poor African population. Even after, it was the disease born out of ‘African culture’ that had now become a threat to the international world order. The narrative emphasized local-level poverty and cultural and ecological practices as the major factors of causation in the epidemic. (Shelley-Egan and Dratwa, 2019) The blame was put on ‘cultural’ ways of living (such as congested housing, community practices, overpopulated colonies etc.) rather than locating the reasons for this spread in poverty and marginalization. Before this, Ebola had become a mysterious, enigmatic disease that was affecting an othered people. So, when it reached other regions, the immediate aim became to stop the disease from entering the ‘clean’ First World from the ‘dirty’ Third World.
One may see the differential importance given to affected bodies in an instance noted by Shelley-Egan and Dratwa (2019). The unapproved drug ZMapp was administered to a Spanish priest and two US aid workers before they were evacuated, but two top African doctors were denied the drug and refused evacuation. Both died. Unequal and selective care were prevalent, even though most international intervention was due to a white savior complex – in the form of assistance provided to the diseased African incapable of protecting himself.
What is also relevant to note is the immediate international response to the spread of the disease – a security response, instead of immediate humanitarian aid, rooted again in colonial attitudes of control and militarization. The British military deployed several personnel in Sierra Leone. There was a violent, militarized response internally as well. The Congolese army, for example, deployed armored vehicles accompanied by soldiers and imposed violent techniques of ensuring vaccinations and isolation. In countries reeling from the effects of colonialism, war and conflict, extreme poverty and increasingly authoritarian governments, these acts further weakened people’s trust in both international and local forces.
Does the Virus Discriminate?
The Ebola epidemic was the first disease outbreak which elicited a global response, and in its wake left behind several important lessons for the global community to learn from. So, it was expected that the COVID-19 pandemic would be tackled better.
Bambra, Riordan, Ford and Matthews (2020) have termed COVID-19 a ‘syndemic pandemic.’ A syndemic exists when risk factors or comorbidities are intertwined, interactive and cumulative - adversely exacerbating the disease burden and additively increasing its negative effects. In a sense, COVID emerged due to the existing apparatus of inequality and disparity. An intricate interplay between economic systems and global power dynamics contributed to its spread.
A similarity we can locate between Ebola and COVID are that both were initially racialized diseases. COVID was the disease that stemmed out of ‘unclean’ and ‘barbaric’ Asian food practices. Since it had emerged first in China, it created the narrative of a ‘biological weapon’ manufactured by Chinese agencies to establish hegemony in global politics, never mind the losses that China itself had incurred because of the pandemic.
COVID laid bare existing social inequalities in access to healthcare in both local and global contexts. While leaders of countries repeated that ‘the virus does not discriminate’, in reality, it did. In developed countries such as the USA, the larger burden of suffering was borne by black people, with higher infection and mortality rates, mostly because of living conditions that made social distancing difficult, along with high poverty rates which made access to necessary medical care difficult. Besides this, there were disparities in the mortality rates in developing and developed countries, with some countries still struggling to get the pandemic under control.
Healthcare systems rooted in capitalism perpetuate structural inequalities, which has had a disproportionate effect on marginalized people. Not only did they get affected more, they were also less able to access adequate treatment. It would not be wrong to say that the immense and uncontrolled spread of the COVID 19 pandemic was a neo-liberal crisis that could have been prevented through people-centric aid and relief policies. Ibrahim Abdullah (from Ali et al, 2016) said this in the context of Ebola years ago, but it is still extremely relevant – ‘This is the neo-liberal scourge: if you privatize health care in the context of mass poverty, you get an epidemic (Ebola). If, however, you put people at the center of development by modernizing health and education, you can prevent it.’
The other related consequences of the pandemic are also likely to be similarly unequal – with marginalized communities suffering more health consequences, increased poverty, unemployment, and subsequent gendered and racial abuse.
Today, a separate COVID epidemic is building in Africa owing to the lack of testing and vaccinations. In Ghana, for example, there are five laboratories that can test for coronavirus. Nigeria, which has a population of more than 200 million, has only 25 laboratories that can test for the virus. (Mogoatlhe, 2020) What is also relevant to look at the unfairness in how several people in African countries were subjected to COVID testing without their prior permission or awareness, by both state and international actors. This was a serious case of violation of the bodily autonomy of marginalised peoples, aggravated by the narrative of the African in need of protection, as was seen already during the Ebola epidemic. Due to lack of infrastructure and capital, it is possible that the African people might see more disproportionate effects of the pandemic than the rest of the world, again.
Global health inequalities, exacerbated and aggravated by social inequalities and the social determinants of health should be dealt with not through a security perspective, but through a social justice perspective that centers the lives and experiences of people. There is the need for human rights-based language when dealing with health epidemics and pandemics in the future. An active involvement of marginalized communities in planning and policy, along with intervention that focuses on the transformation of social relations is what will help in effectively reducing inequality in exposure to disease and violence in times of a health crisis.
Nguyen, V., & Peschard, K. (2003). Anthropology, Inequality, and Disease: A Review. Annual Review of Anthropology, 32, 447-474. Retrieved August 16, 2021s, from http://www.jstor.org/stable/25064838
McKeown Thomas. The Role of Medicine: Dream, Mirage, or Nemesis? Princeton, NJ: Princeton University Press; 1979.
Navarro Vicente. Medicine under Capitalism. New York: Prodist; 1976.
Ali H., Dumbuya B., Hynie M., Idahosa P., Keil R., Perkins P. (2016) The Social and Political Dimensions of the Ebola Response: Global Inequality, Climate Change, and Infectious Disease. In: Leal Filho W., Azeiteiro U., Alves F. (eds) Climate Change and Health. Climate Change Management. Springer, Cham. https://doi.org/10.1007/978-3-319-24660-4_10
Shelley-Egan, C., & Dratwa, J. (2019). Marginalisation, Ebola and Health for All: From Outbreak to Lessons Learned. International journal of environmental research and public health, 16(17), 3023. https://doi.org/10.3390/ijerph16173023
Lerato Mogalthe (2020) Lack of COVID-19 Testing Is Leading to a 'Silent Epidemic' in Africa, Warns WHO