Health and politics in pandemic times: COVID-19 responses in Ethiopia

Abstract

With a focus on responses to coronavirus disease 2019 (COVID-19) in Ethiopia and on political developments that have occurred in the country during the pandemic, this article contributes to the existing scholarship that explores the relationship between health and politics. Drawing on qualitative data from the project ‘COVID-19 Impact Tracing in Ethiopia: Social, Economic, Political, and Security Ramifications’, carried out in the Tigray, Amhara and Oromia Regional States (RS) from June to September 2020, we offer new empirical and theoretical perspectives that shed light on the political status of health and health policies in Ethiopia and beyond. In all the three regions, COVID-19 and the government’s pandemic response was subject to politicization and securitization. The degree of securitization and politicization differed between the regions and fluctuated over time; in areas with strong opposition to political authorities, the COVID-19 mitigating efforts were—during the first phase of the pandemic—more politicized and securitized than in areas with less opposition. Yet, as the political opposition and instability increased, threatening national security and Prime Minister Abiy Ahmed’s political project, the authorities and the public paid increasingly less attention to the pandemic and the mitigating policies. In our analysis of these dynamics, we draw on a classic distinction that scholars of global public health have borrowed from political science: that of ‘low’ and ‘high’ politics. We argue that a contextually situated use of the high/low distinction allows us to recognize the fleeting and context-dependent nature of health’s political status, providing valuable insights that help us understand the ways that health emerges and disappears as high politics. The temporal and inter-regional shifts that appeared in, and as a response to, Ethiopia’s pandemic policies illustrate the importance of a continuous analysis of the relationships between health and politics at national as well as at sub-national levels.

COVID-19, Ethiopia, health, politics, politicization, securitization

Key messages

• In the Amhara, Oromia and Tigray Regional States of Ethiopia, the government’s COVID-19 response was subject to politicization and securitization.

• The degree of securitization and politicization differed between regions and fluctuated over time. In areas with strong opposition to political authorities, the COVID-19 mitigating efforts were—during the first phase of the pandemic—more politicized and securitized than in areas with less opposition.

• As the political opposition and instability increased, threatening national security and Prime Minister Abiy Ahmed’s political project, the authorities and the public paid increasingly less attention to the pandemic and the mitigating policies.

• A contextually situated use of the ‘high politics’ vs ‘low politics’ distinction allows us to recognize the fleeting and context-dependent nature of health’s political status, providing valuable insights that help us understand the ways that health emerges and disappears as high politics.

• The temporal and inter-regional shifts that appeared in, and as a response to, Ethiopia’s pandemic policies illustrate the importance of a continuous analysis of the relationships between health and politics, at national as well as at sub-national levels.

Introduction

Within public health research, the relationship between politics and health has often been disregarded. In many scholarly publications, health interventions and systems appear purely technical and scientific—as apolitical, detached from political systems and ideologies, and aloof from the everyday messy context of political contestation. The coronavirus disease 2019 (COVID-19) pandemic has reminded us, however, that regardless of whether states have succeeded in controlling the pandemic or not, health and politics are deeply intertwined. In many countries, such as in the USA, the pandemic and the public health response have been highly politicized, fuelling political polarization and resistance and eroding trust between governments and citizens (Jasanoff et al., 2021). In other countries, such as in Australia and Canada, coordination and commitment across political divides have laid the ground for some of the most successful COVID-19 responses.¹

With a focus on responses to Covid-19 in Ethiopia and on political developments that have occurred in the country during the pandemic, this article contributes to the existing scholarship that explores the relationship between public health and politics. While the impact of power and politics on health and health systems have been thoroughly analysed and discussed by scholars of anthropology and political science (Gore and Parker, 2019; Gomez, 2016; Navarro, 2008; Kenworthy and Parker, 2014), this scholarship has largely ‘been off the radar of the global health research community’ (Storeng and Mishra, 2014, p. 859). In addition to brining conversations that have been ongoing within political science and anthropology into mainstream public health research, our overall aim in this article is to offer new theoretical and empirical perspectives that can shed light on the political role and status of health and health policies, not only in Ethiopia, but also beyond.

In our analysis and discussion, we draw on a classic distinction that public health and global health scholars have borrowed from political science: that of ‘low’ and ‘high’ politics. Political science and international relations scholars use this distinction to differentiate between political issues that are in an assumed hierarchy of importance. ‘High politics’ typically refers to issues that are ‘of existential importance to the state and which concern its very survival’ (Youde, 2016, p. 157), such as national security, issues of war and peace and competition for power (Fidler, 2005). ‘Low politics’, in contrast, denotes issues that are assumed to be of less importance, such as economic and social policies. David P. Fidler has argued that health often has been treated as if it is ‘really low politics’ (Fidler, 2005, p. 180)—a status he explains with the ‘assumed’ technical, humanitarian, and non-political nature of health.

Global health and international relations scholars have, however, increasingly challenged the idea that health belongs solely to ‘low politics’ (Davies, 2010; Kickbusch and Reddy, 2015). With reference to global initiatives such as the Millennium Development Goals—now transitioned into the Sustainable Development Goals—and the increased investment in and inclusion of health as a key issue in international and national security strategies, some have argued that health has entered into the realm of ‘high politics’ (Kickbusch and Reddy, 2015, p. 841). Jeremy Youde has, on the other hand, questioned these claims and argued that the high/low distinction makes little sense for thinking about global health politics (Youde, 2016, p. 157). He situates the high/low dichotomy within the realist and neorealist traditions in international relations and points to some of the key assumptions that underpin this framework: an emphasis on a strict, timeless hierarchy where national security trumps all other issues, and a lack of recognition of the fact that what states consider important and choose to prioritize is contextually dependent. While we are sympathetic to Youde’s argument, particularly his critique of the assumptions that underpin the high/low politics dichotomy, we have nevertheless found the distinction useful. In this article, we use the high/low distinction as a heuristic device for making sense of Ethiopia’s COVID-19 mitigating efforts, the public responses and political developments that have occurred during the pandemic. We argue that a contextually situated use of the high/low distinction allows us to recognize the fleeting, temporal, and context-dependent nature of health’s political status, providing valuable insights that helps us understand the ways that health emerges and disappears as high politics.

While global health and international scholars typically use the high/low politics distinction to make sense of health in foreign policy and international relations, we apply this distinction to account for inter-regional and temporal differences and shifts. A sub-national analysis is particularly useful for making sense of political processes and dynamics in Ethiopia since the federal arrangement allows for different regional policies. As we will demonstrate, in all the three regions of research, the federal and regional government’s COVID-19 response was subject to politicization and securitization. The degree of securitization and politicization and the public’s perceptions of the government’s mitigating efforts differed between the regions and fluctuated over time, however. In areas with strong opposition to political authorities, the COVID-19 mitigating efforts were—during the first phase of the pandemic—more politicized and securitized than in areas with less opposition. Yet, as the political opposition and instability increased, threatening national security and Prime Minister Abiy Ahmed’s political project, the authorities and the public paid less attention to the pandemic and the mitigating policies. The temporal and inter-regional shifts that appeared in, and as a response to, Ethiopia’s pandemic policies illustrate the importance of continuous analysis of the relationships between health and politics, at the national as well as sub-national level.

To substantiate our argument, we draw on qualitative data from the project ‘COVID-19 Impact Tracing in Ethiopia: Social, Economic, Political, and Security Ramifications’, carried out in the Tigray, Amhara, and Oromia Regional States (RS) from June to September 2020. In what follows, we first provide a brief description of our methodological approach and an overview of the Ethiopian political context. We then outline key features of Ethiopia’s COVID-19 response, paying particular attention to three major political developments that shed light on the ways that health was interpreted, emerged and disappeared as high politics: (1) the postponement of regional and national elections, (2) the declaration of a regional (Tigray) and national State of Emergency (SoE) and (3) the assassination of Hachalu Hundessa—a popular Oromo artist. Finally, we discuss our findings by situating these events and processes in a broader historical and political context.

Methods

The study was carried out by Oslo Analytica, a Norwegian-based policy research institute, in collaboration with researchers at 10 universities in Ethiopia. The overall aim of the project was to explore the social, economic, political and security ramifications of COVID-19 in Ethiopia. The research team, which was led by this article’s first and last author, consisted of altogether 16 members. With a focus on what was happening on the ground in the Amhara, Tigray and Oromia RS, we organized the project participants into three regional teams. The lead researchers were all social scientists with decades-long research experience working in Ethiopia. All the field-researchers, except for one who had a position within the health system, worked as lecturers or assistant professors at local universities in the three regions and had training in the social sciences or the humanities.

We designed the study as a qualitative, multi-scalar research project. The initial project document contained an overview of research objectives, a breakdown of the different sectors and levels of administration we planned to assess and a detailed list of research questions. The project took an unexpected turn, however, when the donor (the United States Agency for International Development) encouraged us to leave aside preconceived questions and rather adopt an exploratory approach. As social scientists with a strong foundation in anthropology, we welcomed this opportunity. In communication with the field-researchers, we emphasized the importance of anthropological methodologies such as participant observation, informal conversation and self-reflexivity. While this explorative turn did not prevent us from developing question guides, it allowed us to be flexible; to let the cues from our respondents decide what to focus on and which data to collect. During the research period, we asked our field-researchers to conduct weekly interviews and to trace how perceptions shifted over time. In total, more than 400 interviews were conducted with a wide range of informants, including but not limited to government officials, religious leaders, business owners, public servants, health professionals, taxi drivers and people living on the street. In addition, we closely followed public statements and discourses, including on social media.²

Study context

To fully understand how the COVID-19 pandemic, the government’s mitigating efforts and political developments in Ethiopia unfolded, we need to consider regional demographics, historical developments and political context. Our focus on the Oromo, Amhara and Tigray RS reflects the political and historical salience of these regions in Ethiopian politics. Oromia is the largest RS, with a population of ca. 37 million people (ca. 35% of the population, mainly the Oromo ethnic group). With regard to central political power, however, the Oromo people have—along with many other ethnic groups—historically, been marginalized. The Amhara RS is home to 30 million people (ca. 30% of the population, mainly the Amhara ethnic group). The Amhara, who for centuries have been associated with the ruling elite, are also found as minorities in other RS across the country.³ Located in northern Ethiopia, bordering Eritrea, the Tigray RS represents a smaller constituency of about 6 million people. Yet, being the site of the ancient Axum empire⁴ and the cradle of the Ethiopian Orthodox Church (EOC), Tigray has played a significant role in terms of political representation, both historically and, as we shall see below, in contemporary politics. To make sense of Ethiopia’s COVID-19 response, it is pivotal to understand both the political dynamics within and between these regions and the role they play in national politics.

The historical Ethiopian Empire was marked by elaborate hierarchical and militaristic feudal structures and centralized power. A process of state expansion at the end of the 19th century, which involved the conquest and subjugation of many autonomous ethnic groups and polities in the southern and eastern parts of the country, laid the foundation for Ethiopia’s current territory. The combination of a centralizing state and nation-building processes during the 20th century, often coined as ‘Amharization’, forced other ethnic groups to assimilate into the state-bearing Amhara culture. Through these processes, the language, religion and symbols of the Amhara came to represent the Ethiopian state and identity. People outside the Amhara realm, and primarily the Oromo and Tigray, largely resented this domination, reflected, among others, in the emergence of Oromo and Tigrayan ethno-nationalist movements during the 1970s. While the Revolution in 1974 and the Marxist Derg government (1974–1991) abolished the feudal structures, political power remained centralized and became increasingly hierarchically rigid. In 1991, the Tigray People’s Liberation Front (TPLF), which had launched its resistance struggle in 1974, toppled the Derg government and became the leading party within the new government coalition: the Ethiopian Peoples’ Revolutionary Democratic Front (EPRDF). The EPRDF reconfigured the unitary state into a multinational federation (‘ethnic federalism’) with nine, in principle autonomous, RS delineated according to assumed ethno-linguistic boundaries. With the new constitution in 1995, which was closely aligned with international democratic and human rights standards, the transition into multinational federalism initially indicated a movement towards decentralization of power and democratization. However, the EPRDF government coalition, with TPLF as the dominant fraction, soon reverted to the same authoritarian mode of governance as its predecessors, using the party to centralize power and wield unchecked power (Aalen, 2002).

After a long period of popular protests led by the Oromo (Qeerroo) and Amhara (Fano) youth movements, political unrest and internal power struggle within EPRDF, the Oromo fraction with Abiy Ahmed at the helm assumed power in April 2018. As Prime Minister Abiy Ahmed initially promised democratic reforms, his popularity skyrocketed. In addition to releasing thousands of prisoners and inviting back exiled opponents of the regime, he initiated a diplomatic dialogue with President Isaias Afwerki of Eritrea to settle a decade-long conflict over border issues. The broad-sweeping reforms carried out in 2018 earned Abiy Ahmed the 2019 Nobel Peace-prize.

Abiy Ahmed’s popularity eroded quickly, however. This was partly due to his failure to deliver on his promises, institutionalize the reforms and maintain peace and security but more importantly was the perception that he deserted an ethno-national and Oromo policy in favour of a pan-Ethiopian nationalistic one. The move to replace the old ethnic-based EPRDF coalition with the new pan-Ethiopian Prosperity Party (PP) in December 2019 generated much political dissent, leading to the withdrawal of TPLF from the coalition and federal government and contributing to increased opposition from Oromo factions and other groups in Southern Ethiopia. PM Abiy Ahmed responded to this resistance by reverting to the authoritarian modes of governance of the former EPRDF, which in turn further escalated existing tensions and unrests.

Results

When news of a novel, potentially devastating virus outbreak started circulating, Ethiopia was quick to implement COVID-19 mitigating measures. Following the activation of the Public Health Emergency Operation Center in late January 2020, the authorities launched several policies, protocols and organizational platforms to control the emerging pandemic. On March 16, three days after the first COVID-19 case was detected in Ethiopia, all schools were closed, and public gatherings were banned. In the weeks that followed, additional measures were implemented, including the closure of borders and mandatory quarantine for arriving international passengers. The pandemic generated much concern and fear among the public. During the first phase of the pandemic, apocalyptic sentiments and religious interpretations circulated widely (Østebø et al., 2021b). It did not take long for political interpretations to surface and dominate, however.

Contested elections

On March 31, 2020, the Ethiopian government became one of the first countries to postpone national and regional elections indefinitely due to COVID-19. Nearly all opposition parties protested the decision, which sparked a broader debate on the constitutionality of a possible postponement. Some argued that the situation gave Ethiopia the opportunity to establish an inclusive transitional arrangement to anchor the political reforms and combat the pandemic.⁵ The Prime Minister rejected all calls for national dialogue and transitional government and insisted that the PP form the government alone until an election could be organized after the pandemic.⁶ Public health experts played a central role during what was deemed as a constitutional crisis, citing public health concerns to legitimize the postponement. When the Council of Constitutional Inquiry, in late May, 2020, held a hearing session on the postponement of the election, Minister of Health Dr Lia Tadesse and the Director of the Ethiopian Public Health Institute, Dr Eba Abate, were both present, conveying supportive arguments and recommendations.⁷ The Health Minister and Senior Health experts were, in other words, actively participating in high politics—providing arguments that clearly positioned them in a process that was about competition over power.

While some, including a few regional opposition parties, supported the postponement, most of our informants in all the three RS questioned the decision and the public health arguments that were used to legitimize it. They believed that the postponement was politically motivated, driven by the Prime Minister’s and the ruling party’s fear of losing the vote. Interviewees in the Amhara region, for example, claimed that the government was using COVID-19 as an excuse because ‘they are trying to extend their time in power.’ Considering the limited spread of COVID-19 and the low number of fatalities, they were not at all convinced by the public health arguments. In east Gojam, one respondent argued that the incumbent used the postponement to buy time to marginalize and undermine Amhara representation and opposition: ‘For the Amhara people, suspending the election means extending the time where there are no true Amhara representatives in current politics’.

The strongest display of resistance came from the Tigray region, where the postponement was viewed as an attempt by PM Abiy Ahmed to deconstruct the federation and centralize power once again in Addis Ababa. As expressed by a citizen of Axum: ‘COVID-19 is a blessing in disguise for the federal government. The federal government is using the pandemic as a political tool to disband the civil and political rights of the citizens.’ Such a view was also held by the regional government of Tigray, who categorically argued against a postponement of the election and called it a breach of the constitution. Consequently, the regional government of Tigray unilaterally authorized a separate regional election—despite the federal authorities’ warning that the regional election would be considered unconstitutional. The decision to go ahead with regional elections, nevertheless, had wide public support in Tigray, including among members of regional opposition parties:

TPLF has nothing to lose and all to win from such an election, as it likely will strengthen its legitimacy in the eyes of the Tigrayans and ethnic federalist supporters…As a member of an opposition party, I don’t care about the result of the election, but it must be conducted on time as the people of Tigray has fought and sacrificed for this. I don’t deny the undemocratic nature of TPLF…but this must be minimized through the exercise of democratic principles such as an election and not by the help of the federal or any other external forces.

The Tigrayan people went to the polls on September 9 in a well-organized, peaceful and socially distanced election, and even with the participation of four opposition parties, the incumbent TPLF won ca. 97% of the popular vote.⁸ Rather than being the mere election of a regional government, the dire security context in the country led the electorate to perceive the vote as a referendum on self-determination and security provisions for Tigray.⁹ In such a context, TPLF emerged as the only ‘party’ capable of defending the collective interests, including public health, and the territorial integrity of Tigray. In the weeks that followed the election, the federal government implemented several sanctions on Tigray, such as withholding federal grants and personal protective equipment from the regional government. This deliberate failure to deliver in terms of key pandemic measures is another example of how public health was used as an instrument in contestation over power—and hence emerged as high politics.

The Tigray election was one of the triggering factors that led to the outbreak of war between federal and allied forces and Tigray regional forces on November 4. The COVID-19 pandemic and the subsequent postponement of the general elections thus had a dramatic impact on peace and stability in Ethiopia, as it directly contributed to the outbreak of armed conflict.

State of Emergencies

A second political instrument that illustrates how health emerged and was perceived as high politics in Ethiopia was the use of SoEs. Prior to the federal government’s declaration of an SoE on April 10, the Tigray RS introduced its own SoE. This was done not only to stop the spread of COVID-19 but also to prevent political interference by the federal government, as the relationship between the regional and federal governments had deteriorated rapidly after the establishment of the new government PP, in 2019. With the implementation of a regional SoE, the Tigray government took effective control over the security sector in Tigray and showed a swifter response to combatting the COVID-19 pandemic than federal authorities. As the regional SoE was viewed as undermining the federal government’s pandemic strategy, it provoked many and triggered calls for federal interventions against the regional government’s policy. For Tigray, on the other hand, it was important to independently organize quarantine rules and testing centres as this showed the region’s capacity as a ‘de facto state’.¹⁰ Even federal government army units, offices and institutions located in Tigray were subjected to the Tigray SoE rules, as the regional government claimed that the Ethiopian Constitution contained no ‘supremacy clause’ for the federal government to overrule regional governments’ decisions.¹¹

When the federal government subsequently declared a nationwide five-month SoE, the politicization and securitization of COVID-19 and its attendant mitigating efforts further intensified. The federal SoE contained a detailed list of regulations and restrictions intended to halt the spread of the virus. In addition to mandating that COVID-19 positive- and suspected cases stay in government-designated quarantine and isolation centres, the SoE required ‘any person’ to report suspected COVID-19 cases to the police or health authorities. The SoE caused concerns among the opposition, who were worried that the decree provided the government with sweeping powers that could be abused for political purposes.

Among our informants in Oromia and Amhara, the national SoE was interpreted as a tool the government introduced to crack-down on opposition activities. Some claimed that the government was using the SoE to pacify and keep protesting youth movements at bay. As described by an informant in the Amhara region: ‘It is evident that the SoE has been used to secure politics, rather than preventing the spread of the virus. In Amhara region, following the declared SoE, military intervention took place to silence and control the Fano (youth movement) structures.’ As the high expectations of genuine political responses to Oromo and Amhara grievances were not met under the new PP, representatives of the Amhara Fano and Oromo Qeerroo youth movements were intent to continue their protests. With the introduction of the SoE such mobilizations became impossible.

The uneven implementation of the SoE, which in many areas were followed by increased securitization and human rights abuses, further fuelled political interpretations. For instance, while opposition parties were denied permission to hold meetings, the government party held mass meetings with their member base. ‘The government is acting like a bad religious leader, who teaches something but does the opposite’, an opposition supporter in Oromia concluded. Many also believed that the regulations that the SoE mandated—such as mandatory quarantine in government assigned centers—were politically motivated. One of our interviewees, who was kept in a quarantine centre, claimed: ‘I do not have the virus, but Biltsigina [the ruling PP] brought me here’. In some areas, the government—e.g. the PP—was considered a greater threat than COVID-19. ‘We are now drained by and tired of COVID-20’ a Bajaj driver claimed; COVID-20 having been adopted as the local, satiric term for the PP.

While political interpretations circulated in all the three regions, the security situation in Oromia—particularly in Guji and Wollega, the areas of the Oromo Liberation Army’s insurgency—fuelled a highly politicized discourse. Prior to the pandemic, in early 2020, the federal government had implemented a communication black-out in Wollega, cutting both mobile phone and internet connections to prevent communication between political activists and to block news reports about its counter-insurgency campaign from reaching the public. As the virus spread, the federal government was increasingly criticized for the black-out, since it prevented the dissemination of essential COVID-19 information from reaching the Wollega area. After a massive social media campaign, which forced the federal government to give in, the mobile phone and internet infrastructure was restored on March 31, 2020.

The federal structure allows the RS to operate separate law enforcement agencies (police and para-military forces). The public perceptions of these law enforcement agencies differed greatly between the regions. In some areas, they were viewed as protectors of peoples’ interests (mainly in Tigray), while they in others were seen as suppressors (mainly in Oromia). Thus, when it came to monitoring and in ensuring that people complied with quarantine and isolation regulations, the level of securitization and reports about human rights abuses was considerably higher in Oromia than in Tigray. For example, our field-researchers in Tigray did not report the presence of the Regional Special Security Forces at the quarantine centres, whereas such forces were heavily present and operational, not only at the quarantine centres but also on the streets in eastern Oromia.¹² The felt lack of genuine political representation in combination with the heavy presence of law enforcement units and the military in Oromia, and to a certain extent in the Amhara RS, partly explains the scepticism and mistrust that the general population had towards the government in general and to its COVID-19 policies.

From very high to very low politics

A more radical shift in the perceptions of the pandemic, the attendant health interventions, and of the government itself occurred in the end of June 2020, when the famous Oromo artist Hachalu Hundessa was gunned down by unknown assailants in Addis Ababa. The killing sparked protests and unrest in parts of the capital but more significantly in southeastern Oromia. This incident and the subsequent arrests of prominent (mainly Oromo) opposition politicians soon spiralled into inter-communal violence. While the Ethiopian Human Rights Commission said that a total of 126 people died in Oromia during the clashes, the Oromia regional police reported the number to be at least 239 and also claimed that 10 000 were displaced (Østebø et al., 2021a). Private properties and government infrastructure were also burned.¹³ The government’s response was swift and, in many instances, violent. It included widespread arrests of suspected culprits, local officials and opposition politicians. As of early August 2020, more than 9000 persons had reportedly been incarcerated, mainly in Oromia RS. The government also instigated a 3 week long national internet shut down immediately after the unrest—and the SoE gave the authorities the legal framework to implement these measures.

The government’s response to the unrest was a starting point for an intense securitization in Oromia. Many of our respondents felt victimized by the government’s policies and the security forces’ harsh measures. Several witnesses described atrocities committed by the armed forces against civilians in these areas. One informant concluded: ‘They [the security forces] are doing as they like under the coverage of the SoE’. The mass-arrests were interpreted as a way of deliberately infecting people with the virus while in prison,¹⁴ and some argued that the government was using the virus as a biological weapon. After being released from a 2-months detention without any formal charges pressed, a member of a local Abba Gadaa Council¹⁵ concluded: ‘In my lifetime I have never seen anything like this. The government is killing people without any reasons, and arresting people without any legal procedures or claims.’ As the state diverted its attention and resources—from mitigating the COVID-19 pandemic to quelling protests and insurgencies—health went from being an important political priority and instrument, to becoming largely neglected. We may say that health became very low politics. The public’s attention also shifted, from social distancing and mitigating efforts, to joining protests—or trying to avoid them and the ensuing police crackdowns.

The internet shutdown had a significant impact on national and local COVID-19 prevention and relief programmes and, furthermore, illustrates how the status of health shifted, with heightened security concerns and competition over power, taking precedence over COVID-19 preventive efforts and health concerns. During the first phase of the pandemic, government organizations, from federal to district level, actively used social media, particularly Facebook, for spreading awareness. Among the most frequently viewed and shared posts were the daily dashboard updates from the Federal Ministry of Health (FMoH) and the Ethiopian Institute of Public Health that showed the number of national daily COVID-19 tests, new positive cases, deaths, number of patients in treatment centres and in intensive care units, and recoveries. As the internet was shut down, the daily dashboard reports were no longer available. While the government TV and Radio stations provided daily COVID-19 reports, these were aggregated national reports and did not convey regional and locally specific data. In the absence of local reports, one of our field-researchers concluded that ‘people forgot that the virus was spreading [in their community]’. Informants from all the three regions claimed that the lack of daily alerts led to less communication among community members regarding the severity of the disease, ultimately leading to reduced interests and compliance with preventive measures. As one of our informants in the Amhara region concluded: ‘There was no flow of information so people in Gondar completely ignored COVID-19. However, the confirmed positive cases doubled during that period.’

The health system was also heavily affected by the shutdown. During the past 10 years, the FMoH has developed several programmes that rely on digital solutions to improve health care monitoring and delivery. Health workers and administrators particularly use Telegram—an application that requires less bandwith than WhatsApp and Messenger and that allows for the fast transmission of larger files and documents, including images—as the preferred means of communication. A health worker in Oromia explained how the internet shutdown hampered the testing and contact tracing work: ‘We were using Telegram to share information about suspected cases and to trace their contacts. With the internet shut down, we were unable to conduct contact tracing and unable to send daily COVID-19 reports to Oromia regional health bureau’. A pharmacist interviewed in Amhara also explained how the lockdown impacted the supply chain. ‘Since we were unable to send reports, we could not order and receive our supplies. We had created our channel through Telegram or e-mail, so we had no way to communicate. There was no alternative backup system.’ In addition to interrupting the flow of communication within the health system, the internet shutdown impacted health workers’ access to important information. Many of the health workers we interviewed talked about how they, through the internet or via regular online meetings, would receive COVID-19 updates. A medical doctor in Amhara explained:

‘Before the shutdown, we had regular online meetings about Covid-19 related issues. I would also search for information about Covid-19 on the internet. We also used to send daily, weekly, and monthly reports about Covid-19 related issues. But during the internet blackout, we were completely shut down. We could not use internet to update ourselves. We could not receive nor send information.’

‘Politics has overpowered everything’, a middle-aged man in the Eastern Part of Oromia concluded. He argued that the Ministry of Health’s attention had been ‘snatched away by politics’ and that they ‘completely have forgotten about Corona’. In late Summer 2020, this was, in fact, how most of our respondents, in all the three regions, perceived Ethiopia’s COVID-19 response. As expressed by a civil servant in Addis Ababa:

People feel as if there is no Corona. They wear masks only on some occasions due to fear of the police. All discussions are about politics. Even mainstream media are concentrating on politics. In the past few weeks, the agenda of the government is not Corona, rather it is politics. At the federal level, the issue of the Tigray regional election is the hottest topic. In government institutions currently, there is no provision of basic facilities like masks, alcohol, and sanitizers. This used to be given to all civil servants.

The general population also started to question the government’s behaviour and the seriousness of the pandemic. As reflected in the following statement from a rural kebele leader in eastern Shewa:

People’s perception has changed. After Hachalu’s death, large crowds gathered. But still, we did not see an increase in Covid-19 infections. This changed people’s perception about Corona – it is looked upon as a simple disease, as common cold. Before this happened [Hachalu’s death], policemen were taking measure against those who did not wear face masks, but now the police don’t care. They are busy with the unrests.

Discussion

Ethiopia’s COVID-19 response and the political developments that have occurred during the pandemic very clearly shows that health and health policies cannot be treated as if it belongs in the realm of low politics alone. The current pandemic has brought public health to the forefront of high politics. This does not mean, however, that the pandemic has generated a totally new situation, that COVID-19 has pushed health from the realm of low to high politics. Rather, as Jasanoff et al. recently argued (Jasanoff, 2021), COVID-19 has aggravated pre-existing conditions, and revealed underlying political values and structures of power. As we will show below, historically, the policies and programmes that have been implemented to improve public health in Ethiopia have, indeed, been highly politicized. Health—here understood in an expanded sense, as a ‘pre-eminent political value’ (Fidler, 2005, p. 184), an activity and a public good—has been used as a tool for political control and surveillance (Maes et al., 2015; Østebø et al., 2018), for legitimizing the state and the visions and ideologies of ruling elites (Lavers, 2019; Croke, 2020), and as a strategic tool during times of war (Barnabas and Zwi, 1997).

Surveillance and control of neighbours, which during the first phase of the pandemic emerged as a key feature of the Ethiopian government’s response,¹⁶ has been an integral part of Ethiopia’s highly acclaimed Health Extension Programme (HEP) (Maes et al., 2015). While the HEP, a primary health care initiative established in 2004, has been hailed as a model for other countries to emulate (Donnelly, 2011; Prata et al., 2012), its proponents, including global health scholars, have largely overlooked its political nature (Østebø et al., 2018). For instance, many of the Health Extension Workers (HEW) were recruited as political cadres, who in addition to carrying out health-related activities, were actively involved in political events organized by the ruling party. Additionally, the Women’s Development Army, which was established in 2010 to ‘take over’ the preventive aspects of the HEP (Maes et al., 2015, p. 468), was part of the politically charged one-to-five networks (Chinigò, 2014; Lefort, 2012). These miniscule cell structures, which drew heavily on, and extended the hierarchical, authoritarian administrative structures that had been established during the Derg regime, enabled the federal government to implement and oversee centralized policies and extend the state’s presence and control into each and every small local community across the country, including at household level (Emmenegger, 2016; Clapham, 2002; Chinigò, 2014). In some areas of the country—particularly in Oromia—health and development interventions were also securitized, with local militia using ‘guns as a coercive means of mobilization’ when people refused to participate or failed to comply with government policies (Emmenegger, 2016, p. 274). During a visit to a rural district in Oromia in 2017, this article’s first author was told that if a pregnant woman failed to deliver her child at a proper health facility, her husband would be put under arrest by the local authorities. Hence, the coercive nature of the government’s COVID-19 interventions, including mandatory quarantine in government-controlled facilities and the use of security forces to enforce pandemic policies, emerged as a continuation of practices that many of our informants were well familiar with.

While the hierarchical and partially coercive nature that has characterized the HEP and other development programmes implemented during the rule of the EPRDF in many ways represented a continuation of health initiatives and strategies developed during previous regimes (Kloos, 1998), it is moreover pivotal to recognize the historical links between HEP and TPLF’s struggle for self-determination. As Mulugeta Gebrehiwot Berhe recently argued, ‘Ethiopia’s health revolution began as a political revolution: with the 17 year long people’s war waged by the rebel forces of the Tigray People’s Liberation Front (TPLF) in the field.’¹⁷ According to him, to maintain popular support for the struggle, the TPLF had no choice but to develop social and health services. Securing basic services, including health, was in other words an important part of the strategy to defeat the Derg military regime in 1991. Phrased as ‘health for the struggle’, TPLF’s overall aim was to develop a health system that would ‘enable the public and the army to survive the war’ and that ‘would lead to peace and development’ (Barnabas and Zwi, 1997, p. 44). Health was, in other words, very much ‘high politics’; it was closely intertwined with a quest for peace and security and a value and public good that TPLF actively used to build its political legitimacy. This strategy continued into the EPRDF’s era, reflected in a strong focus on building a developmental state that could deliver tangible, socio-economic progress, including within the field of health.

The extent to which people in Ethiopia complied with and adapted the various health and development interventions the EPRDF implemented differed between the regions, however. In a study of Community-Based Health Insurance in Ethiopia, Tom Lavers argues that the state’s ‘infrastructural power’—its ‘capacity (…) to actually penetrate civil society and implement its actions across its territories’ (Mann, 2008, p. 355)—was significantly weaker in the Oromia region, compared to Tigray (Lavers, 2021). Insurance enrolment was, for example, much lower and community resistance significantly higher in the Oromia region. As we have shown in this article, these regional differences also emerged during the COVID-19 pandemic, reflected in a higher degree of securitization and a much more elaborated politized discourse in the Oromia region than in Tigray.

Conclusion

As our data and analysis of Ethiopian health policies illustrate, health cannot be separated from questions of high politics, whether during a pandemic or not. For people in Ethiopia, health and development interventions are not simply ‘technical’ matters; their experiences with and perceptions of the health system are closely intertwined with and colored by the ideologies and the modes of governance that the various Ethiopian governments have exhibited to craft the nation and impose the state’s legitimacy. The fact that health policies and interventions are at times part of high politics—of struggle for power and issues of securitization—explains why Ethiopia’s COVID-19 response early on generated a highly politized discourse and became contested and charged of being politically (mis)used.

While health in the Ethiopia context, often has been perceived as a matter of high politics, it would be too simplistic to conclude that the relationship between health and politics is static. As we also have shown here, health’s status is shifting—both in time and place. Health holds an ambiguous character of being low politics in certain contexts or timeframes while being elevated to high politics in other. In addition to illuminating regional differences, the political developments that occurred in Ethiopia during the COVID-19 pandemic illustrate how health—over time—was sidelined by more pressing issues, when political instability and survival of those in power, trumped health policies. Just as a virus, health is an unstable and unpredictable category. Depending on contextual and relational factors, health, and its place within larger systems of power, changes and mutates. And, just as a pandemic, the relationship between health and politics requires continuous analysis and careful spatio-temporal attention.

Supplementary data

Supplementary data are available at Health Policy and Planning online.

Data availability statement

The data underlying this article cannot be shared publicly to protect the privacy of research participants but may be shared on reasonable request to the corresponding author.

Funding

This study was conducted with funding from The United States Agency for International Development.

Acknowledgements

We thank Roza Abesha, Lwam Ferede, Girmay Tadele, Teklu Gebremedin, Muhammed Jemal, Kedir Jemal, Seife Hailu, Meressa Tsehaye and six individuals who remain anonymous for their contribution as field researchers in this study.

Ethical approval

Ethical approval for this type of study is not required by our research institute.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Endnotes

1.

See Bremmer (2019).

2.

See supplemental file for more information about our methodological approach, including a discussion of the researchers’ positionality and the politics of writing.

3.

Amhara is a highly complex category, containing spatial, ethnic and religious dimensions. Historically, the Amhara political elite has moreover been composed of other ethnic groups, including the Oromo, constituting what Brian Yates refers to as the Abyssinian—or Habasha—elite.

4.

The predecessor state of Abyssinia/Ethiopia.

5.

See Kiruga (2020).

6.

See Corey-Boulet (2020).

7.

See Fana Broadcasting Corporate (2020).

8.

Aljazeera (2020). Governing party in Ethiopia’s Tigray sweeps regional polls. Last accessed June 28, 2021, see https://www.aljazeera.com/news/2020/9/11/governing-party-in-ethiopias-tigray-sweeps-regional-polls.

9.

See Tronvoll (2021).

10.

See Tronvoll (2020).

11.

The Ethiopian Constitution defines the ‘nations, nationalities and peoples’ as the sovereign entities, represented by their administrative units who have given the mandate to govern to the centre, represented by the federal government. Power is, thus, not devolved from the centre to the regional governments, as is usual in federal arrangements, but vice versa. All RS under the Ethiopian federation also hold power to exit the federation and establish sovereign states, according to constitutional procedures.

12.

The Special Security Forces are regional forces, often called ‘Liyu Police or Poolisii Addaa’ (Amharic/Oromo, special police). They are usually tasked with maintaining domestic peace and order.

13.

See also ‘Ethiopia arrests suspects over Haacaaluu Hundeessaa killing’, Aljazeera. Last accessed April 30, https://www.aljazeera.com/news/2020/07/10/ethiopia-arrests-suspects-over-haacaaluu-hundeessaa-killing/.

14.

https://www.voanews.com/covid-19-pandemic/covid-19-spreads-inside-ethiopian-detention-centers.

15.

The Oromo were historically governed according to what is called the ‘gadaa’ system, a presumed egalitarian system based on generation groups. Recent years have seen the revitalization of ‘gadaa’ institutions, leading to the establishment of the Oromo Abba Gadaa Council in 2014. The council has played an active role in the ongoing political developments in Oromia, being instrumental in negotiating between different political actors.

16.

Rumors and alerts were key measures the Ethiopian government used to detect new COVID-19 cases in Ethiopia. A national toll-free hotline was established, and people were told to call in and report suspected cases. The SoE mandated ‘any person’ to report suspected COVID-19 cases to the police or health authorities.

17.

See Gebrehiwot (2020).