This article identifies the long-term political factors that contributed to the Ebola crisis in Sierra Leone, which are largely overlooked by the emerging international focus on building resilient health systems. We argue that the country exhibits critical symptoms of the recurrent crises of a gatekeeper state, including: acute external dependency, patron-client politics, endemic corruption, and weak state capacity. A coterie of actors, both internal and external to Sierra Leone, has severally compromised the health system. This left certain sections of the population acutely at risk from Ebola and highlights the need for political solutions to build stronger, inclusive health systems.
Health crises pose fundamental challenges to international relations and have been a major focal point of contests for global influence, particularly in the global South, where such crises are most acute. This necessitates a focus on the arenas of global health diplomacy and the power struggles that emanate from them, including the often-overlooked agency of African actors within these arenas. Drawing upon a total of 3 months of fieldwork in 2007 and 2014 that included 68 key-informant interviews, participant observations, and informal discussio ns, this article interrogates the mechanics of multi-stakeholder health diplomacy in Malawi, where a near-permanent state of health crisis and underdevelopment has generated extreme dependency on external health assistance. This article conceptualises shadow diplomacy as the informal networks and channels of influence that run parallel to, but are not recognised as part of, formal diplomacy. This concept reveals how health is key to struggles for leverage by both international and local actors, giving rise to informal and subversive manifestations of diplomacy in the 'shadows'. It enables us to understand not only how Western powers consolidate and obscure their enduring power, but also how the 'shadows' benefit African political elites as they leverage their dependency to subvert global power structures for their own ends. It disrupts the external/internal binary of international donors/African states and reveals that these are not monolithic actors but instead comprised of complex individuals with multi-faceted motivations and divided loyalties. 1 The author would like to thank Alexander Beresford, Sophie Harman, the editorial team of IR, the anonymous reviewers and the POLIS reading group at the University of Leeds for feedback on this article.
During fieldwork at a Lusaka AIDS clinic in 2011, an elderly woman approached one of the authors, wanting to "tell her story" as a person living with HIV and AIDS (PLHIV). 1 The woman was poorly dressed and quite thin; she had come to the clinic to get her monthly supply of antiretroviral treatment (ART), drugs paid for by the US Emergency Plan for AIDS Relief (PEPFAR). Hearing people's personal stories was common during fieldwork, though these testimonials usually were given in the context of solicited interviews. And while some researchers paid "sitting fees" to hear such stories, this author did not. Because the author had several appointments, there was no time to meet with the woman. The author explained the situation and went to her meetings, assuming the woman would leave. At the end of the day, the woman was still at the clinic, sitting under a tree. She approached the researcher and asked for a ride to the city center. With several clinic officials watching the exchange, the author felt uncomfortable. She knew the traffic would be terrible, but she had spent the day interviewing people about the economic needs of PLHIV. Wouldn't it be hypocritical to not give this elderly woman a ride? And she felt guilty that the woman had waited all day, even though she was pretty sure that the woman had understood that there would be no interview. Ultimately, she gave the woman a ride and a 5,000 kwacha note. Only after the woman bounded from the car at the final destination did the author realize she had never even heard 1 We use the acronym PLHIV to stand for both the single and plural form, or person or people living with HIV. 2 the woman's story (Participant observation, PLHIV-author encounter, Lusaka, May 10, 2011). This participant observation highlights the broader themes of this volume: the various ways that individuals and communities respond to Africa's high dependency on donor health funds. We refer to these local actors as "dependent agents" and develop the concept of "dependent agency"-the condition in which these actors can simultaneously act and be dependent. Ask most people in the West about their impressions of Africa, and they will probably highlight the continent's perceived weakness and powerlessness in the international realm, its high rates of poverty and unemployment, and its deep dependence on foreign aid and commodity exports (Ayittey 1999; Englebert 2009). The continent is like the elderly woman in the Lusaka clinic: it has economic needs, some of which are met by external actors. Yet even within these broader structures of dependence, Africans show agency. They maneuver in "tight corners" in ways that demonstrate the capacity "to resist, and sometimes to deflect what appears to be their structural fate," with effects that are not inconsequential (Lonsdale 2000). For example, African states raise new issues at the United Nations, and some manipulate donors to gain material benefits or to avoid criticism of their authoritarian practices (Brown and Harman 2013). As an agent, the Zambian woman s...
This article identifies the long-term political factors that contributed to the Ebola crisis in Sierra Leone, which are largely overlooked by the emerging international focus on building resilient health systems. We argue that the country exhibits critical symptoms of the recurrent crises of a gatekeeper state, including: acute external dependency, patron-client politics, endemic corruption, and weak state capacity. A coterie of actors, both internal and external to Sierra Leone, has severally compromised the health system. This left certain sections of the population acutely at risk from Ebola and highlights the need for political solutions to build stronger, inclusive health systems.
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