In your own way

The challenges and lessons from Ebola crisis for zoonotic disease preparedness and Control

Yukyum Kim*

Abstract

Ebola crisis in West Africa was one of the greatest health tragedies in modern times. This tragedy is partly attributed to the acuteness of the virus, but the lack of preparedness and inappropriate responses exacerbated the situation. This article explores the challenges shown during the Ebola crisis and finds lessons for better zoonotic disease preparedness and control. The greatest lesson is that the responses based on solely biomedical and epidemiological approaches are not enough to address the zoonotic disease epidemic. Rather, the underlying factors that affect systems, interventions, behaviours must be considered and addressed.

Introduction

Zoonosis indicates the diseases that are transmissible from vertebrate animals to humans and vice-versa (Acha and Szyfres, 2003). In fact, 60% of new emerging infectious diseases since 1940 are zoonotic including HIV, Severe Acute Respiratory Syndrome (SARS), and Lassa fever (Jones et al., 2008). The emergence of new zoonotic diseases often causes epidemic and a serious threat to global health, and therefore, raising disease preparedness and ability to control is very important.

Dominant approach of achieving zoonotic disease preparedness and control is to ensure rapid identification and isolation of ‘patient zero’ to prevent the second transmission which is human-to-human, and appropriate treatment (Richards et al., 2015). To achieve this, World Health Organization (WHO) made regulations such as International Health Regulations, recommended its application of the member states, and conducted monitoring (Gostin and Friedman, 2014). Moreover, since prompt response requires effective health systems, WHO has also promoted health system strengthening to ensure universal health coverage (WHO, 2010).

This dominant approach is based on biomedical and epidemiological perspectives which mainly deal with direct risks of diseases and treatments, but often overlooks underlying social and economic factors such as international political economy, poverty and inequality, urbanization, conflict, and social exclusions (Richardson et al., 2015) Although eliminating direct health risks and giving effective treatment are important and challenging, these efforts cannot bare desirable effects because the social and economic factors greatly affect the disease infection and prevention through not only the health-related behaviours of people, but also the embeddedness in health systems in national and global level (see Ibid.; Wilkinson and Leach, 2014; Leach, 2015). The recent Ebola crisis in West Africa has shown the limits of this dominant approach and gave challenges to the existing health systems of disease preparedness and control.

Ebola crisis in three West African countries including Guinea, Sierra Leone and Liberia, was one of the greatest health tragedies in modern times that has caused more than 11,300 deaths (CDC, 2016). This tragedy is partly attributed to the acuteness of the virus, but the lack of preparedness and inappropriate responses exacerbated the situation. These include the belated response of global health governance, deterioration of national health systems and inappropriate interventions to control the disease. These poor outcomes are also interlocked with underlying economic and social factors. In this regard, exploring the limits and challenges shown during the Ebola crisis and finding lessons for the future will give directions to achieve better disease preparedness and control.

This article consists of the following sections. Section 2 discusses the tendency of Ebola outbreak before 2013 and the emergence and progress of Ebola crisis in West Africa. Section 3 gives discussions on the challenges to the zoonotic disease preparedness and control. These will be divided into three analytical levels; global health governance, national health system and the process of interventions for disease control. Section 4 suggests some lessons for the future in two perspectives; strengthening health systems in global and national level, and dealing with underlying social and economic factors. Then, Section 5 synthesises the findings.

2. Emergence of West African Ebola outbreak and the progress

Ebola virus disease (EVD), initially founded in 1976 in Democratic Republic of Congo (DRC) and Sudan simultaneously, is a fatal zoonotic disease with around 50% fatality rates that causes acute haemorrhage fever resulting in death (WHO, 2016). Since the first EVD outbreak, there have been more than 25 times of outbreaks in central African countries including DRC, Sudan, Gabon, Uganda, Republic of Congo, and Angola. In the 1990s, EVD was perceived as a global threat and served a momentum of revising International Health Regulation of WHO in 2005 (Leach, 2008). However, until the outbreak in Guinea in 2014, the outbreaks happened only in remote rural areas and stayed locally. Therefore, the perception of the disease has changed to ‘deadly local disease event’ that appears in some rural areas in sub-Saharan Africa (Ibid., p. 9).

The Ebola crisis in West Africa started in December 2013 from a child living in a rural area of south-east Guinea, and the first spill-over was thought to have happened through direct or indirect contact with an infected bat (Bausch and Schwarz, 2014). The mysterious fever was transmitted to family members, local health workers and other people through kin and trading networks. However, it took more than three months until the test confirmed the Zaire-strain Ebola virus. Thanks to the ruined national health system and movement of the infected people, the virus spread across the borders to towns of Sierra Leone and Liberia. As shown in Figure 1, the cases increased drastically and reached over 2,000 cases by August 2014 (CDC, 2016). Moreover, unlike the fact that earlier outbreak of Ebola virus was constrained in remote rural areas, it has expanded to the cities including capitals of the three countries (Waldman, 2015).

Figure 1. The cases of EVD in three countries from March to August 2014

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Source : CDC (2016)

However, the international societies showed little interest until the emergence of western patients. Once United States and Spanish citizens were transmitted, international societies started to accept the situation as a threat that can affect their nations (Wilkinson and Leach, 2014). WHO declared global public health emergency on 8 August 2014, followed by military interventions of western countries including a dispatch of 3,000 United States’ troops in Liberia and 750 United Kingdom’s troops in Sierra Leone (Ibid.). Despite increasing interests and interventions from international organisations, the situation was already out of control. As shown in Figure 2, the increasing trend of the new cases didn’t stop during the early intervention periods meaning that the interventions were not effective. After long suffering periods, the trend was repressed after the early months of 2015. Now EVD is almost halted with over 28,000 cases and 11,600 deaths (CDC, 2016).

Figure 2. The cases of EVD in three countries from March 2014 to January 2016

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Source : CDC (2016)

3. Challenges to the zoonotic disease preparedness and control

The failure of Ebola control is explained by the following reasons; belated response of global health governance, deteriorated national health systems, and the problems occurred during the process of interventions including uncontextualised top-down approaches, mistrust and culture (Richardson et al., 2015). Therefore, this section will explore the challenges on the zoonotic disease preparedness and control posed by the Ebola crisis in three analytical levels; global health governance, national health system and the process of interventions for disease control. Meanwhile, it is important to note that the three analytical levels are highly interrelated and embedded in underlying social and economic contexts such as global political economy, poverty/inequality and history of exploitation and conflict.

The challenges on the global health governance

WHO is the most important actor in global health governance. WHO declares its role in its constitution as ‘the directing and coordinating authority on international health work (WHO 2009, p. 2). However, WHO is not playing such a role, instead, it acts as if it is a ‘technical agency’ as Margaret Chan, the Director-General of the organisation said (Gostin and Friedman, 2014). The shrinking of WHO role and its capacity is attributed to three following factors; (i) the financial structure that gives little autonomy (ii) financial cuts followed by the shrinking of emergency unit, and (iii) increase of new global health burdens such as non-communicable diseases and climate changes.

First, given that only 20% of the budget comes from the contributions of member states while 80 % is dependent on voluntary contributions for the earmarked programmes, the financial structure of the organisation gives little autonomy to WHO (Clift, 2014). In this situation, WHO was not able to have the contingency funds for tackle health emergency, and initial mobilisation of funds to tackle Ebola was difficult (Gostin and Friedman, 2014). Secondly, the global financial crisis in the late 2000s caused the shortfall in the budget of WHO followed by reducing emergency unit and losing some epidemic control experts (Ibid.). This impeded appropriate response when Ebola crisis happened. Finally, the emergence of new global health burdens gives more challenges to WHO. Non-communicable diseases and emerging health threats caused by climate change and globalisation are posing new challenges for the global health while the traditional health burdens such as infectious diseases and maternal/child health and nutrition are still prevalent especially in low-income countries (Frenk and Moon, 2013). The increase of global health burdens combined with the difficulty of mobilising adequate resources resulted in the absence of leadership in global health emergency like Ebola (Gostin and Friedman, 2014).

While WHO is not playing a role as global health leader, the governments of wealthier countries intervene only when it is suitable for their national interest. For example, the United States started to engage in the crisis after the emergence of American patients. That is because responding the global health emergency is a global public good, as similar as the market failure in ordinary public goods, the national governments have little incentives to intervene unless it becomes an instant threat for them. This explains the initial indifference of nations and belated response of international communities.

Moreover, the vaccines and drugs for Ebola virus were not developed well, even though it took around 40 years after the virus was first found. Given the dependency of big pharmaceutical companies to develop vaccines and medicines, there have been little incentives for them because Ebola was a local disease in Africa until the West African outbreak (Elbe and Roemer-Mahler, 2015). The absence of medicines of the initial period of Ebola crisis showed another challenge for developing appropriate medicines at a global level.

The challenges on the national health systems

When the spill-over of a zoonotic disease from animal to human happens, the effective national health system is essential to implement the measures to control and prevent the spread of the disease. However, the public health systems in the Guinea, Sierra Leone and Liberia were severely deteriorated. As a result, prompt and proper responses were not conducted at the emergence of the infected patients or the death of probable patients, and this contributed to the spread of the disease. As shown in Table 1, the public health expenditure of the three countries was far below than 86 USD per capita, the latest estimate of minimum amount for universal primary healthcare, and they have also suffered from the shortage of health workers (Kamal-Yanni, 2015; Bloom et al., 2015). Especially, in rural areas of the countries, there was a lack of public health services with adequate medicines resulting in people in the area relying on traditional healers or drug peddlers (Lind and Ndebe, 2015).

Table 1. Basic health system data for 2011

Sierra Leone Liberia Guinea Africa Region
Health expenditure per capita (current USD)   … (α) 192 92 27 99
Public health expenditure per capita (current USD)* 31 27 7 48
Public health expenditure as percentage of total   … (β) 16.2% 29.7% 24.3% 48.3%
Private health expenditure as percentage of total 83.8% 70.3% 75.7% 51.7%
Physician density per 10,000 population 0.2 0.1 N/A 2.6
Nursing/midwife density per 10,000 population 1.7 2.7 N/A 12

*author’s own calculation of (α)*(β)

Source: World Health Statistics (2014) cited in Bloom et al. (2015)

The deterioration of public health systems is attributed to three factors; poverty, legacies of conflict, structural adjustment of IMF. First, poverty impeded the development of health system. The ranks of gross national income (GNI) per capita of Sierra Leone, Guinea and Liberia were 193rd, 205th, and 210th respectively among 213 countries in 2014 (Worldbank, 2016). This low income resulted in low government revenue followed by low public investment such as health. Secondly, the legacies of conflict also impeded the development of effective national health systems. Liberia and Sierra Leone suffered from prolonged civil war, and Guinea underwent periods of violence with a series of coup d’état (see Bausch and Schwarz, 2014; Lind and Ndebe, 2015). Wars and conflicts separated the state from people’s everyday life and left legacies of little provision of public services including health (Lind and Ndebe, 2015). Finally, the structural adjustment programme from International Monetary Fund (IMF) exacerbated the situation as they imposed the conditions of reducing public spending and setting limits for public officials including health workers (Kentikelenis et al., 2015). As a result, public health spending has been reduced and the number of community health workers of Sierra Leone decreased from 0.11 per 1,000 people in 2004 to 0.02 in 2010 (Ibid.).

The challenges on the process of interventions for disease control

One of the greatest challenges on the process of controlling Ebola was the negative outcome caused by uncontextualised top-down interventions. These measures include the curfew, isolation of a region, ban of traditional funerals and using forces for the measures (Oosterhoff and Wilkinson, 2015). Their strategy was to change peoples’ behavioural patterns that increase the risk of infection. However, this top-down measures that overlooked the underlying contexts beyond just cultures such as high travel cost to hospital, opportunity cost of quarantine, mistrust of the government, fear of stigma and fear of disrespectful funerals were not successful (Ibid.). Especially, a funeral of spouses was an activity to show the rearrangement of economic relations such as land right that had been built through marriage, and the ritual of cleaning body was associated in this context (Richards et al., 2015). However, the ban of cleaning body without considering the context brought people conducting secret funerals and contributed to the spread of the disease consequently (Ibid.).

The Second challenge was mistrust to government and external people. The legacies of exploitation from slavery trading to colony and recent extraction of natural resources such as iron ore built mistrust to the government and external people including health workers (Allouche, 2015). In the beginning of the outbreak, people did not believe the Ebola was real, rather they thought that it was made by the government or the western exploiters (Leach, 2015). Also, there was a rumour of health workers spreading the disease followed by people killing health workers in Guinea. Because local people were suspicious of external interventions, they did not follow the measures imposed by the governmental and international health workers resulting in a massive spread of Ebola (Ibid.).

Lastly, urbanisation also contributed to the massive spread. While the urbanisation in Africa has been progressing very rapidly, it fostered peri-urban areas and urban slums where people migrated from the rural areas to find opportunity. The residents of the areas are mostly poor and living without adequate sanitation facilities, but less attention was given to these areas from international development actors than rural areas (Waldman, 2015). Meanwhile, they are frequently in touch with people due to high population density and move around the rural areas and cities for economic activities. All of the characteristics greatly increase risks of infection if not addressed properly. When Ebola hit the cities and peri-urban areas of the three countries, these features accelerated the spread (ibid.).

4. Lessons for the future

The challenges mentioned in Section 3 gives lessons for the future. We need to build the adequate abilities to prevent and control zoonotic diseases in order that this kind of preventable tragedy never happens again. This section will explore lessons learned from the Ebola crisis in two angles; the lessons for strengthening health systems in global and national level, and the lessons related to dealing with underlying socio-economic factors.

The lessons for strengthening health systems in global and national level

Above all, WHO’s roles must be redefined as the global health authority. Because the response of global health emergency is a global public good, it cannot be done successfully by national governmental level as they seek to their national interests. The role of WHO should be changed from technical agency to global health authority and coordinator in order to actively respond the global health emergencies in proper timing. To perform this role adequate financial and human resources are needed, so World Health Assembly should increase member states’ contributions and reform its emergency response teams and regional offices for rapid response (Gostin and Friedman, 2014). New zoonotic disease spill-over and the following epidemic can happen at any time, so WHO should ensure the autonomy of financial use by setting contingency budgets, for example (Ibid.). Moreover, more public funding should be put in the development of vaccines, diagnostics and medicines of new diseases such as Ebola (Kamal-Yanni, 2015).

Secondly, public health systems should be strengthened. Most of the low-income countries are suffering from the shortage of health budgets and health workers. As a result of the poor public health system, low-quality private drug sellers and out-of-pocket payments is prevailing in low-income countries. In those countries, poor people living in remote rural areas cannot receive adequate health services because of lack of accessibility and affordability. While most of the international health assistance was put on tackling particular diseases such as HIVs, more attention and funding are needed on public health system strengthening in low-income countries. Another challenge for resilient public health system is human resources. Given that raising professional health workers in a short period is very difficult, raising lay community health workers is a good short-term alternative if proper training and monitoring are persistently followed. Because they are from the local communities and know the local context well, they can help contextualise health interventions and build trust to the government health services (Kamal-Yanni, 2015). Cautions are needed on the limitation of their roles, and the health experts such as doctors and nurses should be filled in the long run.

The lessons related to dealing with underlying social and economic factors

The health systems in global and national level and the health interventions are interlocked with underlying social and economic contexts. Therefore, besides the measures mentioned above, it is needed to consider and tackle these underlying factors to prepare and control zoonotic diseases. In this perspective this part found three related lessons; contextualised response to the risky behaviours and traditions of local people, promotion of trust to the governments, fighting against poverty and inequality.

First of all, the health interventions to deal with risky behaviours must be carried carefully and flexibly with an understanding of the local contexts. The funeral practice in the infected countries is a good example. The body-washing activities should be discouraged, but other alternative measures to ensure dignity should be introduced such as a ritual. If body-washing was inevitable for any reason, protective equipment must be provided (Richards et al., 2015). During the Ebola crisis, it was shown that the cultural practice could be compromised with proper consultation with and respect to the local people (Ibid.). Moreover, after early failure, WHO made a guidance of protocol that included respectful funerals in local conditions and it was great progress (Ibid.). This kind of measures increases the receptivity of health interventions and help disease control.

Second, the trust to the governments and public health systems is essential in controlling diseases. Since deadly infectious diseases such as Ebola induce horror and panic to people, they can easily go out of control unless they trust the governments. The mistrust to the governments is based on long historical experiences. In the three countries, mistrust was formulated by the conjunction of legacies of lasting exploitation from colonies to the extraction of iron ore and prolonged conflicts followed by the absence of governmental services including health (see Allouche, 2015; Lind and Ndebe, 2015). Therefore, promoting trust is not easy and needs continuous efforts. The governments must seek pro-poor development policies and be more responsive to the local people. Institutionalising participation of local people in the decision-making process of government policies including health is a good way to start.

Lastly, the poverty and inequality must be tackled. It is not a coincidence that Ebola crisis happened in world’s poorest countries. Multiple deprivations caused by poverty such as low income and health accessibility, poor sanitation and the absence of proper governance interacted one another to amplify the spread of Ebola. In addition to the traditional rural poor, urbanisation and the emergence of the urban poor increase the demand for broad interventions to reduce poverty. More international efforts are needed to reduce poverty and inequality. Wealthier countries should increase their official development assistance at least to 0.7% of gross national income guided by the United Nations and focus on the investment to low-income countries. Despite the plenty of problems and criticism of aid, it is the ‘second best solution’ for low-income countries suffering financial gaps that cannot be filled with domestic funding (Manning 2012, p. 3; Sachs, 2012).

5. Conclusion

The Ebola crisis gave us many challenges for zoonotic disease preparedness and control. The first challenge was the malfunction of global health governance. WHO did not play as global health leader and showed belated response because of little financial autonomy, recent financial cuts with shrinking of emergency unit, and the increase of new global health burdens such as non-communicable diseases and climate changes. Secondly, the deteriorated public health systems in the three countries made the crisis out of control. This poor public health system is attributed to three factor; poverty and low public investment including health, legacies of conflicts separating the state from people’s everyday life, and structural adjustment of IMF that imposed the reduction of public spending. Finally, several problems appeared during the process of interventions including uncontextualised top-down interventions that brought people’s resistance, mistrust formulated by the conjunction of legacies of lasting exploitation and prolonged conflicts followed by lack of governmental services, and the urban poor’s vulnerability to infection caused by their poor living condition, intimacy, and high mobility.

We need to learn from the failure and build capacities to prevent this kind of health disasters. Strengthening global health governance and national health systems in low-income countries are very crucial. The role of WHO should be changed from technical agency to global health authority and coordinator. To play such a role, WHO should ensure the autonomy of budget using contingency budgets, reform its emergency teams and regional offices and increase the contributions from member countries. Also, national health systems should be strengthened especially in low-income countries. International interventions should be more focused on building resilient health systems, and human resources should be raised including lay community health workers and health professionals.

Besides the measures mentioned above, it is important to acknowledge underlying social and economic factors to prepare and control zoonotic diseases because health systems in global and national level and the health interventions are interlocked with these underlying factors such as global political economy, poverty/inequality and history of exploitation and conflict. In this perspective, the health interventions to deal with risky behaviours must be carried carefully and flexibly with an understanding of the local contexts. Also, the trust to the government must be promoted through institutionalising local people’s participation in the decision-making process and seeking pro-poor policies. Finally, tackling poverty and inequality is crucial. To achieve this goal, the international assistance to low-income countries must increase.

The greatest lesson of the Ebola crisis is that the responses based on solely biomedical and epidemiological approaches are not enough to address the zoonotic disease epidemic. Rather, the underlying factors that affect systems, interventions, behaviours must be considered and addressed. This may exceed direct health interventions and demand holistic approach in reducing poverty and inequality. This is very complex and not easy to achieve because there are structural constraints and lots of stakeholders involved. However, if we want to be prepared for emerging health threats including zoonosis and not to repeat this failure again, transformative efforts from various actors including international actors, governments  and civil societies, must be put.

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*Yukyum Kim is studying MA in Development Studies at the Institute of Development Studies (IDS) in the UK. He has been working in Korea International Cooperation Agency (KOICA).

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