In August of this year, when the Ebola outbreak escalated in Liberia and a state of emergency had been declared for the country, Fatu Kekula, a young Liberian nursing student, improvised personal protective equipment (PPE) to care for her father, mother, sister, and cousin. After three of the relatives survived, her method was featured prominently in the international news media as the “trash bag method” (CNN, 2014). The reports were meant to ignite a spark of hope in the Ebola epidemic in Guinea, Sierra Leone, and Liberia. International organizations, like UNICEF, even started to promote this ‘better-than-nothing’ method. In most other Ebola reports, by contrast, health workers in white or yellow PPEs, collecting dead bodies or admitting sick patients to isolation units, have come to symbolize the grim and desperate situation in the region. What strikes us most in the story of Kekula’s improvised PPE is how notions of security and safety are reinscribed into gloves, trash bags, and rubber boots to enable a form of care in the context of a broken health system. When we recall that during the first months of the epidemic many people were caring for their sick relatives without any protection measures, then Kekula’s trash bag method reveals quite dramatically how care itself has become a source of existential insecurity.
In this piece we pull together a set of observations on quarantine measures and care to ask how security is embodied in everyday practices of care in a public health system which is short of the beds and basic equipment needed to address Ebola. To follow this question, it is necessary to ask how global health has transformed the intricate relationship between security and care, turning care into a source of existential insecurity. Moreover, are there alternative views on security and care which may help to orient global health approaches to the Ebola epidemic?
Between security and care
The prevalence of unprotected and unrecorded practices of care at hospitals and at homes, as well as the death of more than 5,000 people, have to be understood against the background of a public health system that even in normal times is hardly able to provide and sustain basic health services: Kekula’s father was first turned away by several hospitals occupied by Ebola patients, before he was eventually admitted. It is assumed that he contracted Ebola in the hospital and was taken home by his daughter, as the hospital was unable or unwilling to help him. However, the media coverage of Kekula’s trash bag method ignores the more fundamental and underlying questions of ‘What alternatives did Fatu have?’ and ‘Who else would have cared for her sick relatives?’
What the current outbreak certainly shows is that Ebola does not easily fit into the logic of global health. Both quarantine measures to contain the spread of Ebola and the establishment of isolation units to care for patients require extensive infrastructure. Médicins Sans Frontières’ (MSF) humanitarian intervention in Guinea, which ran for several months before it eventually reached the limits of its capacities, revealed the enormous logistical challenges of moving tons of material to maintain a few isolation units and provide care to Ebola patients. The national public health systems in the affected countries were hardly able to replicate these efforts.
Such problems are characteristic of global health challenges more broadly. The extraordinary amount of funding for global health was over the last few years largely spent on life-saving medicines like antiretrovirals, antimalarials, test kits, and other equipment to address HIV, malaria, and tuberculosis. Little or no attention was paid to the importance of a functioning public health system. According to Uli Beisel, global health operates in a spatio-temporal logic of “vertical and time-bound projects” (Beisel, 2014), privileging measurable impacts and focusing on specific diseases. In the view of most global health organizations investments into public health systems are not easily measured and accounted for. Medicines and equipment are largely distributed through projects constituting a complex and fragmented global health infrastructure that bypasses national public health systems.
It is crucial to note that Ebola was not even entirely off the global health agenda. According to Andrew Lakoff, one has to distinguish two regimes of global health (Lakoff, 2010). The humanitarian side of global health’s attempts to respond to emergency situations—this would include the MSF operations in Guinea, and then in Sierra Leona and Liberia—dovetails with two decades of intensive work on the creation of a global infrastructure for pandemic preparedness in the name of global health security. These infrastructures include high-tech futuristic isolation wards, where trained personal can approach infected people, as protective gears allow for hermetic isolation of the caregiving individual. But such an understanding of security is largely preoccupied with its application in Western settings and is less concerned with the translatability of the concept into non-Western settings. Thus in a response to calls to step up quarantine measures, Laurie Garrett, a global health specialist, cautions that the “hubris is the greatest danger in wealthy countries – a sort of smug assumption that advanced technologies and emergency-preparedness guarantee that Ebola and other germs will not spread” (Garrett 2014).
The convergence of these two regimes of global health in the Ebola crisis reflects a biopolitical moment in global health. Foucault’s analysis of security as a dispositif may be useful in capturing how pandemic preparedness inscribes a distinct notion of security into technologies and infrastructures to contain Ebola. Following Foucault (2007), such technologies reveal a political rationality to regulate populations by isolating ‘bad’ circulations from ‘good’ circulations (protective care from dangerous care, infected from non-infected people moving across space and time). The difference between underequipped hospitals in Sierra Leone, Liberia, and Guinea turning away sick people and their relatives and the trust or illusion that 50 beds in specialized clinics in Germany or France are able to contain the spread of Ebola in Europe reflects the uneven distribution of security in global health infrastructures. According to Guillaume Lachenal and Vinh-Kim Nguyen, the geopolitics in these infrastructures of pandemic preparedness “produced this Ebola epidemic” (Lachenal, 2014; Nguyen, 2014).
What interests us most is how contradictions in these two overlapping regimes of global health turned hospitals and public health systems in Liberia, Sierra Leone, and Guinea into vectors for Ebola (Abramowitz 2014). Furthermore, these contradictory regimes of security and care form the background for understanding how practices of care became an existential insecurity. For Benjamin Hale, the tragedy of Ebola is that this epidemic “preys on care and love” and ultimately on “humanity” (Hale, 2014). This tragedy involves confusion and dilemmas about how and by whom patients will be cared for. According to public health instructions, patients should not be touched—not at the isolation wards in the hospital nor at home. One risk indicator for Ebola that summarizes the problem of existential insecurity is “have you helped someone confirmed with Ebola?“ But how should one not help nor care? What does care mean when closeness, intimacy, and sociality must be avoided? Instructions to report relatives with Ebola to hospitals immediately may have in fact been one of the first confusions in Ebola responses. Once patients and their relatives reach a hospital, they are often told to wait, as most hospitals are short in beds. Ebola patients, including those at risk, are only admitted to isolation units if someone dies; even then, these units often lack gloves, medicines, PPEs, and other basic equipment, transforming hospitals into hot zones of infection. Families are discouraged from burying their dead and are told to wait for government agencies to come and collect the dead bodies. The isolation of infected individuals from families and the prevention of burying them with proper rituals undermines the intuitive response to take greater care in times of distress and crisis. For healthcare workers, safety and care too is a dilemma. MSF employees are aware of this dilemma: “It is very hard to turn down patients and to know also there are many people out there that don’t have the possibility to come in.” Health workers are rigorously instructed to implement safety measures in underequipped hospitals. In spite of this, hundreds of health workers (and doctors) have already died, aggravating the lack of staff at hospitals.
These dilemmas demonstrate that care goes beyond the provision of medical relief. Matters of individual and collective security are at stake. Care is a technology of belonging, which restores security by producing closeness, intimacy, and trust. In current efforts to step up quarantine measures, these dimensions of care constitute a risk for contracting Ebola. While the measures are necessary, our major concern is that ignoring a broader notion of security in care may lead to exacerbate the confusions, mistrust, and stigma in current global health interventions to contain Ebola.
Human security – an alternative notion of security to understand care in crisis?
The reports and comments depict the tragedies and vicious circles in the embodiment of care in isolation units and at homes by health workers, patients, and their wider networks. The confusions created by current global health suggest that prevailing notions of security are insufficient to capture how care has become an existential insecurity.
Certainly, immediate action is now needed to contain Ebola and provide medical support so that as many patients as possible survive the virus. Still, we believe that it is not too late to embark on a discussion of alternative notions of security. As the Ebola epidemic has clearly surpassed the reach of biomedical interventions and requires a political response, we need to think more urgently about alternative notions of security, in order to build a more consistent global public health response, which goes beyond the current militarization of Ebola interventions (Waal 2014).
A few of our observations on the nexus of safety, insecurity, and care call for elaboration. First, it strikes us that the concept of human rights has so far played only a minor role in the discussion of quarantine measures. A human rights framework may prove to be useful to open a discussion about whose individual freedoms and human dignity are at stake in quarantine measures. Protecting individuals from contracting Ebola is certainly necessary, but large-scale militarized interventions, cordoning off cities, districts, and whole regions raise the question of how far quarantine measures can be expanded. In regards to the detrimental effects of such measures, the scope of quarantine measures cannot be determined by global health rationalities and individual governments alone. Yet, there is little public debate, which reflects the emergence of novel moral and political borders in the militarization of Ebola epidemic. A human rights perspective may help to steer such a debate and mobilize a broader range of actors and organizations to improve care. By contrast, to paraphrase the philosopher Mary Zournazi, if we only evoke security for our benefit, ignoring others’ loss of security, we run risk of creating a global public health system based on fear (Zournazi, 2003, p. 15).
A human rights framework is certainly not enough to capture how care itself has become an existential insecurity. Another important impulse to address these insecurities may come out of the concept of ‘human security’, which has been discussed for some years by authors like Mary Kaldor and Thomas Hylland Eriksen (Kaldor, 2007; Eriksen, 2010). This concept was originally fuelled by critical engagements with the securitization of development and humanitarian interventions (Duffield, 2005). To counter these tendencies, this concept has been promoted to construct a people-centered, rather than state-driven, notion of security.
The concept of human security builds upon ongoing human rights advocacy, but argues that freedom from want and fear must be the main pillars of any program aimed at addressing people’s experiences of radical insecurity under current conditions of globalization. The emphasis on a people-centered approach to security is most crucial for understanding how Fatu Kekula, whom we mentioned above, and many others maintain care under radically changed circumstances. Human security is in this respect a holistic framework that captures the complex interactions between post-Cold War conflicts, natural disasters, poverty, social inequality, and broken institutions, which all characterize the point of origin of the spread of Ebola in Guinea, Sierra Leone, and Liberia.
What does an understanding of security as freedom from fear and want mean for global public health? We believe it could be taken as a point of departure to embark on efforts to understand health as a global public good and reflect critically on the securitization of public life. Such an understanding in turn underlines the importance of stronger health institutions in reducing existential insecurities. Care is the most important but also the most vulnerable institution to address human insecurities arising out of the nexus of war, poverty, and disease in the Ebola crisis. Taking the complex interplay of these insecurities into account is not only helpful to fully understand the contradictions in current Ebola responses, but also essential for prompting a more holistic response. Despite of its holistic ambition, it is not a new concept. International organizations have been using it already as an analytic framework (e.g. Human Security Commission 2003; World Bank 2011). It thus does not contradict the demand for immediate action. What it does, hopefully, is prompt a people-centered notion of security, which we are desperately missing in debates on what to do against Ebola.
Sung-Joon Park is a lecturer at the Institute of Anthropology of Leipzig University. He received his PhD in Anthropology from the University of Halle and worked at the Max-Planck-Institute for Social Anthropology in Halle. He is currently working on a book manuscript with the title Hope in Global Health, which looks at the stock-out of antiretroviral medicines in mass HIV treatment programmes in Uganda and explores the contradictions and hopes of contemporary global public health.
René Umlauf is a research fellow at Bayreuth University. He works in the collaborative research program “Translating Global Health Technologies: Standardisation and organisational learning in health care provision in Uganda and Rwanda,” funded by the German Research Foundation. He is currently pursuing his PhD in Sociology with a thesis on the introduction of novel technologies for the treatment and diagnosis of malaria in Uganda.
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 On September 29 John Campbell, a Senior Fellow for African Policy Studies at the Council on Foreign Relations emphasized in a video message that “the affected African states cannot stop Ebola without outside help. Quarantine, tracing contacts and treatment for Ebola victims requires the resources only the international community can provide.” While nobody would dispute the need of international collaboration and combined efforts to tackle the epidemic ironically the statement was aired a couple of days before nurses in Spain (October 5) and the US (October 12) contracted the virus during quarantine treatment of two infected patients.
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