The microbe is nothing, the terrain is everything – Louis Pasteur

A global pandemic such as Covid-19 naturally focusses our collective attention to the work of epidemiologists and others working in that field. And for the period in which the scourge ravages the earth, there seems to be little else we can do but wait on the edicts and pronouncements of medics.

London feels like I am Legend; Nairobi feels like Outbreak… the world is disturbed and the virus is on the loose. Lurking underneath the mayhem, however, is a vast network of events ranging from the biological, as expected, to the social, the political and the economic.

While a virulent strain of influenza occurs perchance, the underlying institutional fabric – the public health system, existing social capital, and good governance – is the conscious result of an engaged society and is the difference between a lethally ravenous pandemic and a manageable one.

This column has for the past months dedicated itself to the study of institutions for the development of the rule of law. One may doubt the relevance of such pursuit in the midst of a global crisis, yet we find that this situation now, necessitates such study even more as this environment has offered the best testing ground for state and government effectiveness.

The question of what constitutes true development is many at times lost in the obsession we have with economic growth. Human development is however vaster, encompassing more than just GDP trends on a graph. We have attempted to demonstrate this in our research concerning social capital, wealth and income inequality and the cost of corruption among others. Our conclusions have been mostly the same. We need to develop the rule of law in order to strengthen the state’s effectiveness in ensuring human development.

An unexpected threat to human security such as coronavirus tends to bring all the state’s weaknesses to the fore in a brutal manner. It is impossible to prepare adequately for disaster. It is possible however, to build institutions that will cushion the impact of such disaster well beforehand. In order to understand this, we look briefly at conversations that epidemiologists have been having for decades, concerning the bridge between society and disease.

Conversations in science on microbes and society

The work of the chemist Louis Pasteur in 19th century France presented a turning-point for humanity. “For centuries”, Joseph Lister said, “Infectious diseases had been shrouded as it were, under a dark curtain. Pasteur unveiled that curtain to reveal the microbial origin of disease.” What followed, as one would naturally expect was a revolution in the way medicine was conducted, with Joseph Lister going on to pioneer antiseptic surgery, and the development of immunology, whose impact has been immeasurable.

Studying the corpus of work that followed Pasteur’s discovery, Dr Paul Farmer, an anthropologist and physician at the Harvard Medical School in his paper, Social Inequalities and Emerging Infectious Diseases reports that twenty four years ago, the sociologist of science, Bruno Latour reviewed hundreds of articles appearing in several Pasteur-era French scientific reviews to constitute what he called an ‘anthropology of the sciences’ (he objected to the term epistemology).

Latour cast his net widely. “There is no essential difference between the human and social sciences and the exact or natural sciences”, he wrote, “because there is no more science than there is society. I have spoken to the Pasteurians as they spoke of their microbes.”

Latour’s finding echoed that of the philosopher Michel Serres, who once observed that the border between the natural and the social and human sciences was not to be traced by clean, sharp lines. Instead, this border, recalled the Northwest Passage, is long and perilously complicated, its currents and inlets often leading nowhere, dotted with innumerable islands and occasional foes.

The problem, Dr Farmer found, was that modern epidemiology, focussed solely on the natural sciences,  is oriented to explaining and quantifying microbes as the bobbing of corks on the surface waters, while largely disregarding the stronger undercurrents that determine where, on average, the cluster of corks ends up along the shoreline of risk – what Louis Pasteur termed, ‘the microbe’s terrain.’

To Dr Farmer and other social medicine scholars, the importance of understanding human and social sciences in epidemiology, was evident in every major retrospective study of ‘infectious diseases’ outbreaks. This historical regard demonstrated that what was not examined during an epidemic, which is mostly the socio-environmental conditions of those affected, is often as important as what was – the nature of the microbe in question, and that social inequalities were important in the contours of past disease emergence.

Consequently, the study of borders in themselves becomes relevant in understanding the spread and impact of a global pandemic such as the coronavirus as it means, increasingly, the study of social inequalities. To Pasteur, the pre-existing socio-environmental conditions such as levels of poverty, sanitation, malnutrition, environmental degradation, and access to preventive and curative care – to mention but a few, play a crucial role in determining people’s susceptibility to any disease.

Dr Farmer opines that many political borders serve as semipermeable membranes, often quite open to diseases and yet closed to the free movement of cures. Thus, many inequalities of access be created or buttressed at borders, even when pathogens cannot be so contained. In order to understand this, we look at the HIV pandemic in Africa in the context of the Structural Adjusted Programmes (SAPs) imposed by the International Monetary Fund (IMF) and the World Bank.

The HIV/AIDS pandemic and structural adjustment programmes (SAPs)

The HIV/AIDS pandemic that started in the 1980s ground most of sub-Saharan Africa to a halt. By the new millennium, 75 per cent of all people infected with HIV and four in five deaths were in sub-Saharan Africa. While sexual behaviour was undoubtedly an important factor in the transmission of HIV/AIDS, it however appears totally inadequate in explaining HIV prevalence as high as 30 percent of the adult population in some African countries and less than one percent anywhere in the Western world.

Nana K. Poku, Vice Chancellor and Director of HEARD Institute, University of Kwa Zulu Natal, finds a correlation between the particular egregious devastation of HIV/AIDS in the continent and the economic policies of the 1980s. This, he details in his paper, Poverty, debt and Africa's HIV/AIDS crisis.

By the time HIV/AIDS was gaining ground in sub-Saharan Africa in the 1980s, one of the societal legacies of poverty in Africa – the existence of undiagnosed and untreated sexually transmitted diseases among many Africans – facilitated its spread.

Curable STDs (especially those causing general genital ulcers) by virtue of the frequency of their occurrence, when untreated, enhance both the acquisition and transmission of HIV by a factor of up to ten. Yet the lack of antibiotic treatment in some countries or their unaffordability meant that many were undiagnosed or diagnosed and untreated.

This coupled with other social-economic factors such as the continent’s issue of population mobility in search of work such as truck drivers, construction workers, itinerant traders, soldiers, and wildlife workers exacerbated the spread of the disease. Among the mobile workers of the mining community in Carleton, South Africa, 65 per cent of its adults were HIV positive in 1999, a rate higher than any other region in the world.

At the same time, by the mid-1980s, Africa’s public debt was growing exponentially. It was mostly owed to the World Bank and the IMF and this gave these institutions the leverage they needed to implement their newly adopted policies of deregulation and privatisation through what were called structural adjustment programmes (SAPs). These almost invariably included the following elements of what is now called neoliberalism:

- Reduced government spending and greater fiscal discipline to control inflation;

- Privatisation of state enterprises;

- Allowing the market to set foreign exchange rates, interest rates and the price of commodities.

Sub-Saharan Africa’s public debt trends. Multilateral debt increased substantially in the 1980s accessed from: Africa rising? The economic history of sub-Saharan Africa https://isj.org.uk/africa-rising/

Long term debt of the continent stood at $315 billion in 2000. To understand the severity of what might seem like a modest amount, as a result of SAPs, Ethiopia at that time spent 45 per cent of its $783 million export earnings in debt payments for its $10 billion public debt. In contrast, Europe spent $11 billion on ice-cream in 1997.

The SAPs meant that all sub-Saharan countries were spending more in debt servicing than in health care in 2000 except South Africa despite the increasing HIV/AIDS infections and deaths. For most of them, their annual health budget was less than $10 (Sh1000) per person for health.

Therefore, despite the fact that African countries had had successful primary health care in the 1970s and impressive achievements in literacy, child mortality, and life expectancy, which may have been beneficial in the struggle against HIV/AIDS, these achievements were eroded as money was diverted from social spending to debt servicing throughout the 1980s as a result of SAPs.

Noting this, Peter Piot, the director for UNAIDS (1995-2008), pointed out that structural adjustment raises particular problems for governments because most of the factors which fuel the AIDS pandemic are also those factors that seem to come into play in SAPs. Thus, at a time when up to 70 per cent of adults in some hospitals were suffering from AIDS-related illnesses – placing extreme pressure on health services – many African governments had to cut their health expenditure in order to satisfy IMF and World bank conditionalities.

How the HIV/AIDS epicentre shifted from North America to Africa and Asia is a testament of the socio-economic nature of pandemics. It does not only reveal a pattern of how pandemics spread, but also foreshadows the virulence of pandemics in different regions. There are many cultural and social reasons that could explain why HIV/AIDS spread like wildfire in sub-Saharan Africa. However, the crippling poverty, government ineffectiveness, and misplaced policy priorities, that were synonymous with the SAPs-era in Africa, provided the terrain on which the disease travelled, leaving untold havoc in its wake.

Data sourced from https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/

Discerning Coronavirus’s Terrain

The IMF is resounding the alarm on the levels of public debt in sub-Saharan Africa. It notes that debt servicing costs are becoming a burden, especially in oil-producing countries. In Angola, Gabon, and Nigeria they absorb more than 60% of government revenues. It has therefore, been keenly focusing its strategies on ensuring that sub-Saharan countries service their debts. This unfortunately means that these countries are once again spending less on social public investment such as health.

This coupled with increasing political uncertainty should be a cause for alarm. Our institutions are further weakened, not only by the existing ineffectiveness, corruption, lack of rule of law, and the threat of instability, but also by the public’s lack of trust and confidence in the system and as we have witnessed recently, the state’s inherent penchant for violence against its people.

We are divested of our financial resources to repay debt accumulated as a result of weak public finance management practices such as financing of the Standard Gauge Railway. The rest of the funds are lost to unfathomable corruption. If the coronavirus is as aggressive here as it has been in the West, we are not doomsayers in predicting a worse outcome for African countries.

Of importance is the ironic interconnected nature of our problems. Untold and unmitigated suffering is the price we have to pay for decades of poor governance structures, corruption, and the absence of the rule of law. We should take this time to think of how to strengthen the State going forward. The social and economic nature of pandemics and disease reveals the importance of functional and effective institutions. It is these that we should seek to develop.

While speaking to Marc Silver, a journalist, Dr Farmer expressed concern over the ruin that coronavirus could occasion in poor countries. Despite the infections and deaths in the West, he said he was mostly concerned with what he termed “clinical deserts”. If climatological reasons did not intervene to constrain the virus’s virulence, it is in these clinical deserts that we would see the most damage. The microbe is nothing. The terrain is everything.

This article is part of a long series of articles on the rule of law in the context of politics and ethics. The views expressed here are personal and do not represent institutional views. The series is researched and co-authored by:

• Karim Anjarwalla, Managing Partner of ALN Anjarwalla & Khanna, Advocates

• Wandia Musyimi, Research Associate at ALN Anjarwalla & Khanna, Advocates

• Kasyoka Mutunga, Research Associate at ALN Anjarwalla & Khanna, Advocates

• Prof Luis Franceschi, Senior Director, Governance & Peace, The Commonwealth, London