The World Health Organization recently released its long-awaited final report on the organization’s response to the 2014 Ebola epidemic. The report opens by explaining that, however tragic the epidemic was, it also provides us with a chance to learn. “The sole consolation of the Ebola disaster is that it has galvanised the world into analyzing the failures and ensuring that it is better prepared for the next global health threat,” it states. “Crisis is hardship but also opportunity.”
The release of the report reminds us that alongside the epidemiological end of an epidemic, there is also an administrative end. In the case of the 2014 Ebola epidemic, we can mark the date of the latter much more sharply than the former. On March 29th of this year, the Director-General of the World Health Organization, Margaret Chan, officially terminated the epidemic’s status as a “public health emergency of international concern.” This was a classificatory shift meant to signify a change in how the disease is to be governed. Even as cases of Ebola in West Africa continued to appear, the end of the emergency signaled a return to normalcy, the entry into a period of reflection on the meaning of the event—the “epilogue” of the epidemic narrative (Rosenberg 1989), in which retrospective moral judgment can be made: who is to blame? What should we have done differently?
A surprisingly simple answer to this question was offered last year by the Swedish statistician Hans Rosling, who said: “If you want to blame somebody for this epidemic,” he said, “blame me. It was my mistake.” Rosling had been among those experts who, in the summer of 2014, advised the World Health Organization against declaring the epidemic to be a global health emergency—a decision that has since been blamed for the slow response of international authorities to the outbreak, and for its explosion into a global health catastrophe by the early Fall.
At the time, Rosling argued that such a declaration would divert scarce health resources in the region away from more epidemiologically significant problems such as malaria, diarrheal diseases and bacterial infections. He shared the view of many experts that Ebola was a “small problem” in comparison to these less sensational but much more widespread afflictions. There was a solid epidemiological rationale to this position: Ebola had never before caused more than a few hundred deaths. It was understood to be a highly dangerous, but ultimately manageable disease.
There are, of course, a number of reasons why the outbreak proved much worse than international health authorities initially anticipated: the breakdown of basic health infrastructure in afflicted areas, public distrust of officials in a context of recent civil conflict, poor communication among disparate response organizations, and so on. And Rosling’s mea culpa, in the wake of the epidemic, was part of a larger process of retrospectively apportioning blame. Some of this blame was diffusely targeted at the “global community” for its slow and tepid response to the outbreak. But gradually an effort has built up to find more specific sites of responsibility. Much of this process has taken the form of committee investigations. In addition to the WHO Internal Review Committee, at least five other panels of experts have issued official reports that diagnose sources of failure in the international response to the outbreak and recommend reforms to prevent the occurrence of another such catastrophe.
The effort to officially allocate blame in the wake of a catastrophic outbreak is not new. We can date the genre of the “Commission of Inquiry” report at least back to mid-nineteenth century investigations of cholera outbreaks in Europe. In 1854, for example, the Cholera Inquiry Commission appointed by the British Parliament found that authorities in the town of Newcastle had ignored the advice of medical experts as the disease approached:
“That ‘the continued vigilance on the part of the authorities,’ which according to the report of that medical committee, had been ‘proved to be necessary in order to guard against a further and more destructive outbreak’—such as actually occurred last autumn—does not appear to have been exercised by those authorities.’”
The practice of the Commission of Inquiry comes into play when a collective misfortune is understood to be at least in part the result of a governmental failure—a wrong decision made or an improper action taken. The epidemic, or at least its surprisingly devastating consequences, is seen in retrospect as “a preventable tragedy.” The post-hoc investigation assumes the temporal-causal framework of risk (Luhmann 1993): what might have seemed to be an external source of danger—the onset and course of an epidemic—is treated instead as the product of an internal decision. The task of the Commission is to pinpoint the locus of failed action in order to target future reform measures.
But alongside its similarity to this historical schema, the post-hoc assessment of the response to Ebola in 2014 also has some distinctive features. One of these features is the sheer multiplicity of commissions of inquiry that have been established. The World Health Organization has issued two reports, and other groups that have weighed in include the United Nations, the World Bank, the World Economic Forum, the US National Academy of Medicine, and a consortium from Harvard and the London School of Tropical Medicine and Hygiene. This proliferation of reports indicates—in contrast to nineteenth century Britain—that in the case of the 2014 Ebola epidemic, it is not clear what governmental agency or body of experts has jurisdiction over the management of epidemic response at a global scale. Who exactly comprises “the global community” that, as one critique put it, “was sluggish in reacting to the crisis, with inadequate coordination and confused decision making”?
Another distinctive feature of the post-Ebola report is the type of diagnosis it seeks to make. The reports all center on a failure of preparedness. The global community was exposed by the epidemic as “altogether unprepared,” concluded the independent panel of experts convened by Harvard and the London School of Tropical Medicine and Hygiene. The outbreak revealed “gaping holes in preparedness,” stated the National Academy of Medicine in its report, the Global Health Risk Framework. Multiple failures “demonstrated that the world remains ill-prepared to address the threat posed by epidemics,” said the report from the UN High Panel on the Global Response to Health Crises. And according to the WHO’s Internal Review Committee, “Ebola starkly revealed the fact that we still remain ill-prepared in the face of a major public health emergency.”
The application of the concept of preparedness to infectious disease outbreaks is relatively recent. The theme of “emergency preparedness” as a governmental problem initially arose in the context of economic mobilization for total war in the mid-twentieth century United States (Collier and Lakoff 2015). Mobilization preparedness asked: what kinds of anticipatory measures—the stockpiling of scarce materials, tools to manage the allocation of resources, plans for civil defense—must be put in place before the onset of war? Famously, scenario-based planning was invented during the Cold War as a technique of preparing for the unprecedented catastrophe of nuclear conflict. The broader field of emergency management grew out of such planning methods, and included medical supply stockpiling (see figure 1).
Figure 1: the 1950s packaged emergency hospital with its stockpiled medical supplies
Many of the techniques associated with the field of emergency management were assimilated into the field of “global health security” over the course of the 1990s and early 2000s. A key moment for this was the 2005 adoption by the World Health Assembly of the revised International Health Regulations (IHR), which were officially released in 2007 under the rubric of “global public health security” (Lakoff 2010). The IHR institutionalized a view of the future of infectious disease as characterized by the ongoing but unpredictable emergence of novel pathogens. And the problem for health authorities was to detect and contain such outbreaks before they became international catastrophes. It was at this point that the retrospective assessment of a failed response began to pose the question: are we prepared?
To ask the question was to answer it. As summary of the IHR Review Committee on the WHO’s response to the 2009 H1N1 (swine flu) pandemic—in which the organization had been accused of over-reacting to the outbreak by declaring a global health emergency—put it: “We were lucky this time, but as the report concludes, the world is ill-prepared for a severe pandemic or for any similarly global, sustained and threatening public health emergency.”
This is the diagnostic framework of the post-hoc report, in the era of emerging pathogens. In the assessment process, the outbreak of a given disease—whether H1N1 or Ebola—loses its specificity and is brought into a shared space of anticipation, inhabited by a range of diseases, some already known and some as-yet to appear. The generic category is the “public health emergency of international concern” (PHEIC), one of the innovations of the revised International Health Regulations (see figure 2).
Figure 2: The IHR decision tool.
The PHEIC is a decision tool for use by national and international health authorities in assessing whether a given health event should be considered a potential global health emergency. While it may seem like an obscure technocratic instrument, this guide for decisions about how to classify reported health-events has come to the fore in discussions of accountability for the catastrophic scale of the 2014 Ebola epidemic. As the WHO’s Ebola Interim Assessment Panel put it in May 2015, “It is still unclear to the Panel why early warnings, approximately from May through to July 2014, did not result in an effective and adequate response.”
In this panel and in other recent commissions of inquiry, the question has repeatedly been posed: why didn’t WHO declare an official emergency early enough that the outbreak could have been contained, in the late spring or early summer 2014? Given the structure of the post-hoc assessment, which seeks to locate the mistaken decision that led to a preventable disaster, this is a tempting moment to focus on. One potential answer is simply that, epidemiologically speaking, as of the spring 2014, Ebola was “known” not to pose the specter of global catastrophe: as noted above, it was thought to be a relatively easily managed and small scale disease. This assumption was the source of Hans Rosling’s confession of culpability mentioned above, and it was echoed in comments made by WHO officials at the time. As one said in April 2014, “We know very well how this virus is transmitted, we know the kinds of steps that can be taken to stop the transmission of the virus.” We might then consider the WHO’s decision against emergency classification a failure of epidemiological imagination. The broader point, though, is that the practice of accounting for failure works retrospectively to assimilate Ebola into a more general category of event, the “global health emergency.”
While the post-hoc assessment is a means of allocating blame, in retrospect, for a preventable disaster, it is not only that. Let us return, in closing, to the WHO final report that was unveiled last week in Geneva. It is actually a report not on the response to Ebola in general, but specifically on the “role of the International Health Regulations” in the organization’s response. When giving the internal review committee its charge in August 2015, Director-General Chan instructed the committee to focus not so much on the past as on the future: “Our challenge now is to look for improvements that leave the world better prepared for the next inevitable outbreak.” In fact, she continued, Ebola was “not a worst-case scenario,” despite the daunting scale of the disaster it had wrought. Rather, officials needed to be ready for the onset of something even more potentially catastrophic. “Preparedness for the future,” she said, “means preparedness for a very severe disease that spreads via the airborne route or can be transmitted during the incubation period, before an infected person shows tell-tale signs of illness.” The image was that of an uncontainable variant of SARS or a humanly transmissible strain of H5N1 (avian influenza)—the specters that initially galvanized international health officials to implement a system of global health security (Caduff 2015; Keck 2010; MacPhail 2014).
In looking at the various assessments that have been produced in the wake of the Ebola epidemic, it becomes clear that they serve not only as administrative “epilogues”—that is, as ways of achieving closure on an epidemic narrative. They also seek to map out a future of organizational transformation. As the Interim Assessment Panel put it in making its post-Ebola recommendations for reform, “The world cannot afford another period of inaction until the next health crisis.”
Once Ebola is assimilated to the more general category of “global health emergency,” the retrospective critique of failure serves as a means of honing a better diagram of detection and response to a future emerging pathogen. The WHO final report addresses questions such as: who will be the key organizational actors? Where will the necessary funds for emergency response come from? How will poor countries be incentivized to develop “core capacities” for managing outbreaks? The diagnosis of a failure of past preparedness, then, can only point toward a hoped-for future of better preparedness. However, since one does not yet know what the next pathogen will be, one can only anticipate the possibility that we may once again find ourselves to have been unprepared.
Andrew Lakoff is Associate Professor of Sociology, Anthropology and Communication at the University of Southern California. He is the author of Pharmaceutical Reason: Knowledge and Value in Global Psychiatry and co-editor of Biosecurity Interventions: Global Health and Security in Question.
References:
Caduff, Carlo. 2015. The Pandemic Perhaps: Dramatic Events in a Public Culture of Danger. Berkeley: University of California Press.
Collier, Stephen J. and Andrew Lakoff. 2015. Vital Systems Security: Reflexive Biopolitics and the Government of Emergency. Theory, Culture and Society 32:2, 19 – 51.
Keck, Frédéric. 2010. Un Monde Grippé. Paris: Flammarion.
Lakoff, Andrew. 2010. Two Regimes of Global Health. Humanity: An International Journal of Human Rights, Humanitarianism, and Development, 1:1, pp. 59-79.
Luhmann, Niklas. 1993. Risk: A Sociological Theory. New York: Aldine de Gruyter.
MacPhail, Theresa. 2014. The Viral Network: A Pathography of the H1N1 Influenza Pandemic. Ithaca: Cornell University Press.
Rosenberg, Charles E. 1989. What is an epidemic? AIDS in historical perspective. Daedalus 118:2 (Spring), 1 – 17.