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Between Securitisation and Neglect: Managing Ebola at the Borders of Global Health

Abstract

In 2014 the World Health Organization (WHO) was widely criticised for failing to anticipate that an outbreak of Ebola in a remote forested region of south-eastern Guinea would trigger a public health emergency of international concern (pheic). In explaining the WHO’s failure, critics have pointed to structural restraints on the United Nations organisation and a leadership ‘vacuum’ in Geneva, among other factors. This paper takes a different approach. Drawing on internal WHO documents and interviews with key actors in the epidemic response, I argue that the WHO’s failure is better understood as a consequence of Ebola’s shifting medical identity and of triage systems for managing emerging infectious disease (EID) risks. Focusing on the discursive and non-discursive practices that produced Ebola as a ‘problem’ for global health security, I argue that by 2014 Ebola was no longer regarded as a paradigmatic EID and potential biothreat so much as a neglected tropical disease. The result was to relegate Ebola to the fringes of biosecurity concerns just at the moment when the virus was crossing international borders in West Africa and triggering large urban outbreaks for the first time. Ebola’s fluctuating medical identity also helps explain the prominence of fear and rumours during the epidemic and social resistance to Ebola control measures. Contrasting the WHO’s delay over declaring a pheic in 2014, with its rapid declaration of pheics in relation to H1N1 swine flu in 2009 and polio in 2014, I conclude that such ‘missed alarms’ may be an inescapable consequence of pandemic preparedness systems that seek to rationalise responses to the emergence of new diseases.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
* Email address for correspondence: mark.honigsbaum@qmul.ac.uk
Footnotes
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Research for this article was made possible by a grant from the Wellcome Trust (grant no. 107721/Z/15/Z) and forms part of a wider oral history project on the 2013–16 Ebola epidemic. I am particularly indebted to the three anonymous reviewers for their comments on earlier drafts and to João Nunes for graciously recognising my priority to the title, even though a similar idea occurred to him while this article was in peer review.
Footnotes
References
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1. ‘Afro-memorandum, 25 March 2014’, in ‘Bungling Ebola-Documents’, Associated Press, http://data.ap.org/projects/2015/who-ebola/(accessed 17 June 2015); Sylvain Baize et al., ‘Emergence of Zaire Ebola Virus Disease in Guinea’, New England Journal of Medicine, 371, 15 (2014), 1418–25.

2. ‘WHO, Emergency Response Framework (ERF)’, http://www.who.int/hac/about/erf/en/(accessed 17 June 2015).

3. ‘WHO, International Health Regulations (2005)’, Annex 2, 43, http://www.who.int/ihr/publications/9789241596664/en/(accessed 17 June 2015).

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7. ‘Ebola: Pushed to the Limit and beyond’, Médecins Sans Frontières International, http://www.msf.org/article/ebola-pushed-limit-and-beyond(accessed 29 April 2015); see also Lawrence O. Gostin and Eric A. Friedman, ‘A Retrospective and Prospective Analysis of the West African Ebola Virus Disease Epidemic: Robust National Health Systems at the Foundation and an Empowered WHO at the Apex’, The Lancet, 385, 9980 (2015) 1902–9; ‘WHO, Report of the Ebola Interim Assessment Panel – July 2015’, http://www.who.int/csr/resources/publications/ebola/ebola-panel-report/en/ (accessed 6 August 2015).

8. Adam Kamradt-Scott, ‘WHO’s to Blame? The World Health Organization and the 2014 Ebola Outbreak in West Africa’, Third World Quarterly, 37, 3 (2016), 401–18; Colin McInnes, ‘WHO’s Next? Changing Authority in Global Health Governance after Ebola’, International Affairs, 91, 6 (2015), 1299–1316.

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10. Melinda Cooper, ‘Pre-Empting Emergence: The Biological Turn in the War on Terror’, Theory, Culture and Society, 23 (2006), 113–35; Jean Comaroff, ‘Beyond Bare Life: AIDS, (Bio)politics, and the Neoliberal Order’, Public Culture, 19 (2007), 197–219; Frédéric Keck, Un Monde Grippé (Paris: Flammarion, 2010); Theresa MacPhail, ‘A Predictable Unpredictability: The 2009 H1N1 Pandemic and the Concept of “Strategic Uncertainty” Within Global Public Health’, Behemoth A Journal of Civilisation, 3, 3 (2010), 57–77; Sudeepa Abeysinghe, ‘Zika, Uncertainty and Global Health Policy’, Somatosphere, 17 February (2016).

11. The interviews were conducted in Sierra Leone, London, Washington DC and Atlanta between March 2015 and February 2016 as part of an oral history project funded by the Wellcome Trust and included interviews with government ministers, health responders, clinical researchers, nurses, Ebola survivors, members of NGOs and key international scientific experts and agency officials (grant number 107721/Z/15/Z).

12. , While ‘Ebola virus’ was the name given to the virus isolated in 1976 in the first outbreak in Yambuku in the DRC (former Zaire), in 2002 the species name was contracted to Zaire ebolavirusor ZEBOV for short. However, as many writers continued to use the generic term to describe both the Zairean and other subtypes, in 2010 it was proposed to retain the previous species names but to revert to the common name used in the field, with the Zaire strain being known as EBOV. Jens H. Kuhn et al., ‘Proposal for a Revised Taxonomy of the Family Filoviridae: Classification, Names of Taxa and Viruses, and Virus Abbreviations’, Archives of Virology, 155, 12 (2010), 2083–2103.

13. Baize, op. cit. (note 1).

14. Farmer Paul, ‘Social Inequalities and Emerging Infectious Diseases’, Emerging Infectious Diseases, 2, 4 (1996), 259269.

15. Nunes João, ‘Ebola and the Production of Neglect in Global Health’, Third World Quarterly, 37, 3 (2016), 542556.

16. Muyembe-Tamfum Jean-Jacques et al. , ‘Ebola Virus Outbreaks in Africa: Past and Present’, Onderstepoort Journal of Veterinary Research, 72, 2 (2012), 451; WHO, ‘Table: Chronology of Previous Ebola Virus Disease Outbreaks’, http://www.who.int/mediacentre/factsheets/fs103/en/ (accessed 12 November 2015).

17. ‘Ebola and Emerging Infectious Diseases: Measuring the Risk’, Royal Institute of International Affairs, Chatham House, 6 May 2014, https://www.chathamhouse.org/events/view/198881(accessed 12 November 2015).

18. Pierre Rollin, interview with author, Centers for Disease Control and Prevention, Atlanta, 26 October 2015.

19. Knobloch J., Albiez E. J. and Schmitz H., ‘A Serological Survey on Viral Haemorrhagic Fevers in Liberia’, Annales de l’Institut Pasteur/Virologie, 133, 2 (1982), 125128.

20. The Ebola virus was isolated by scientists at the CDC and Porton Down from blood samples forwarded from Yambuku via the Institute of Tropical Medicine in Antwerp. The first filovirus to be recognised was Marburg in 1967. Karl M. Johnson et al., ‘Isolation and Partial Characterisation of a New Virus Causing Acute Hæmorrhagic Fever in Zaire’, The Lancet, 309, 8011 (1977), 569–71.

21. Preston Richard, The Hot Zone (London and New York: Doubleday, 1994), 8183.

22. King Nicholas B., ‘Security, Disease, Commerce Ideologies of Postcolonial Global Health’, Social Studies of Science, 32, 5–6 (2002), 763789.

23. Garrett Laurie, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Straus and Giroux, 1994), 593595. The war game exercise uncannily presaged the 2013–16 Ebola epidemic, imagining an outbreak at the border of three fictitious equatorial countries where civil war had led to a dangerous concentration of refugees living in unsanitary encampments.

24. David Heymann, interview with author, London, 19 March 2015.

25. Joshua Lederberg, Robert E. Shope and S. C. Oaks (eds), Emerging Infections: Microbial Threats to Health in the United States (Washington DC: National Academy Press, 1992), 34–5, 83.

26. Stephen S. Morse (ed.), Emerging Viruses (New York: Oxford University Press, 1993); Garrett, op. cit. (note 23); Richard M. Krause (ed.), Emerging Infections, Biomedical Research Reports (San Diego, CA: Academic Press, 1998).

27. Lederberg, Shope and Oaks, op. cit. (note 25), 42, 47.

28. See Nicholas G. Evans, Tara C. Smith and Maimuna S. Majumder (eds), Ebola’s Message: Public Health and Medicine in the Twenty-First Century (Cambridge, MA, and London: The MIT Press, 2016); Daniel G. Bausch and Lara Schwarz, ‘Outbreak of Ebola Virus Disease in Guinea: Where Ecology Meets Economy’, PLoS Neglected Tropical Diseases, 8, 7 (2014), e3056.

29. Peters C. J. and Peters J. W., ‘An Introduction to Ebola: The Virus and the Disease’, Journal of Infectious Diseases, 179, 1 (1999), ix–xvi.

30. Quammen David, Ebola: The Natural and Human History (London: Bodley Head, 2014), 31.

31. ‘Ebola Vaccine Research and NIH Funding Cuts: Reviewing the Numbers’, PolitiFact, http://www.politifact.com/truth-o-meter/article/2014/oct/17/was-ebola-vaccine-research-hindered-nih-funding-cu/(accessed 14 June 2015).

32. Gostin and Friedman, op. cit. (note 7).

33. King, op. cit. (note 22); Theodore M. Brown, Marcus Cueto and Elizabeth Fee, ‘The World Health Organization and the Transition from “International” to “Global” Public Health’, American Journal of Public Health, 96 (2006), 62–72; Lorna Weir and Eric Mykhalovsky, ‘The geopolitics of global public health surveillance in the twenty-first century’, in Alison Bashford (ed.), Medicine At The Border (Basingstoke: Palgrave Macmillan, 2006), 240–64.

34. Launched by the WHO in 2000, GOARN is a virtual network drawing on 120 institutional partners worldwide that links institutions and individuals with specialist knowledge of and expertise in epidemics. Its first test came in March 2003 when the WHO issued an alert about a new respiratory virus in Hong Kong – what would later be identified as SARS. Within four months, GOARN had traced all the chains of transmission and interrupted an outbreak that affected 27 countries worldwide. David Heymann and Rodier Guénaël, ‘Global Surveillance, National Surveillance, and SARS’, Emerging Infectious Diseases, 10, 2 (2004), 173–5.

35. Bausch Daniel G. and Rollin Pierre E., ‘Responding to epidemics of ebola hemorrhagic fever: progress and lessons learned from recent outbreaks in Uganda, Gabon, and Congo’, in Murray Barbara E., Scheld W. Michael and Hughes James M. (eds), Emerging Infections 6 (Washington DC: American Society of Microbiology, 2004), 3558.

36. Frederick A. Murphy and C. J. Peters, ‘Ebola virus: where does it come from and where is it going?’ in Richard M. Krause (ed.), Emerging Infections, Biomedical Research Reports (San Diego, CA: Academic Press, 1998), 375–410.

37. Bausch and Rollin, op. cit. (note 35).

38. Muyembe-Tamfum et al., op. cit. (note 16).

39. WHO, ‘Ebola Virus Disease, Fact Sheet 103, Updated August 2015. Table: Chronology of Previous Ebola Virus Disease Outbreaks’, http://www.who.int/mediacentre/factsheets/fs103/en/(accessed 4 December 2015).

40. Bausch and Rollin, op. cit. (note 35).

41. David Heymann and Rodier Guénaël, SARS: Lessons From A New Disease (National Academies Press, 2004), https://www.ncbi.nlm.nih.gov/books/NBK92444/ (accessed 30 November 2016).

42. Pierre Formenty, ‘WHO inline-graphic $|$ Ebola Diaries: First Signals – March 2014’, http://www.who.int/features/2015/ebola-diaries-formenty/en/ (accessed 28 April, 2015); Laurie Garrett, ‘Ebola’s Lessons’, Foreign Affairs, https://www.foreignaffairs.com/articles/west-africa/2015-08-18/ebolas-lessons (accessed 3 November 2015).

43. Kamradt-Scott, op. cit. (note 8).

44. ‘Implementation of the International Health Regulations (2005). Report of the Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response’, WHO, 13 May (2016), 39.

45. Heymann, op. cit. (note 24).

46. For further discussion, see Mark J. Siedner et al., ‘Strengthening the Detection of and Early Response to Public Health Emergencies: Lessons from the West African Ebola Epidemic’, PLOS Medicine12, 3 (2015), 1–8.

47. Andrew Lakoff, ‘Two States of Emergency: Ebola 2014’, Limn, 5 (2015), http://limn.it/issue/05/(accessed 29 May 2015).

48. The IHR (2005) defines a pheic as an ‘extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response’. WHO (2005), op. cit. (note 3).

49. Stefan Elbe, Security and Global Health (Cambridge: Polity Press, 2010), 172–5.

50. Bingham Nick and Hinchcliffe Steve, ‘Mapping the multiplicities of biosecurity’, in Lakoff Andrew and Collier Stephen J. (eds), Biosecurity Interventions: Global Health and Security in Question (New York: Colombia University Press), 173191: 177.

51. D. Cohen and P. Carter, ‘Conflicts of Interest: WHO and the Pandemic Flu “Conspiracies” ’, BMJ, 340 (2010), c2912; Sudeepa Abeysinghe, ‘An Uncertain Risk: The World Health Organization’s Account of H1N1’, Science in Context, 27, 3 (2014), 512–529.

52. These obligations included monitoring bird flu in China, the MERS virus in Saudi Arabia, wild polio viruses in Africa, Asia and Syria, plus humanitarian crises such as Typhoon Haiyan in the Philippines in 2013.

53. WHO (2005), op. cit. (note 3).

54. ‘WHO Statement on the Meeting of the International Health Regulations Emergency Committee Concerning the International Spread of Wild Poliovirus’, http://www.who.int/mediacentre/news/statements/2014/polio-20140505/en/(accessed 1 December 2015).

55. By contrast, once the WHO had triggered a pheic, it played a key role in removing regulatory and financial hurdles to enable fast-track trials of experimental Ebola drugs and vaccines, creating ‘an exceptional political space’ for pharmaceutical development. Anne Roemer-Mahler and Stefan Elbe, ‘The Race for Ebola Drugs: Pharmaceuticals, Security and Global Health Governance’, Third World Quarterly, 37, 3, 487–506.

56. At the time of the outbreak, the only laboratory in West Africa with the equipment to conduct rapid diagnostic tests for Ebola was the former Lassa fever laboratory at Kenema General Hospital. The next nearest laboratories were in Gabon and South Africa: Nadia Wauquier et al., ‘Understanding the Emergence of Ebola Virus Disease in Sierra Leone: Stalking the Virus in the Threatening Wake of Emergence’, PLOS Currents Outbreaks, 20 April (2015), edition 1; Bausch and Rollin, op. cit. (note 35).

57. Oliver Johnson, interview with author, Freetown, 10 March 2015. In fact, it was untrue that there had never been an urban outbreak of Ebola: in 1995 the virus had triggered just such an emergency in Kikwit, a city in the Democratic Republic of the Congo (DRC) with 400 000 inhabitants. Because of weakened infectious disease surveillance systems, the initial cases were wrongly diagnosed as gastrointestinal disease, permitting the virus to spread unnoticed in the community for 13 weeks. It was only when health workers in Kikwit also became infected that the outbreak came to the attention of the authorities in Kinshasa and the WHO was alerted. David Heymann et al., ‘Ebola Hemorrhagic Fever: Lessons from Kikwit, Democratic Republic of the Congo’, Journal of Infectious Diseases, 179, 1 (1999), S283–86.

58. ‘We Need Support’, 14 April 2014. Associated Press, op. cit. (note 1).

59. ‘WHO, Ebola situation report, 13 May 2015’, http://www.who.int/csr/disease/ebola/situation-reports/archive/en/(accessed 17 June 2015).

60. ‘WHO, Global Alert and Response, One Year into the Ebola Epidemic: A Deadly, Tenacious and Unforgiving Virus’, WHO, 2015, http://www.who.int/csr/disease/ebola/one-year-report/introduction/en/(accessed 19 December 2016).

61. Briand Sylvie et al. , ‘The International Ebola Emergency’, New England Journal of Medicine, 371, 13 (2014), 11801183.

62. James Fairhead, ‘Understanding Social Resistance to Ebola Response in Guinea, Ebola Response Anthropology Platform’, April 2015, http://www.ebola-anthropology.net/evidence/1269/(accessed 27 January, 2016); Samuel Cohn and Ruth Kutalek, ‘Historical Parallels, Ebola Virus Disease and Cholera: Understanding Community Distrust and Social Violence with Epidemics’, PLoS Currents, 26 January (2016), edition 1.

63. Alan Feuer, ‘The Ebola Conspiracy Theories’, The New York Times, 18 October (2014).

64. White Luise, Speaking With Vampires: Rumor and History in Colonial Africa (Berkeley, CA: University of California Press, 2008), 82, 312.

65. Graboyes Melissa, The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940–2014 (Athens, OH: Ohio University Press, 2015), 34, 46–7, 133.

66. Mark Honigsbaum, ‘Jean-Jacques Muyembe-Tamfum: Africa’s Veteran Ebola Hunter’, The Lancet, 385, 9986 (2015), 2455; ‘WHO Declares End of Ebola Outbreak in the Democratic Republic of Congo’, 2014, http://www.who.int/mediacentre/news/statements/2014/drc-ends-ebola/en/(accessed 28 November 2016).

67. Fairhead; Cohn and Kutalek, op. cit. (note 62).

68. ‘Red Cross Ebola Teams in Guinea Attacked 10 Times a Month’, Reuters, 12 February (2015), http://www.reuters.com/article/us-health-ebola-guinea-idUSKBN0LG1GO20150212(accessed 29 November 2016).

69. ‘Report of WHO Interim Assessment Panel’, op. cit. (note 7), 20.

70. Muyembe-Tamfum, email to author, 17 June 2015.

71. Denise Grady, ‘Ebola Vaccine, Ready for Test, Sat on the Shelf’, The New York Times, 23 October (2014).

72. Transcript, ‘Ebola and Emerging Infectious Diseases: Measuring the Risk’, Chatham House, 6 May 2014,https://www.chathamhouse.org/events/view/198881(accessed 11 November 2015).

73. Armand Sprecher, ‘The MSF Response to the West African Ebola Outbreak’, The Ebola Epidemic in West Africa, Institute of Medicine, Forum on Microbial Threats, Washington DC, 25 March 2015.

74. Keiji Fukuda, ‘Ebola in West Africa: An Analysis of the Current Situation’, Institute of Medicine, Forum on Microbial Threats, Washington DC, 24 March 2015.

75. ‘Travel Summary Report’, 8 July 2014, Associated Press op. cit. (note 1).

76. Médecins Sans Frontières, op. cit. (note 7).

78. Wauquier et al., op. cit. (note 56).

79. Gire Stephen K. et al. , ‘Genomic Surveillance Elucidates Ebola Virus Origin and Transmission during the 2014 Outbreak’, Science, 345, 6202 (2014), 13691372.

80. Samuel A. Sheku Kargbo, interview with author, Freetown, 3 March 2015.

81. Simon-Lorière Etienne et al. , ‘Distinct Lineages of Ebola Virus in Guinea during the 2014 West African Epidemic’, Nature, 524, 7563 (2015), 102104.

82. Wauquier et al., op. cit. (note 56).

83. Nadia Wauquier, interview with author, Paris, 28 May 2015.

84. Joseph Fair, interview with author, Washington DC, 24 March 2015; Will Pooley, interview with author, Eycke, Suffolk, 24 May 2015.

85. Joshua Hammer, ‘My Nurses are Dead and I Don’t Know if I’m Already Infected’, Medium, 2015, https://medium.com/matter/did-sierra-leones-hero-doctor-have-to-die-1c1de004941e#.pslijyrgh(accessed 4 February 2015).

86. Bausch Daniel et al. , ‘A Tribute to Sheik Humarr Khan and All the Healthcare Workers in West Africa who Have Sacrificed in the Fight against Ebola Virus Disease: Mae We Hush’, Antiviral Research, 111 (2014), 3335.

87. Joel Montgomery, interview with author, CDC, Atlanta, 27 October 2015.

88. Baize, op. cit. (note 1).

89. Simon-Lorière, op. cit. (note 81).

90. Allison Arwady M. et al. , ‘Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014’, Emerging Infectious Diseases, 21, 4 (2015), 578584: 173.

91. Kevin De Cock, interview with author, London, 26 June 2015.

92. This view was cogently expressed by Oliver Morgan, who served as the CDC’s country head in Sierra Leone from November 2014 to August 2015 and was a witness to high-level discussions at the National Ebola Response Control Centre. Interview with author, CDC, Atlanta, 27 October 2015.

93. De Cock Kevin M. and El-Sadr Wafaa M., ‘A Tale of Two Viruses: HIV, Ebola and Health Systems’, AIDS, 29, 9 (2015), 989991.

94. James Nye and Associated Press, ‘Ebola Victim who Sparked Fears of a Global Outbreak was American’, Mail Online, 29 July (2014), http://www.dailymail.co.uk/news/article-2709180/Ebola-victim-sparked-fears-global-outbreak-American-Father-died-incurable-virus-Nigeria-taking-international-flight-going-visit-children-Minnesota.html(accessed 17 November 2015).

95. Nigeria’s successful containment of secondary spread of Ebola was also heavily reliant on infrastructure and human capital investments it had received for polio eradication. De Cock and El-Sadr, op. cit. (note 93).

96. Apparently, Sawyer, whose wife and children lived in Minnesota, had been intending to travel to the United States in August. Nye and Associated Press, op. cit. (note 94).

97. De Cock, op. cit. (note 91).

99. Monica Mark, ‘Ebola Outbreak “Moving Faster than Efforts to Control it”, says WHO Chief’, The Guardian, 1 August (2014).

100. De Cock, op. cit. (note 91).

101. http://www.un.org/ebolaresponse/response.shtml(accessed 29 November 2016).

102. ‘Report of WHO Interim Assessment Panel’, op. cit. (note 7).

103. Suerie Moon et al., ‘Will Ebola Change the Game? Ten Essential Reforms before the next Pandemic: The Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola’, The Lancet, 386 (2015), 2204–21: 1009.

104. ‘Global Health Risk Framework, National Academy of Medicine’, 2016, https://nam.edu/initiatives/global-health-risk-framework/(accessed 5 August 2016).

105. ‘Report of WHO Interim Assessment Panel’, op. cit. (note 7).

Research for this article was made possible by a grant from the Wellcome Trust (grant no. 107721/Z/15/Z) and forms part of a wider oral history project on the 2013–16 Ebola epidemic. I am particularly indebted to the three anonymous reviewers for their comments on earlier drafts and to João Nunes for graciously recognising my priority to the title, even though a similar idea occurred to him while this article was in peer review.

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