When institutions decay, people die

HEALTH CRISIS: A Liberian Red Cross health worker disinfects a courtyard after the body of an Ebola virus victim was found in Monrovia. Ebola is a recurring problem, yet the world seems unprepared. The response has been slow and uncoordinated.


    Sep 17, 2014

    When institutions decay, people die

    IMAGINE two cities.

    In City A, town leaders notice that every few weeks, a house catches fire. So they create a fire department - a group of professionals with prepositioned firefighting equipment and special expertise.

    In City B, town leaders don't create a fire department. When there's a fire, they hurriedly cobble together some people and equipment to fight it.

    We are City B. We are particularly slow to build institutions to combat long-running problems.

    The most obvious example is the fight against jihadism. We've been facing Islamist terror for several decades now, but every time it erupts - in Lebanon, Nigeria, Sudan, Syria and beyond - leaders start from scratch and build some new ad-hoc coalition to fight it.

    The most egregious example is global health emergencies. Every few years, some significant epidemic strikes, and somebody suggests that we form a Medical Expeditionary Corps, a specialised organisation that would help coordinate and execute the global response.

    Several years ago, then senator Bill Frist went so far as to prepare a Bill proposing such a force. But, as always, nothing came out of it.

    The result, right now, is unnecessary deaths from the Ebola virus in Africa.

    Ebola is a recurring problem, yet the world seems unprepared. The response has been slow and uncoordinated.

    The virus' spread, once linear, is now exponential. As Michael Gerson pointed out in The Washington Post, the normal countermeasures - isolation, contact tracing - are rendered increasingly irrelevant by the rate of increase.

    Treatment centres open and are immediately filled to twice the capacity as people die in the streets outside.

    The catastrophe extends beyond the disease. Economies are rocked as flights are cancelled and outsiders flee.

    Ray Chambers, a philanthropist and United Nations special envoy focused on global health, points out the impact on health more broadly. For example, people in the early stages of malaria show similar symptoms to those of Ebola and other diseases.

    Many hesitate to seek treatment, fearing they'll get sent to an Ebola isolation centre. So, death rates from malaria, pneumonia and other common diseases could rise, as further Ebola cases fail to be diagnosed.

    The World Health Organisation has recently come out with an action plan, but it lacks logistical capabilities. President Barack Obama asked for a strategy, but that was two months ago.

    Aid is scattershot. The Pentagon opened a 25-bed field hospital in Liberia. The United States donated five ambulances to Sierra Leone. Coordination and logistical support are just not there.

    This is a governance failure. The disease spreads fastest in places where the health-care infrastructure is lacking or nonexistent.

    But it's not just a failure of governance in Africa. It's also a failure of governance around the world. I wonder if we are looking at the results of a cultural shift.

    A few generations ago, people grew up in and were comfortable with big organisations - the army, corporations and agencies.

    They organised huge construction projects in the 1930s, gigantic industrial mobilisation during World War II, highway construction and corporate growth during the 1950s. Institutional stewardship, the care and reform of big organisations, was more prestigious.

    Now, nobody wants to be an Organisation Man.

    We like start-ups, disrupters and rebels. Creativity is honoured more than the administrative execution.

    Post-Internet, many people assume that big problems can be solved by swarms of small, loosely networked non-profits and social entrepreneurs. Big hierarchical organisations are dinosaurs.

    The Ebola crisis is another example that shows that this is misguided. The big, stolid agencies - the health ministries, the infrastructure builders, the procurement agencies - are the bulwarks of the civil and global order.

    Public and non-profit management, the stuff that gets derided as "overhead", really matters. It's as important to attract talent to health ministries as it is to spend money on specific medicines.

    As recent books by Francis Fukuyama and Philip Howard have detailed, this is an era of general institutional decay. New, mobile institutions languish on the drawing board, while old ones are not reformed and tended.

    Executives at public agencies are robbed of discretionary power. Their hands are bound by court judgments and regulations.

    When the boring tasks of governance are not performed, infrastructures don't get built. Then, when epidemics strike, people die.