Growth-at-any-cost economics has health costs, a reality the COVID-19 pandemic brings into sharp relief. Governments must manage the tension between economics and health, but they should not stray from their original mandate to protect people. Too much dependence on the private sector weakened pandemic response, argues Susan Erikson.
As a medical anthropologist who was in Sierra Leone when Ebola broke out in 2014, I am struck by the similarities between the early days of the COVID-19 pandemic and the West African Ebola outbreak. In both cases, denialism and an initial slow response proved deadly, albeit understandable: humans don’t tend to quickly embrace changes to their circumstances, no matter where they are in the world. Defiance of social-distancing and home-isolation imperatives is common. Citizens of wealthy countries now know the feeling of having to break home quarantine to find food or care for sick loved ones. Unexpected, though, are the similarities in an initial inability to protect healthcare personnel and provide essential health technologies during a pandemic. Nurses, doctors and paramedics lack personal protection equipment (PPE). Home health aides have no health insurance. Test kits are in short supply. The governments of some wealthy countries did not rapidly organize their engineers to build quick-setup diagnostic and treatment facilities, nor did they expeditiously direct manufacturers to ramp up the production of PPEs, test kits and ventilators. Inconsistent enactment and enforcement of laws against hoarding and supply profiteering prevail. Such tasks fall within the social contract governments have with their citizens, and the failure to swiftly fulfill those responsibilities has long been evidence of failed statehood. With COVID-19, we see how small-government ideologies leave too much health preparedness to ‘the market’, creating a perfect storm in rich countries too.
As COVID-19 forces national economies to slow to a near-halt and life is stripped down to its essentials, we see the purposes of government. At the time of writing (24 March), governments are shelling out money for stopgap funding to corporations, communities and individuals to break the financial freefall that happens when people comply with social distancing. But they will soon move out of the government-as-cash-machine stage of pandemic response. Many federal coffers will run short, and the kicker is that those shortfalls were created intentionally. In recent decades, the tax base in many countries has declined precipitously relative to the country’s wealth. Many rich citizens and corporations now pay a smaller percentage of their incomes than their fellow citizens in the middle and working classes. Government laboratories studying infectious disease were shut or short-funded when they could not show rapid return on investment. Just-in-time supply systems, in which companies deliberately avoid stockpiling and order inventory on an as-needed basis, were imposed on societal sectors, including health.
The idea that government is a big bungler began in the 1970s, took hold in the 1980s, and has since only become more popular. Government decline and disparagement correlates with a rise in the view that the private sector can do everything better and faster. Private sector provisioning of government responsibilities, though, is not always cheaper or more efficient over the long-term. I worked for a large federal government in the 1980s and saw first-hand what occurs when governments reduce the federal workforce to save money: human need does not go away when government workers are laid off; governments typically pay more to private sector employees to do the same jobs instead. And, as we have seen during the COVID-19 pandemic, some governments are extremely efficient providing for the healthcare needs of their citizens.
The shift to the private sector was a trend that spread and accelerated in the 1980s and 1990s, reaching newly independent postcolonial countries with fledgling economies like Sierra Leone. Such nations were forced to embrace macroeconomic austerity plans as a condition of getting cash to build hospitals, roads and utilities. Decades of deals came with strings attached. Aid for infrastructure was often conditional on spending 40–70% on private sector business from the donor country, depriving aspiring young economies of new business development and sovereignty.
The good news is that government response can change from one pandemic to the next. Since 2017, the African continent has built its own Centres for Disease Control and Prevention. Nigeria, which skillfully managed its few cases of Ebola during the 2014–2016 outbreak, quickly sequenced the SARS-CoV-2 genome (https://www.ncbi.nlm.nih.gov/genbank/sars-cov-2-seqs/). At Sierra Leone’s international airport, passengers have been quarantined since 3 February 2020 (to get a sense of how early in the outbreak that was: it was two days before the US Senate voted on their president’s impeachment). Since mid-February, handwashing stations have been set up outside of businesses in the capital city. Sierra Leone’s president has visited the airport, border checkpoints and hospitals, where he calmly encouraged people to use their experience with Ebola to fight COVID-19. Sierra Leone’s preparedness has limits, but the point is that people there know what to do in a pandemic. Its government, which negotiated the timely import of test kits and secured external funding, knows its role too. Sierra Leone, the country ravaged by Ebola 6 years ago, has been testing for coronavirus but as of 24 March is one of the few countries in the world without a single confirmed case of COVID-19.
When the COVID-19 pandemic emergency ends, there needs to be a worldwide reckoning with what governments are for. Governments cut to the bone cannot respond easily or quickly. Pandemics are no longer unexpected events and those who claim otherwise are using old stochastic models and ignoring the world around us. It’s not just that population pressures—for food, housing and income—will continue to push humans into wildlife habitat that will set off other unknown animal–human disease chains. Pandemics are also a result of economic growth-at-any-cost ideologies, those that call for ploughing down rainforests, systematically indenturing huge swathes of frontline healthcare workers and fighting the regulation of health sector profit-mongering. Governments cannot exist solely as payers-of-last-resort. They too need to be valued and nurtured back to health, so that they can sustain us when our needs hit pandemic proportions.
The author declares no competing interests.
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Erikson, S. Pandemics show us what government is for. Nat Hum Behav 4, 441–442 (2020). https://doi.org/10.1038/s41562-020-0871-4