Preface

AFRICA BEARS AN INORDINATE proportion of the world’s diseases and epidemics. Recent outbreaks of cholera and Ebola caught several countries off guard and without the strategies needed to combat them.

The rate at which devastating diseases emerge, spread, and re-emerge has generated much discussion about the efficacy of African countries’ health systems. This pertains to such issues as health policy, infrastructure, staffing, funding, and management models.

However, across the continent there have been both failures and successes in dealing with epidemics.

The manner in which the threat of Ebola was swiftly contained and eliminated in Nigeria in 2014 and the encouraging outcomes in managing malaria in southern Africa bear positive appraisal. Despite resource constraints, some countries, such as Ghana and Rwanda, are progressively introducing forms of national health insurance. On the other hand, Zimbabwe has over the past decade experienced two major outbreaks of cholera, which resulted in a combined death toll of over four thousand residents.

Establishing a direct correlation only between the sturdiness of health systems and success in dealing with epidemics can, at times, be a thankless exercise. For instance, Nigeria’s health system is not much different from those of Guinea, Sierra Leone, and Liberia which bore the brunt of the 2014 Ebola crisis. South Africa’s maternal mortality rates are far higher than in countries with much fewer resources and weaker health infrastructure.

These experiences underline the need to approach epidemics from a much broader perspective. The Ebola episode in Nigeria, it is argued in this volume, speaks to the professionalism of health workers such as Dr Ameyo Stella Adadevoh, who stood her ground in the face of pressure, given the diplomatic status of Patient Zero. Mobilisation by government and other sectors of society to prevent a disaster of monumental proportions in as heavily a populated a city as Lagos was also fundamental. Dr Adadevoh, who had come into contact with Patient Zero after he had been misdiagnosed, herself succumbed to the disease.

The collapse of governance and the neglect of sanitation and water infrastructure in Zimbabwe’s capital city of Harare was in large measure responsible for the outbreak of cholera and the resulting high fatality rates. This was also a consequence of the dire economic situation and the monstrous disjuncture between national government and the opposition-led urban municipality.

Herein lies the relevance of a syndemics approach to the management of disease, which informs much of this volume. It is an approach that proceeds from the perspective that political dynamics, socio-economic issues as well as environmental factors do contribute to the outbreak and management of disease. Combined with these are internal and cross-border migration, quality of nutrition rather than just food security, and a myriad of cultural and other factors. In other words, the biosocial complex has an important bearing on the outbreak of diseases and interactions among them.

Authors in this book also draw attention to the organisational hierarchies in health facilities and the workloads borne by doctors, the mass of frontline health workers, and the communities of care. How the health professionals are managed, including striking the right balance between paperwork and clinical duties, is crucial in determining the quality of care. This calls for multidirectional empathy between patients, health workers, and communities.

In the recent period, non-communicable diseases have started to take their toll on larger numbers of African populations. Ironically, the rise of the middle strata – combined with the chaotic manner in which sections of the population are urbanising and adopting new lifestyles – is largely responsible for this.

The central message of this book is that strengthening health systems and countering outbreaks of diseases require an integrated, inclusive, and transdisciplinary approach. A critical element of this is the need for African countries to forge partnerships in developing research capacity that is responsive to the lived experiences and health needs of their populations.

The Mapungubwe Institute hopes that by examining the challenge of epidemics in Africa from a broad, biosocial perspective, this book will encourage panoptic reflections and integrated policy development and implementation.

MISTRA wishes to thank the authors, peer reviewers, and other partners – across the continent – who worked with us in conducting this research. Profound gratitude is also due to the Department of Science and Technology and the extended family of funders who render such work possible.

– Joel Netshitenzhe

Executive Director

Acknowledgements

THE MAPUNGUBWE INSTITUTE for Strategic Reflection (MISTRA) would like to express its gratitude to Zamanzima Mazibuko, who was project leader and editor of this volume, and Wandile Ngcaweni, who provided valuable support and assisted with the co-ordination of the project. Thanks also go to Salimah Valiani and Nolwazi Mkhwanazi, who assisted with the conceptualisation and initial direction of the project.

Thank you to the other MISTRA staff who contributed to the successful outcome of this project: the project management directorate led by Xolelwa Kashe-Katiya, supported by Dzunisani Mathonsi and Towela Ng’ambi; the operations directorate led by Barry Gilder, supported by Terry Shakinovsky, and the fundraising and financial management department led by Lorraine Pillay, with support from Magati Nindi-Galenge. We thank all in the research directorate who contributed to this body of work and helped pull the volume together: the researchers, including Anelile Gibixego, who provided all-important assistance with the manuscript, and Director Research Susan Booysen for her efforts to ensure that this publication meets the highest standards. MISTRA also extends its appreciation to Alison Lowry for editing the manuscript and to Jacana Media who are responsible for the design, layout and production of the book.

PROJECT FUNDERS

Intellectual endeavours of this magnitude are not possible without financial resources. The Department of Science and Technology (DST) deserve our special thanks for their support of this project.

MISTRA FUNDERS

MISTRA would also like to acknowledge the donors who were not directly involved with this particular research project but who support the Institute, and make its work possible. They include:

•ABSA

•Airports Company of South Africa Limited (ACSA)

•Albertinah Kekana

•Anglo American Platinum

•Anglo Coal

•Aspen Pharmacare

•Batho Batho Trust

•Belelani Group

•Discovery

•Exxaro

•First Rand Foundation

•Friedrich-Ebert-Stiftung (FES)

•Goldman Sachs

•Harith General Partners

•Jackie Mphafudi

•Kumba Iron Ore

•National Institute for the

•Humanities and Social Sciences (NIHSS)

•Oppenheimer Memorial Trust (OMT)

•OSF - SA (Open Society Foundation for Southern Africa)

•Phembani Group

•Power Lumens Africa

•PEU

•Robinson Ramaite

•Royal Bafokeng Holdings

•South Africa Breweries

•Safika

•Shell South Africa

•Simeka

•Standard Bank

•Vhonani Mufamadi

•Yellowwoods

Contributors

Zamanzima Mazibuko, editor of this volume, is the Senior Researcher in the Knowledge Economy and Scientific Advancement Faculty at The Mapungubwe Institute for Strategic Reflection (MISTRA) in Johannesburg, South Africa. She obtained her MSc (Med) in Pharmaceutics cum laude and has published on nano-enabled drug delivery systems.

Samuel Adu-Gyamfi is a lecturer in the Department of History and Political Studies at the Kwame Nkrumah University of Science and Technology (KNUST), Ghana. His research focus is on evolutions in health, public health, and health policy, environment, policy in science and technology, traditional and integrative medicine research, as well as social and political development of Africa.

Miriam Di Paola is a PhD candidate at the University of the Witwatersrand and a Research Fellow at the Tricontinental Institute for Social Research. She has participated in international research projects and authored several publications on the South African labour market, labour migration, and on the contribution of nurses to public health.

Kenneth Juma is a researcher at the African Population and Health Research Centre, Kenya. Kenneth is a doctoral student in Clinical Epidemiology and Biostatistics at Makerere University, Uganda. He holds an Erasmus Master in Public Health in Disaster Settings from the University of Oviedo and Catholic University of Louvain, an MSc in Epidemiology, and a Bachelor of Science from the University of Nairobi.

Pamela A. Juma works as a health systems and policy research and capacity building consultant. Pamela holds a Master’s in Community Health and Development, and a PhD in Nursing with a focus on Health Systems and Policy from the University of Ottawa, Canada.

Bill H. Kinsey holds three postgraduate degrees from Stanford University, including a PhD from Stanford’s Food Research Institute. He has done extensive fieldwork on southern Africa, particularly in Zimbabwe. He is currently a Visiting Fellow at the African Studies Centre at Leiden University in The Netherlands.

Farai D. Madzimbamuto is an anaesthesiologist and associate professor at the University of Zimbabwe. Prof. Madzimbamuto is the Chair of the Department of Health Professions Education and a founding Chair of the Zimbabwe Association of Doctors for Human Rights.

Kaka Mudambo is a malariologist and public health specialist employed as the Focal Point/Regional Coordinator of the RBM Partnership to End Malaria for East, Central, Southern, and West Africa. Brigadier General (Dr) Mudambo is also the regional coordinator of the SADC 16 Member States Military Health Services (MHS), of which he was a founder member, and responsible for all Military Health programmes. He is a board member of the Malaria Elimination Eight (E8) and Chairperson of the E8 Board oversight committee (OC).

Steven Mufamadi is the founder and managing director of Nabio Consulting (Pty) Ltd, a start-up company that provides consulting services on nanotechnology, biotechnology, and pharmaceutics, since 2015. His PhD is in Pharmaceutics from University of the Witwatersrand, Johannesburg.

Sunanda Ray is a medical doctor and public health physician. She is also a Fellow of the Faculty of Public Health (UK) and is currently employed by the Department of Community Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Dr Ray has 35 years’ experience of working in public health in Zimbabwe, Botswana, and England and as an activist for social justice in health.

David Sanders is Emeritus Professor and founding Director of the School of Public Health at the University of the Western Cape, Cape Town, South Africa, and is a paediatrician qualified in Public Health. He was awarded an Honorary Doctorate by the University of Cape Town for his contribution to the global policy of Primary Health Care. He is a founder and currently Global Co-chair of the Peoples’ Health Movement.

Nathaniel Umukoro is senior lecturer and head of the Department of Political Science and Public Administration, Edo University, Iyamho, Nigeria. He obtained a BSc degree from the University of Benin before proceeding to the University of Ibadan, Nigeria, where he obtained MSc, MA, and DPhil degrees.

Beth Vale is an independent researcher and writer. Her research interests span youth sex and body politics, nocturnal cities, health and illness, and the everyday production of sociality, power, and privilege in South African society. Dr Vale holds a DPhil in Social Policy and Intervention from Oxford University, an MA in Sociology from the University of Cape Town, and a BA Honours in Philosophy and Political Studies from Rhodes University.

Alex van den Heever presently holds the Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, Johannesburg. He is an adjunct professor and has a Master’s degree in Economics from the University of Cape Town. He has published extensively in the field of health policy, the implementation and review of health public private partnerships, and the regulation of health systems.

Gerald Yonga is the President of the NCD Alliance in East Africa and a Visiting Professor at the NCD Research Thematic Unit, School of Medicine, University of Nairobi, Kenya. He is founder chair of the NCD Alliance Kenya, the East Africa NCD Alliance and the Africa NCD Alliances Network, and is a board member of the NCD Alliance (Global).

List of abbreviations

Section One

Epidemics and Syndemics in Africa: Disease in Context

THIS FIRST SECTION OF THE BOOK provides a context for epidemics and health conditions in Africa. It initially offers a brief history of some of the world’s deadliest epidemics, showing how far the global health status has come – from a time when an outbreak would cause millions of deaths to the present time when control of epidemics means mortality is limited. Although there has been great improvement in health conditions across the globe and in Africa, there remains a disproportionate burden of disease in sub-Saharan Africa. This section explores the reasons behind the imbalance and also offers alternative frameworks for understanding the prevalence of epidemics in Africa.

Chapter 1, which is the introductory chapter of the book, argues that epidemics do not occur in a context-free vacuum. Zamanzima Mazibuko shows how underlying structural drivers have rendered certain populations, especially African women, vulnerable to disease. This argument is further supported by Bill Kinsey’s chapter, which describes how diseases often interact with one another and are exacerbated by the social, economic, environmental, and political situations of affected populations (Figure 1). This interrelationship is referred to as ‘syndemics’, and is drawn on throughout the book to help understand the extent to which social conditions and health are synergistic.

Figure 1: Syndemics Model

Chapter 1 also explores so-called ‘zoonotic’ diseases, namely those diseases which are transmitted between humans and animals. Mazibuko points to the World Health Organization’s (WHO) call for greater resources, including research, to fight these emerging diseases, and warns of the danger of these becoming the diseases of the future. She argues for the importance of taking into account the factors that promote zoonotic diseases when analysing how best to counter epidemics and strengthen health care systems in Africa.

In Chapter 2, Kinsey uses the syndemics perspective and examines undernutrition in Zimbabwe to show the multifactorial issues that result in worsened health conditions. Kinsey argues for broader conceptual frameworks that take account of varied factors in order to better address health concerns.

This first section lays the foundation for the rest of the volume and for a comprehension of how and why the African continent is vulnerable to disease. The two chapters challenge conventional thinking and medical understanding to push for a more multifaceted understanding that acknowledges the context of illness on the continent. The authors argue that this syndemic approach will assist in the development of inclusive public health policies and will improve the probabilities of effective interventions.

ONE

___

Introduction

Epidemics and Health Systems in Africa

ZAMANZIMA MAZIBUKO

‘Epidemics do not just happen.

They are not random events. They have histories.’

(Barnett & Whiteside, 2006: 65)

THESE WORDS ARE EMINENTLY true for epidemic outbreaks that have occurred in Africa. Often details of these outbreaks are presented without the relevant backdrop, or reference to the chains of preceding triggering and facilitative events and conditions. As De Waal (2017) notes, it is as if an epidemic disease ‘simply arises from the miasmas of Africa’s forests, in a context-free vacuum’. Africa’s vulnerability to disease can be attributed to several factors which influence both the spread and prevalence of disease, as well as to the effectiveness or lack thereof of measures for prevention, reduction, or elimination (Fonn, 2018). These factors are a function of historical, political, environmental, and economic forces (Dzingirai et al., 2017; Fonn, 2018). It is important that the underlying foundation and structural drivers of Africa’s vulnerability to diseases be stated clearly. Disease occurs commonly because of political and economic influences. These factors have a strong bearing on the way diseases are managed and controlled and on what happens to the affected populations (Mackey et al., 2014; De Waal, 2017; Dzingirai et al., 2017).

Historical interventions such as exclusionary urbanisation, in forcing certain populations out of their homes and displacing them into areas where they are vulnerable to disease, are described by Dzingirai and colleagues (2017), underpinning their argument: conditions that are ripe for the spread of disease among poor and marginalised people are commonly created by the state (through poor governance) and by the private sector (in its quest for accumulation and industrialisation). Poverty, low status, and inequality, together with forced migrations (Farmer, 2004), have been linked to vulnerability to infection.

Syndemics is a conceptual framework used to describe and understand the impact of the above phenomena by highlighting the effect of macro-level social factors on disease clustering, and the effects of this on both entire population groups as well as on individuals (Mendenhall et al., 2017). Adopting a syndemics approach, and so interrogating such phenomena, would enhance comprehension of the connection between disease and society. It would lead to a more exhaustive understanding of the foundational drivers of disease, and equip societies and decision-makers for their better prevention and control. Going further, mainstream medicine and its framework for disease, which is often preferred over alternative ways of understanding and practising medicine, should also be interrogated as these have implications for how treatment is given and, in turn, received.

This is the basis for the reasoning – now widely accepted – that efforts to counter outbreaks of disease and epidemics in sub-Saharan Africa need to be expanded beyond the biomedical approach. More valuable would be to integrate the biomedical approach with understanding and incorporating structural factors closely associated with susceptibility to disease.

It is important to emphasise that diseases do not occur in isolation. Diseases interact with one another, as well as with multiple social and/or environmental factors (Singer et al., 2017). Often, co-infection occurs with two or more pathogens and this affects the pathway of each infection, causing them to deviate from their natural courses (Corbett et al., 2003). This is commonly observed with HIV infections where exposure to other pathogens, particularly tuberculosis, exacerbates infections and increases transmission of both pathogens (Corbett et al., 2003). In recent years the burden of epidemics has been worsened by a significant increase in non-communicable diseases (NCDs) such as heart disease, stroke, cancer, and diabetes. Previously thought of as diseases of the more affluent, NCDs are on the rise in sub-Saharan Africa (Ezzati et al., 2018). Mental illness, which is often neglected, is another NCD that needs to be addressed. There is thus an increased risk of the interplay of diseases (both communicable and non-communicable); the impact of this interplay is aggravated by the social, economic, environmental, and political conditions in which a population finds itself (Sharma, 2017).

HISTORY OF EPIDEMICS IN THE WORLD AND IN AFRICA

Medical research, technology, and innovation have improved health across the globe. Throughout history, epidemics of diseases that are now (mostly) under control have caused the deaths of millions of people globally within short periods of time. Epidemic diseases, which can be viral or bacterial, are highly communicable and they rapidly infect large numbers within a population. The number of cases reported in one area is generally higher than expected (Newman, 2002; Wilke, 2017). Outbreaks of some of the worst and deadliest epidemics in history impacted permanently on the population at the time that they occurred (Pariona, 2018). One of the earliest recorded was the Antonine Plague, which killed about 2,000 people a day in Rome, totalling 5 million deaths over the period 165–180 AD (Wilke, 2017). The Plague of Justinian, which struck from 541–542 AD, is recorded as an epidemic in which the highest number of lives was lost, with an estimated 20–25 million deaths in the Roman Empire (Horgan, 2014; Wilke, 2017). This plague was carried across the world by rodents on trading ships, resulting in the infection spreading rapidly from China to Northern Africa and throughout the Mediterranean (Pariona, 2018).

Today, influenza is far from being the deadly disease it was a century ago when the Great Flu Epidemic of 1918 took its punishing toll. Spread by soldiers returning from around the world at the end of World War 1 (Wilke, 2017), it killed between 20 and 40 million people. Among other epidemics which caused millions of deaths were The Black Death (1334); the Cocolitzli Epidemic (1576); the Third Cholera Pandemic (1852–1860); the Third Plague Pandemic (1855); Typhus fever in the later years of World War 1 (1917); the Asian Flu Pandemic (1957); and lastly, the HIV/AIDS global pandemic (1960s–present), which has killed an estimated 25 million people and infected 65 million people since it was first reported in 1981 (Wilke, 2017).

A comprehensive history of epidemics in Africa is not easy to compile because data prior to 1970 is inadequate. Table 1 provides a summary of the epidemics in the WHO African region from 1970–2016, along with the number of times they have occurred. Cholera outbreaks have occurred the most frequently (476 times), closely followed by polio (439). Both diseases are now preventable, although a few cases of polio reappear now and then in inaccessible areas or conflict zones where efforts to vaccinate and to maintain disease surveillance are thwarted (Polio Eradication, 2017). Cholera outbreaks remain persistent in sub-Saharan African countries with areas in which conditions of poverty – contaminated water, inadequate sanitation, lack of hygiene – prevail (Lessler et al., 2018).

Table 1: Summary of outbreaks or epidemics reported in the WHO African region period 1970–2016 by known disease

Source: WHO, 2016a

LEADING CAUSES OF DEATH IN AFRICA

In Africa, epidemics and endemicsi remain a public health challenge. Over the years, a plethora of diseases have attacked the continent and some still persist, causing a significant burden of illness, disability, and mortality. These diseases range from periodic outbreaks, such as malaria and cholera, to endemics such as HIV, and even outbreaks of uncommon diseases like listeriosis.ii Of the ten leading causes of death in Africa as shown in Graph 1, the first seven are epidemics (infectious diseases and NCDs), the two afer those relate to maternal deaths, and the last stems from injury (in this graph, road injury) (WHO, 2016b).

If one puts the above statistics into context, it becomes clear that while infectious diseases remain the leading cause of death in Africa the mortality rates in this category are declining, while deaths from NCDs are on the increase. In 2015, out of a total of 9.2 million deaths in Africa, 5.2 million (56.5 per cent) were from infectious diseases. This figure was down from 5.7 million (61.4 per cent) in 2010. In 2015, the deadliest infectious diseases were lower respiratory diseases, HIV/AIDS, diarrhoeal diseases, tuberculosis, and malaria. NCDs accounted for 3.1 million deaths (33.5 per cent), which was an increase from 2.7 million (29.4 per cent) in 2010. The leading causes of death in this group were stroke, ischaemic heart disease, and cirrhosis of the liver. The last category, which is death caused by injury, accounted for 930,000 (10.1 per cent) in 2015, an increase from 841,750 (9.1 per cent) in 2010. These statistics show that, although infectious diseases are still the leading cause of death in Africa, the percentage of cases is decreasing, while that of NCDs (and to a lesser extent, injuries) is growing. This trend is projected to continue: expectations are that Africa will see a rise in NCDs previously associated with the developed world, especially with increasing urbanisation.

Graph 1: Top 10 leading causes of death in Africa

Source: WHO, 2016b

Health issues are a global concern. When compared to the rest of the world, however, sub-Saharan Africa carries a disproportionately high disease burden. In 2015, 90 per cent of global malaria cases and 92 per cent of malaria deaths (WHO, 2016b) were in the sub-Saharan region; and between 2000 and 2015, 83 per cent of global cholera deaths occurred in sub-Saharan Africa (Lessler et al., 2018). In addition, sub-Saharan Africa has some of the widest gender income disparities in the world and African women are among the poorest people. This makes African women even more vulnerable to infections (see UNESCO, 2015; UNESCO, 2017).

This book aims to explore the reasons behind this imbalance. It focuses on a selection of epidemics from which lessons can be drawn on the importance of a strong health system in preventing, detecting, and responding to calamitous diseases, thereby preventing outbreaks from becoming epidemics. The cases cited also highlight the effects of political interference and governmental neglect on the occurrence and prevalence of epidemics. They are a basis for policy analysis. Included in the selection, based on the immensity of its impact, is Ebola, which devasted the West African region in 2014–2016 and provided key lessons for addressing epidemics.

Sections in this book thus use specific cases of epidemic outbreaks to explore how structural and/or political-economic factors play a role in the vulnerability to disease. In their individual chapters the authors demonstrate that at the core of this vulnerability are weakened or weak health systems. At a second level, they show how the interactions between diseases and with socio-economic factors further exacerbate the occurrence and spread of epidemics – the implications being support for a multifaceted approach to addressing epidemics.

THE BURDEN OF EPIDEMICS

Together, communicable and non-communicable disease outbreaks cause millions of deaths throughout sub-Saharan Africa yearly (WHO, 2016b) and although the status of health care has improved over the years (WHO, 2014), the burden of disease still afflicts the continent disproportionately (WHO, 2016b). In many parts of the world, diseases that cause epidemics have been eradicated or brought under control (Tatem et al., 2006). Sub-Saharan Africa, however, continues to battle outbreaks and endemics. This is not due to either simple bad luck or purely medical reasons. Rosenberg (1992) argues that epidemic diseases should be regarded as a ‘configuration’ because of the structural and relational characteristics necessary for the transmission of pathogens between persons. This approach moves away from the notion of ‘contamination’, which is the reductive, technical mechanism of transmission; in that framework epidemics are not viewed as a result of the intersection of pathogens and social factors.

Africa was exploited by colonialists, with populations left in poverty and in areas of disrupted ecologies (De Waal, 2017; Dzingirai et al., 2017). Post-colonial development has not made sufficient progress in addressing inequalities and systemic underdevelopment (Obeng-Odoom, 2015), and nor have resilient health systems been established (Dzingirai et al., 2017; Olu, 2017).

Through a few case studies – the 2008–2009 cholera outbreak in Zimbabwe, the 2014–2016 Ebola outbreak in West Africa, the HIV endemic in South Africa, malaria in the Southern African Development Community (SADC) region, and the ever-increasing rise of NCDs on the continent – the authors show how structural drivers affect health services and outbreak response. The aim is to help inform health practitioners, policy makers, and researchers about ineffective as well as successful approaches to disease containment and health care provision in Africa.

Cholera in Zimbabwe: political-economic drivers

The worst cholera outbreak in Africa, which took place in Zimbabwe in 2008–2009, resulted in 98,531 recorded, suspected cases and 4,282 deaths (Youde, 2010). Political and economic choices, more than health-related decisions, were what led to this crisis. A combination of the large-scale collapse of the water and sanitation infrastructure, a weakened health care system, and a struggling economy contributed to the outbreak.

In the years prior to the outbreak, government policies and actions resulted in the disintegration of Zimbabwe’s water and sanitation infrastructure and the incapacity of the health care system to provide even the most basic services (Muzondi, 2014). The ZANU-PF-led national government took over the municipal water supply from the opposition MDC party in order to weaken the latter’s position and to gain more political power (Musemwa, 2008). The Zimbabwe National Water Authority (ZINWA) was established in 1998 to head the development and management of national water resources and associated infrastructure throughout the country (Bulawayo resisted the ZINWA takeover and had very few cholera cases). However, instead of reinforcing the country’s water infrastructure and increasing access to clean and safe water, ZINWA was used as a political tool and a source of funding for ZANU-PF (Youde, 2010). Consequently, the water and sanitation infrastructure deteriorated and access to clean and safe water decreased considerably (Musemwa, 2008; Youde, 2010). The politicisation of water by ZANU-PF thus played a big role in creating conditions for the outbreak of cholera and for the disease to flourish.

A decade later, in 2018, Zimbabwe experienced another cholera outbreak. Questions arose regarding the reasons behind the recurrence of a preventable disease. What became apparent was that the water and sanitation infrastructure was still dilapidated, with burst pipes gurgling sewage onto the streets (Nyoka, 2018). Water supplies were contaminated by blocked sewers that had been left unattended (Mutsaka, 2018; Nyoka, 2018). The emergence and re-emergence of cholera in Zimbabwe goes far beyond the field of public health. It has to do with a government making political decisions which have a ripple effect, leaving its citizens dying from avoidable infections. This is discussed in more detail in Chapter 3.

Ebola in West Africa: weak health care systems

Weakened health systems underpinned the unprecedented spread of the Ebola virus in West Africa in 2014. Calamitous civil wars experienced by Guinea, Liberia, and Sierra Leone led to the collapse of those countries’ health system infrastructures. They were left with the weakest health care system infrastructures in the world, with the lowest human development indices (WHO, 2000; UNDP, 2014). Therefore, when they were hit with the Ebola outbreak, their public health systems were not equipped to control it; in addition to this those countries also lacked a strong health care workforce. Table 2 depicts the poor health systems in the three countries and how they lacked the necessities required to manage an outbreak.

Table 2: State of health care systems in Guinea, Sierra Leone, and Liberia

Source: Shoman et al., 2017; WHO, 2012; WHO, 2014

The Ebola outbreak further weakened these countries’ health systems by significantly limiting the availability of health care workers, and decreasing financial resources and medical equipment (Save the Children, 2015). A study by Shoman et al (2017) revealed that Ebola claimed more lives among health care workers than any other viral haemorrhagic fever. Because health care workers were in direct contact with symptomatic patients, not only were they at a high risk of infection and death, but they were stigmatised and rejected by communities. This placed additional strain on the remaining health care workers; nurses became the frontline of the outbreak. An expert who was interviewed as part of the study reported that a lack of investment was the biggest problem: in training health care workers, in infrastructure, in supply chain management, and in community engagement (Shoman et al., 2017). The lack of resources meant that treatment of, and vaccinations against, other infectious diseases were not a priority, which led to additional outbreaks. People suffering from any condition other than Ebola were not provided with adequate health care. Moreover, the stigma attached to health care workers resulted in patients opting out of receiving treatment for other conditions out of fear of becoming infected by the health care workers (Shoman et al., 2017). Inevitably, the weakened health workforce enabled the Ebola virus to cause devastation in Guinea, Liberia, and Sierra Leone.

Nigeria, on the other hand, which managed to swiftly contain the 2014 Ebola outbreak, succeeded in rallying the country’s health workforce to prevent the disease spreading. Expeditious and meticulous control measures were required to avert the disastrous effect of an Ebola outbreak on Nigeria’s two large cities – Lagos, with approximately 20 million people, and Port Harcourt (> 1 million people). These were successfully implemented, thereby limiting the number of cases (Musa et al., 2016). The accurate and swift diagnosis of the index case by a female physician at the First Consultants Medical Centre (FCMC), Dr Ameyo Stella Adadevoh, allowed for implementation of a much more strategic process and for the virus across the country to be contained (DRASA, 2018). Health care workers were mobilised and deployed to carry out fast and thorough tracing of all potential contacts, to monitor all these contacts continuously, and immediately to confine potentially infectious contacts (Courage, 2014). The Ebola outbreak in Nigeria clearly illustrates the crucial role of the health workforce in containing a potential epidemic as detailed in Chapter 5.

Chronic diseases: implications for health systems

Non-communicable diseases (NCDs), such as cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases, are predicted to become the leading cause of death in sub-Saharan Africa by 2030 (Marquez & Farrington, 2013). These diseases are caused by modifiable behavioursiii such as tobacco use, high consumption of alcohol, a sedentary lifestyle, and an unhealthy diet, which lead to metabolic changes like increased blood pressure, obesity, increased blood glucose levels, and increased levels of fat in the blood (Naik & Kaneda, 2015). As with the previously mentioned health conditions, prevalent social and economic conditions determine a population’s vulnerability to NCDs and associated health outcomes (WHO, 2010a). The rise in cases of NCDs in low-income countries is influenced by