On the 5th of September, 2014, the blog Konakry Express recounted a report from Mme Fatou Baldé Yansané that there are severe shortages of gloves in health facilities in Guinea. Mme Baldé Yansané writes that midwives have only one or two pair of gloves each week. As a consequence, they have to reuse gloves or merely rub their hands with chlorine after consultations. This message was written over five months after the WHO’s confirmation of an Ebola outbreak in Guinea on their webpage. When I read the blog piece, I was completely stunned: how could it be that five months after the outbreak had entered the world stage, the simplest and cheapest personal protective equipment was still missing in health facilities in the subregion?

Sadly, this is not an isolated incidence. Drew Hinshaw from the Wall Street Journal reports this heartbreaking scenario from Sergeant Kollie Town, Liberia in August:

“Rubber gloves were nearly as scarce as doctors in this part of rural Liberia, so Melvin Korkor would swaddle his hands in plastic grocery bags to deliver babies. His staff didn’t bother even with those when a woman in her 30s stopped by complaining of a headache. Five nurses, a lab technician—then a local woman who was helping out—cared for her with their bare hands. Within weeks, all of them died. The woman with a headache, they learned too late, had Ebola.”

There is a particular irony to the story of missing gloves in Liberia, as the country is also home to the “largest single natural rubber operation in the world”, Firestone Natural Rubber Company. Although Liberian rubber is mainly used in Bridgestone car tires, the company says it also supplies rubber to companies manufacturing “vital medical components”, such as the latex gloves desperately needed in health facilities in the region. However, latex products are not manufactured in Liberia, the natural rubber is only harvested in Liberia and then shipped elsewhere for production—an all too familiar story of natural resource extraction on the African continent. A timely reminder too that not only are troubling racial immuno-logics at play, but that the epidemic is also deeply rooted in colonial histories of expansion and extraction (for a wonderful piece on the history of the Firestone Plantation and the crucial role science and medicine played in its establishment see Mitman and Erickson, 2010).

The lack of gloves is another reiteration of these violences and inequities, but this time refracted through the contemporary configurations of ‘global health’. How can it be that after decades of unprecedented financial investments in healthcare in developing nations, and in particular on the African continent, health facilities are still missing the most basic supplies?

Medical anthropologist James Pfeiffer has, in a recent podcast of Humanosphere, brilliantly analyzed the problems that Structural Adjustment Programmes and the logics of the aid industry more generally have created for health systems in economically poor countries. I do not want to rehash those important points here again; please check out the podcast directly for that. Instead, I want to focus on the temporal and spatial logics of global health that underlie many of the processes James describes.

Over the last decades and not least through the UN’s Millennium Development Goals, health initiatives have received unprecedented attention and funding, and many advances have been made. However, together with the MDGs came a particular framing of health and health interventions. The MDGs name HIV and malaria (‘and other diseases’), as well as malnutrition, child mortality and maternal health as priorities, and this has real-life consequences for policy and funding decisions. HIV, malaria and tuberculosis still receive the biggest share of the funding. Additionally, all MDGs have clear numerical aims: e.g. “reduce child mortality by two-thirds, between 1990 and 2015”. This clear-cut numerical focus has performative effects, as it renders health and progress measureable and accountable, and so – it is assumed – keeps momentum going and funders on board. However, it has also meant that we have in recent years overwhelmingly focused on vertical, single–disease interventions. The rationale behind this is exemplified by a statement from Melinda Gates in 2007, when she introduced the Gates Foundation’s focus on malaria eradication: “And because we can’t fix the whole health care system in all of Africa, (…) the only way to end death from malaria is to end malaria”. For many, the focus on vertical interventions and technological fixes was, and continues to be, pragmatic: the promise is that with the appropriate tools and benchmarks, progress can be measured and the messy realities of international politics and local infrastructures circumvented for more effective results. This has led to a proliferation of vertical disease projects, many of them hybrids involving international donors, NGOs, public-private ventures, research and data collection enterprises. Social studies of global health have shown that this has led to a fragmentation of health care provision, which in turn has resulted in massive uncertainties for patients. In many places it is difficult for patients to determine where medications and care are currently available. Spatially, the logic is one of parachuting specific interventions into selected places. It not only leaves out many places, but also many diseases and illnesses. It is a logic of patchworks, adjuncts and circumvention, or an ‘archipelago of care’ (Geissler, 2013; Rottenburg, 2009).

The temporal imaginary of global health contributes to this dynamic. Interventions are not only patchy, but they are also time-limited. Today most come in the form of projects, a process that has been discussed as ‘projectification’ (Whyte et al., 2013). Under the label of evidence-based medicine, new intervention strategies and technologies are trialed, scaled-up and then all too often handed-over to Ministries of Health that lack the financial and operational means to sustain the interventions (note, most Ministries of Health do not lack the expertise!).

West Africa’s Ebola epidemic all too painfully shows that this spatio-temporal logic of patchy, vertical and time-bound projects has significant shortcomings. Health care infrastructures cannot be circumvented when one aims to improve health care sustainably.[1] Well-functioning infrastructures are flexible and adaptive, able to change gear and respond to shifting disease landscapes. Just like the harvesting of rubber and the production of gloves, they are rooted in history and configured in specific political economies. The predominant logic in global health is based on and has led to an impoverished understanding of health and wellbeing. We assume we know which diseases and ailments are relevant and crucial to address. Ebola teaches us that we are well advised not work from this bold assumption. A humble version of Socrates’ classic “I know that I know nothing” seems to be a better guide to navigating complex and rapidly shifting disease landscapes. The lack of gloves, personal protective equipment and skilled personnel in West Africa’s health facilities is not only a result of war or weak states, but also of the spatio-temporal logic of global health, and it presents us with an urgent call for change in global health approaches and logics.

Uli Beisel is Assistant Professor of Culture and Technology at Bayreuth University. She has worked on human-mosquito-parasite intertwinings in malaria and its control in Ghana and Sierra Leone, where she was particularly interested in how we live together with organisms that are harmful to human health. Her current work focuses on translations of new health technologies in global health initiatives, and their relation to uneven geographies of access to health care in Uganda and Rwanda.

Acknowledgments

Thanks to Ann H. Kelly for feedback on the draft and encouragement.

References

Geissler, P. W. (2013). The Archipelago of public health. Comments on the landscape of medical research in 21st century Africa., In Ruth Jane Prince & Rebecca Marsland (ed.),  Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives.  Ohio University Press.  pp.231 – 256

Mitman, G. and Erickson, P. (2010). Latex and Blood: Science, Markets, and American Empire. Radical History Review 107 (2010): 45-73

Rottenburg, R. (2009). Social and public experiments and new figurations of science and politics in postcolonial Africa. Postcolonial Studies 12 (4): 423-440.

Whyte, S. R., Whyte, M.A., Meinert, L. and Twebaze, J. (2013) Therapeutic Clientship: Belonging in Uganda’s Mosaic of AIDS Projects. In J. Biehl and A. Petryna (eds.) When People Come First: Anthropology and Social Innovation in Global Health. Princeton: Princeton University Press. pp.140-165

Note

[1] The global health community started to learn this lesson and health systems strengthening has started to receive more support and funding. However, most HSS initiatives still happen within the logic and institutional frameworks of vertical, numerical interventions, and are thus limited in their scope and reach.