Category Archives: Health

Ebola: Lessons not learned

[Thanks to Aid Leap for publishing this on their website. Check it out here, along with lots of excellent thinking on aid.]

Tomorrow will mark 42 days since the last new case of Ebola in Sierra Leone, meaning the country will join Liberia in being declared Ebola-free. That brings the world one step closer to a victory over Ebola the killer.

But Ebola has another identity – messenger. We listened. It told us that many aspects of the international aid system are not fit for purpose. Many – too many – of the problems the outbreak revealed are depressingly familiar to us.

Pre-Ebola health systems in Sierra Leone, Guinea and Liberia were quickly overwhelmed and lacked even basic capacity to cope with the outbreak. The World Health Organisation (WHO) failed to recognise the epidemic and lead the response, and international action was late. Early messaging around the disease was ineffective and counterproductive. There was a profound lack of community engagement, particularly early on. Trained personnel were scarce, humanitarian logistics capacity was insufficient and UN coordination and leadership were poor.

The lessons learned should also come as no surprise: rebuild health systems and invest in a ‘Marshall Plan’ for development; make the WHO a truly robust transnational health agency and improve early warning systems; release funds earlier and make contracts more flexible; highlight what communities can do, and engage with them earlier. Except these lessons learned haven’t really been learned at all: they are lessonsidentified repeatedly over the past decades, but not learned. 

Why is the system almost perfectly impervious to certain lessons despite everyone’s good intentions? The short answer: these lessons are too simplistic. They pretend that the problem is an oversight, a mistake to be corrected, when in fact the system is working as it is ‘designed’ to work.  The long answer: what is it about the politics, architecture and culture driving the aid system that stops these lessons from becoming reality?

Take a simple idea, like reconstituting the WHO as an intragovernmental agency with a robust mandate to safeguard global public health, and the power to stop an outbreak like Ebola. Sounds great, but not new. So it also sounds like wishful thinking. It does not address the inherent tension between sovereignty and transnational institutions.

Think of it this way: the more robust an institution, the more of a threat it poses to the individual states that are its members, and hence the greater incentive for those states to set limits to its power. WHO was ‘designed’ not to ruffle feathers.

A robust WHO? Can you imagine the WHO ordering the US or UK governments to end counterproductive measures such as quarantining returned Ebola health workers or banning airline flights to stricken countries? It will never happen.

Here is the true lesson to be learned: at a time of public fear and insecurity, it would be political suicide for any government to allow such external interference. The problem isn’t the institution, it only looks like it is; the problem is the governments that comprise it. That is not to say that WHO cannot and should not be improved. It is to say that the solution proposed cannot address the fundamental problem.

Or take a complex idea, such as community engagement. Our Ebola research found that the ‘early stages of the surge did not prioritise such engagement or capitalise on affected communities as a resource’, a serious omission that ultimately contributed to the spread of the disease, and hence a key lesson learned (see e.g., this Oxfam article).

Disturbingly, this is a lesson with a long history. Here, for example, is what the Inter-Agency Standing Committee (IASC) found in evaluating the international response to the 2010 earthquake in Haiti. The relevance, virtually word for word, to the situation in West Africa speaks for itself:

The international humanitarian community – with the exception of the organisations already established in Haiti for some time – did not adequately engage with national organizations, civil society, and local authorities. These critically-important partners were therefore not included in strategizing on the response operation, and international actors could not benefit from their extensive capacities, local knowledge, and cultural understanding … This is not a new observation. Exclusion of parts of the population in one way or another from relief activities is mentioned in numerous reports and evaluations.

Why is this lesson so often repeated and so often not learned? Does the answer lie in an aid culture where ‘taking the time to stop and think – to comprehend via dialogue, engagement and sociological research – runs counter to the humanitarian impulse to act’? Our report also discusses a greater concern: the degree to which people in West Africa were treated ‘as a problem – a security risk, culture-bound, unscientific – to be overcome’. 

The ‘oversight’ is hardly an oversight: people in stricken communities ‘were stereotyped as irrational, fearful, violent and primitive; too ignorant to change; victims of their own culture, in need of saving by outsiders’. Perhaps that clash of cultures highlights why we should not expect community engagement to spontaneously break out simply because the problem has been recognised.

Powerful forces work against aid actors engaging with the community during an emergency, leaving us with a lesson that has not been learned even after years of anguished ‘never again’ promises to do better.

Lessons learned are where our analysis of the power dynamics and culture of the international aid system should begin, not where it ends.

Ebola the lens: What do we see?

[This blog was first posted at the great Humanitarian Practice Network.  The research paper is expected this summer and will be co-written by Caitlin Wake.]

Saying goodbye to MSF’s Head of Mission in Liberia and thanking her for hosting me during my research visit. As I leaned in for the double cheek kiss that we Anglophone aid workers are so fond of displaying – a badge of cool and humanitarian familiarity that breaks with the sterility of the brisk American handshake – she leaned back. Her face was slightly horrified, her expression confused. Even as I leaned in further, confused myself and self-conscious of making a mistake, she pulled another step back. And then it clicked: No Touch Policy.

There you have it. One small perversity of the Ebola outbreak. One small particularity in a field of many, and yet also representative of a human crisis where humans are prohibited from touching one another in their blackest moments of need, fear and grief. The sanctioned protocol of bumping elbows – or perhaps fists – just doesn’t allow for the level of human connection that people working in such an unforgiving setting deserve.

A plethora of differences set the humanitarian intervention in West Africa apart from those mounted in response to other major crises, whether in Haiti, Syria or the Central African Republic. Some might find that reason enough to question the wisdom of a research project that aims to draw out lessons for future emergency responses from a black swan of a crisis. I would argue just the opposite – by catching the humanitarian aid system off balance, the Ebola epidemic has thrown the system into high relief, magnifying both strengths and weaknesses that might otherwise have gone unnoticed.

The goal of my research with ODI’s Humanitarian Policy Group (HPG) is to use the international response to the Ebola outbreak in West Africa as a critical lens for scrutinising the ‘humanitarian aid system’ as a whole. We hope to avoid duplicating the multiplicity of other assessments, evaluations and reports by focusing on the big picture, at how the fundamental contours of the aid system result in advantages, as well as shortcomings or gaps. We are interested in the power dynamics which govern the aid system’s architecture, culture and identity, and how these shaped the intervention. Hopefully, this research will contribute to ongoing efforts to improve the system’s response capacity, such as informing HPG’s position towards next year’s World Humanitarian Summit.

For now, though, we must come to terms with the immensity and unprecedented nature of the response, which was not just a colossal humanitarian deployment but also a military and scientific one. To begin with, many viewed this solely as a health emergency, some still do. But when was the last time the aid system confronted a ‘health crisis’ that decapitated local health system systems, shut down schools, postponed elections, gutted economies and shook the stability of nations? Sounds more like a classic complex emergency. Yet beyond MSF and a few specialist NGOs, we consistently hear the same refrain: “We wanted to do something but we didn’t know what to do. We aren’t medical. And we were frightened. Really frightened.” Not the best of starting points for what has become a billion-dollar intervention.

Understanding these dynamics and comprehending how an aid system that was so woefully slow to react has managed to produce such a broad, creative response is part of our task. As is figuring out why some of the mistakes made amount to an almost clichéd repetition of blunders that we have seen over and over again. Do we really need a piece of research to tell us that we are better at identifying lessons learned than implementing them?

The Product of Systems

Who is in charge? Part 1.

The richest 1% of the world will soon have a greater share of the world’s wealth than the other 99%. With that eye-catcher of a stat, Oxfam launched a report and a discussion on extreme global inequality. Great stuff. Do not let the quibbling distract you. This is a street child face down on a busy sidewalk in a pool of excrement. Trust your gut: imbalance on this scale is inherently and dramatically wrong. The only debate should be which is worse – what this says about wealth distribution or what this says about power.

But what if I told you that I just read about a place where the richest few control 99.8% of the wealth? Not 48%, as Oxfam’s report denounces, but the whole enchilada? Ninety-nine point eight percent represents an astounding achievement in disparity. Can you guess where? No, not mega-corrupt states like Angola or Equatorial Guinea. No, not the petrol-rich like Qatar or Bahrain. No, not even Mark Zuckerberg’s family. Give up?

The surprise winner of the award for the most inequitable distribution of wealth and control on the planet is none other than us, the ensemble of humanitarian NGOs. Congrats to the likes of MSF and Save and (of course) Oxfam. Here’s Development Initiative’s excellent financial analysis of the humanitarian system (see p. 55ff): National and local NGOs form an essential part of the humanitarian response, but in 2013 only directly received US$49 million – just 0.2% of the total international humanitarian response. That’s US$49M out of about $2.3 billion hitting NGO coffers worldwide.

You can quibble with that figure – it’s not counting indirect flows to national NGOs – but my advice is to trust your gut. Eat your heart out, Donald Trump.

Who is in charge? Part 2

Bill Gates talks solutions. Bill Gates is right. Bill Gates calling for “germ games”. Bill Gates is all over my Twitter feed.

Gates has published an Op-Ed in the New York Times, an article in the New England Medical Journal and done a lot of media work to proclaim that good old human “ingenuity and innovation” can avoid the next Ebola disaster.

Gates makes sense, of course, calling for the development of vaccines, for better surveillance, for a global logistical and medical epidemic response capacity. Gates’ central point, though, is only half correct, and therein lies the flaw in his cunning plan. Gates claims (NYT piece): The problem isn’t so much that the system didn’t work well enough. The problem is that we hardly have a system at all.

Really? Is it that the system doesn’t exist? Or is it that the non-system of epidemic response is the direct product of another system, a highly inequitable international system of interests and power that does not typically place the public good as its paramount ambition? In other words, the very same international system upon whom Gates calls to act.

On one level, Gates forgets what happens to good ideas when their basis for attention and funding is fear and insecurity. What happens when you employ scaremongering to mobilize politicians and Western publics into funding better healthcare systems for the world? My guess: skewed priorities (epidemiological surveillance trumps maternal mortality) and unforeseen consequences, like helping to justify military expansion into global health and humanitarian action. It has not exactly served the lofty goals of international development to have become an integral tool in the global war on terror.

Most importantly, though, Gates seems to be addressing symptoms, not causes. In calling for an international epidemic response system, Gates essentially advocates the same superpower and global institutional approach that helped deliver WHO’s ineffectiveness, Sierra Leone’s woefully inadequate healthcare, or an Ebola response in West Africa that was too late, too slow and too focused on staunching the Westward flow of Ebola rather than healing those who already had it.

Bill Gates outlines a system the world needs to build. Dead right. Now he needs to outline the world that will build it, because he is silent on the need for changes in the way global institutions are conceived, controlled and built in the first place.

“Pound of Cure” Politics

Who hasn’t heard this one: An ounce of prevention is worth a pound of cure. The old adage presents a truism well relevant to the world of international aid. Ebola comes quickly to mind as the latest in a long list of lessons not learned. To wit, at what point – March? May? – would a fairly modest ten million or so have staved off the need for the $1.3B intervention that has been launched to date?

But the proverbial equation generates a false comparison. The “pound of cure” logic dissimulates. That tail of the proverb represents the cost of an intervention at a later stage – the bill for the fix (i.e., action after the problem has materialized). The mistake is to confuse the cost of the fix with the value of the damage. Pound of cure thinking hides ten, twenty or maybe thousands of pounds of loss – 11,000 orphans, schools shuttered, crops unsown or harvests unharvested, businesses bankrupted, national economic growth about-faced. And over 9600 people who are no longer people.

Let’s not be too hard on the proverb. Let’s be hard on ourselves. In the deeply politicized world of international aid and emergency response, the availability of the proverbial ounce of prevention turns out to be part mirage, hence a solid track record of paying for pounds of cure. This study of the 2011 famine in Somalia seems clear enough: Famine early warning systems clearly identified the risk of famine in South Central Somalia in 2010–2011 but timely action to prevent the onset of famine was not taken.

It too often proves more difficult from a political perspective to prevent a problem from arising than to deal later with the consequences of the problem itself. That is because mobilizing preventative action often proves trickier than launching a curative response. Humans seem hardwired to contend with the urgent at the expense of the important. In proverbial terms, that is also because frogs don’t hop out of water brought slowly to boil. And because screeching wheels get the grease before those that merely squeak. Tired yet? How about this? In the aid world, few will pay the early bird to catch the worm.

Enough of the proverbs. Let’s try fairytales. Is it even fair to balance a pound of cure against one sole ounce of prevention? What does the story of the Boy who cried “Wolf!” tell us? If not a boy, then what about the Western NGO? We belong to a business that depends on the production of a veritable smorgasbord of impending disasters; of persistent, strident calls for action (read: squeaky wheels in search of grease). That makes for a fast drip of public alarm, elbow-steered lobbying, and celebrity-endorsed impending doom. Act now! (Or: Send cash!). How many cures – how many actual crises – have actually been averted? Perhaps this is not just a tale of a Boy. Perhaps this is also the work of Chicken Little.

If we flip this around: the emergency aid business is of necessity an industry of alarm. Is there today a cacophony of alarm and media hype that deadens the ear? Have we reached the point where it is actually more efficient and more financially prudent for key donor governments and international institutions to wait and pay for the cure?

And what about the lessons of those fairytales? Cries of “Wolf!” or “The sky is falling” became quite pertinent in the Ebola crisis, where MSF’s early alarm was derided or dismissed in some quarters as yet another NGO fundraising ploy. The NGO cried out that Ebola was real and nobody listened. Real it was. A ton of cure that could have been averted by an ounce of prevention? Seems so. And maybe also a ton of cure that was necessitated by the perception of too many false ounces?


The Hammers and Nails of Ebola

“MSF made a big mistake.” Not a small admission from Claudia Evers, MSF’s Emergency Coordinator in Guinea. Think how much more effective international aid might be if more aid organizations publicized rather than buried such opinion. But that is another blog.

The issue is basic. In its early stages and as the Ebola outbreak mounted, MSF placed almost all its apples in the treatment basket. Fueled by the twinning of high transmission levels and the sloth-paced scaling up of treatment (MSF aside), the virus far outpaced the intervention. Evers concludes: “Instead of asking for more beds we should have been asking for more sensitization activities.”

But did MSF make a mistake? Or is this more of a design flaw in the system? Treatment is what MSF does. Treatment is what MSF is designed to do. When it comes to outbreaks like cholera, or diseases like malaria, or even ‘epidemics’ in some places like maternal mortality, MSF is a hammer of treatment. Nobody, and not even MSF, should be surprised that it sees a world of nails – people who first and foremost need treatment.

To simplify: A good buddy of mine is a cardiologist. His brother is a cardiac surgeon. They disagree bitterly on how best to deal with their aging mother’s heart problems. The former wants to manage it through drugs, diet and exercise. The latter wants to cut. The lesson is that identity determines perception.

So the problem was not MSF calling for a massive, rapid increase in beds and treatment capacity. The problem was that MSF the hammer’s voice stood virtually alone. The problem, in other words, was the absence of other tools in the kit. Where were the wrenches, NGOs that specialize in grassroots mobilization, and who would have seen its potential and pressed for it? Where were the screwdrivers who would have championed decentralized models of care? Where was the diversity of discourse?

Even as sensitization activities scaled up, local communities seem to have been viewed more as targets than as actors. One concern is that the authorities (foreign and international) installed centralized structures for the dissemination of information, rather than capitalizing on local capacities. Another claim is that messages were too simplistic: being told what not to do with a sick child does not provide an actionable solution for a mother with no access to a treatment center. What should she do?

It seems there is an emerging consensus that local communities in Sierra Leone, Liberia and Guinea were sidelined in the rush to contain Ebola, treated more as an obstacle due to their distrust and ‘primitive’ behavior (see, e.g., here). Treated then as a vector for the disease, to be contained rather than sought out as a potential partner in defeating it; not understood to be necessary to generating solutions and disseminating the word. In the end, it seems providential that they did not remain contained, and many communities took the fight against transmission into their own hands (see, e.g., here).

To recap: the Ebola outbreak response reduced communities to a combination of victim, vector, and potential security threat. Otherwise, the aid response and media coverage of it rendered these communities invisible. That invisibility comes because the entire international community – the Western governmental and NGO aid response – is deeply, messianically self-referential. That is the hammer of being a savior, and it blinds us to anything but the nail of victimhood; to the reality that many people, given the shortcomings of international aid, need to know how to save themselves. That is the hammer of being largely Western/foreign, and seeing the nail of disarray, primitivity and ignorance.

One step further: consider this piece from Oxfam CEO Mark Goldring on his recent encounters in Liberia and Sierra Leone. In a few simple paragraphs he conveys the “suffering, bravery and stoicism” of the people. Yet such narratives always fall short. Be it Syrian refugees or civilians in Central African republic or the survivors of Ebola, the sheer scale of grief, social/livelihood devastation and grinding anxiety over life itself evade our comprehension.

For all our efforts, this tremendous suffering remains beyond our ability to fathom with clarity. And it lies beyond our ability to mend. As humanitarian organizations, we find it much easier to be the hammer of crisis response, seeing the nail as the problem called hunger or shelterlessness or, in this case, outbreak. As important as it is to contain and defeat this outbreak, I wonder if we are preconditioned to see the virus, sick people to be mended, and not the millions of people who need something altogether different than the hammers of Western pity, charity, or aid.

When the Pendulum Swings

Be careful what you wish for. That is what I would tell Thomas Frieden, if ever I had an opportunity to talk to the distinguished director of the US Government’s Centers for Disease Control (CDC). While the failures which led to the Ebola epidemic must be addressed and most certainly require difficult changes, we should avoid launching the pendulum too far in the opposite direction. Over-correction can be just as dangerous as doing nothing. (Perhaps even worse if, in the long run, failed change undermines the very case for change itself.).

Speaking as the executive board of the World Health Organization voted to overhaul the organization, here is what Frieden said: “Too many times the technical is overruled by the political in W.H.O. We have to reverse that.” His comments follow the generally accepted observation that the bungled response to the outbreak was in part due to the poor quality of WHO staff in West Africa. Political appointees rather than officials with proper qualifications.

I’ll start with the obvious: Frieden appears to be right. But there is a mistaken underlying assumption – that health, disease, pandemic response constitute primarily technical challenges. This overlooks the degree to which these issues are profoundly political. So: true enough that political savvy can neither replace nor overcome a deficit of technical understanding. Even worse, what of situations where the so-called political appointees lack political savvy, meaning where they are appointed for reasons of political loyalty and ties rather than political acumen? That’s a lose – lose situation.

But Frieden’s comment ignores the opposite risk. All the technical savvy in the world may amount to very little when it hits the political wall. Better qualified WHO appointees in West Africa may have recognized much earlier the threat posed by rising Ebola cases, and may have been less concerned with offending local political sensitivities, but there would have been plenty more hurdles to cross, some of them sadly and resolutely political. Remember, before they felt the threat themselves, the greatest powers in the world chose not to respond to Ebola in this strategic backwater of a region.

My instinct tells me that Frieden comprehends this quite well, and he may be one of those rare individuals who blends technical qualifications with a significant level of political interest and ability. That is not a common combination. A case in point: the bi-annual meetings of the Executive Directors of the various MSF sections. For the six years I was ED, there was never a time when more than one of the nineteen EDs was a doctor (though we often had a number of ex-lawyers), or more than one of the operational directors, and very few of the heads of mission. Throughout the executive level of MSF, from project coordinator to director, one finds few medically qualified personnel sitting in the hierarchy of decision-makers.

This is not the place for an analysis. Suffice it to say that (1) from security management to human resource management to negotiated access, running effective emergency medical missions in places like Sudan or Haiti requires more than medical know-how and expertise; and (2) the organization has built substantial in-house medical expertise across the spectrum of its areas of intervention.  But the problem highlighted by Frieden’s quote is easier to describe than solve. In terms of the political and the technical, integrating those two bodies of knowledge, experience and focus posed a consistent challenge within MSF, and we struggled with various policies aimed at improving organizational structure and culture.

The Executive Board of WHO proposes what we sometimes termed “remedicalization” in MSF. The goal is clear: ensuring that Frieden’s “technical” sufficiently nourishes WHO analysis, decision and action. Sticking technical people into what are often politically charged jobs, though, may simply create the next crisis, the one where the pendulum has swung too far.

5 Shots on Ebola

1. Return of the Jedi

Oh no. Just when there was some good news – falling rates of new Ebola cases in Liberia – the Ghost of Aid Mistakes Past has returned to haunt us. Bob Geldof will launch another Band Aid rendition of “Do They Know its Christmas” (One Direction I can understand, but Elbow? – say it ain’t so).

Thankfully, the response is far from a collective sigh of relief. It is refreshing to see still more cracks in the wall of the West’s narrative on aid and Africa. As I discussed in a previous post, we can now hear the voices of “outsiders” (i.e., people who actually come from places like Liberia or Nigeria instead of people like me): challenging the bias in Ebola media coverage (reinforcing the industrial savior complex); lambasting a 60 Minutes piece that treated Liberians strictly as background props; or questioning the methods/intentions of Geldof and company.

Really, African stars should gather and launch a campaign “Do They Know its a Continent?”

That said, even this critique presumes that the 1984 version of Band Aid constituted some sort of historic success. Trashing Sir Bob for promoting an antiquated vision of Africans as helpless victims misses the tragedy of Ethiopia 1984. People were dying less from drought than from the government’s human rights violations (as concluded by Human Rights Watch). In that perverse environment, aid distributions propelled the forced relocation policies that were destroying whole communities, not to mention the more recent and controversial revelation that famine relief funds helped buy arms for rebel secessionists. (See here for David Rieff’s cogent view).

2. Useful Enemies

The outbreak of fear and hysteria in America is neither funny nor accidental. Amplified by the sheer power and influence of the US, the rest of the world should take note. Nobody is safe on the same planet as a drunken giant.

The USA’s partisan cockfighting means a disease such as Ebola cannot be tackled according to sane public policy. That is because for too many leaders, the usefulness of the virus outweighs its risk. In this case, Republicans have seized the opportunity to produce a state of froth, portraying Obama and the Democrats as soft on defense, with Ebola taking the place occupied only a few months ago by ISIS. Watch here as Roosevelt perfectly hit this nail on the head 80 years ago.

If there are ever significant numbers of Ebola cases in the US, this sort of panic, media hype and political dysfunction will have a good chance of driving the disease underground, shutting school systems, fomenting violence, etc. In other words, of causing the shit to hit the fan. That’s what I would call a frightening dry run for airborne avian flu. And in certain cases, that’s what makes American hysteria a risk factor for global outbreak and collateral economic damage.

3. Two-Thirds

Tuesday I took a break from my break and sat in on a roundtable discussion of the crisis. Twenty-five or so aid workers, government officials, academics from around London. Heaps of good analysis. Lots of experience and first hand knowledge of the situation in Liberia and Sierra Leone. And I’m not sure the entire group could have put together one solid paragraph on French-speaking Guinea. Whatever the bias – language, colonial heritage, aid policy – it marks a structural weakness in the international community.

4. Fear as Policy

Obama has sounded relatively reasonable on the Ebola front. Here’s the Prez hugging medical staff who caught Ebola, and he dispatched Samantha Power to West Africa, both important symbolic gestures which may help curb fears long enough for a little science to sink in.  Or may not. Obama may not like the paranoid response to Ebola, he may even worry that measures like quarantines really will prove to be as counter-productive as the experts say, leading to a greater likelihood of Ebola cases in America, but he can’t be too upset. America’s power, not to mention minor details like its economy and foreign policy, is constructed upon a swirling foundation of irrational fear, not of a virus but of a bewildering series of bogeymen, from Communists to Muslims to terrorism to China.  (For further analysis, see Chapter 8 of David Keen’s excellent Useful Enemies).

Having a budgetary spend greater than the next ten nations combined is not easy to justify through rational political discourse, all the more so in a country (for example) whose infant mortality rate looks more like it belongs to Guinea.  The much-discussed military-industrial complex, firmly rooted in a hysterical reaction to foreign threats, remains impervious to the reality that the security measures of today manufacture ever greater threats in the future. Ditto for the potential of quarantines to increase the likelihood of Ebola cases on American soil.

5. The Secret of Economic Success

Question: What do Las Vegas, personal injury lawsuits, Lady Gaga and Ebola-induced panic all have in common? Answer: Nobody can beat the US when it comes to a penchant for excess.

No wonder West Africa is so poor. Not enough capacity for going OTT. The citizens of Guinea, Sierra Leone and Liberia watched neighbors and family drop dead around them, and yet still didn’t believe Ebola was real. A veritable ostrich head in the sand – never a good model for economic development. With one death to date and 45% of Americans worried a family member will catch Ebola, the greatest nation on Earth more resembles a frantic chicken. That’s the sort of mania needed for a juggernaut economy.

Ebola: Three Ideas (continued)

Ebola 3. A Time To Point Fingers? Yes.

We can’t dawdle on this one”. That is Barack Obama on September 16, inaugurating a litany of Very Important People sounding clarion calls that the world must act to curtail the scourge of Ebola. David Cameron followed suit. Ban Ki Moon jumped up and down, calling for urgent action, also for nations to give lots of money to the UN and for Bono to organize some sort of Live Aid rerun. To date, the action of calling has greatly dwarfed the action of acting.

There is an undeniable truth to the urgent call for action. But having dawdled for so long – allowing this outbreak to infect and kill so many more people than should have been the case – there is a fundamental deceit in the call as well. In terms of preempting the exponential spread of this disease, the time to act passed four, five, maybe six months ago. Now we must talk of action – action on the ground in West Africa (not to be confused with airport screenings, conferences full of petits fours or throwing money at the problem) – and we must talk of accountability for its opposite.

Ellen Sirleaf Johnson in her recent letter to the world: It is time to stop talking and “send a message that we will not leave millions of West Africans to fend for themselves.” With all due respect, Madam President, that ship sailed. The nations of the world long ago decided that they would do exactly that. They decided to act only when it became a matter of self interest. And I note here that this self interest seems largely electoral, a question of curtailing political damage at home rather than a virus overseas.

Rather than save lives, the response of nations like the US or UK seems designed to save political ass. Through months of inaction, these governments are contributors to Ebola’s explosive spread. And yet they are the best the world has to offer right in terms of response.  We need their boots on ground.  The lone exception to self-interest seems to be Cuba, neither threatened by Ebola nor under pressure to respond, who has pledged hundreds of additional medical doctors on the ground.

Let me be very clear: the urgency of accountability exists because at the nation-state level this is not primarily a question of charity or even humanitarianism. This is not a question of choice or option. This is a question of human rights. This is a question of nations violating their obligation to provide international cooperation and assistance to Liberia, Sierra Leone and Guinea. See for example Physicians for Human Rights or Amnesty International. (Whose voices remain curiously muted. Where is a more strident defense of the human right to health? Where are creative R2P-inspired arguments that there is an international responsibility to protect citizens against a massive violation of their human rights when, as in West Africa, the states themselves are unable to do so?).

And then this is also a question of international security in the form of global outbreak response, which has been entrusted to the most powerful nations on Earth and the UN, who had the money, know-how and responsibility to act much earlier. Finally, there is the question of humanity. These nations, in pursuit of national interest and in a rather self-congratulatory fashion, do such a good job of talking the humanitarian talk; of talking the talk of caring and aiding and helping. But when it came to Ebola, they decided against doing the walk.

Another reason to act right now on accountability is to stop its perversion. We are in danger of accepting a simple story that the World Health Organization is to blame. Well, that is true. But there is a difference between blame for WHO shortcomings and exploiting the WHO as a scapegoat. For starters, there is the impact of WHO funding cuts by governments like Obama’s USA. Or even better, as Dr. Anne Sparrow writes in The Nation, world powers have ensured that the WHO has shifted emphasis to the diseases of the Western World. But more importantly, the WHO was only one of he firemen who sat and watched while this flame spread to a fire and then a blaze and then an outright conflagration.

Will heads roll in the governments of Guinea, Liberia and Sierra Leone? It is a simply wrong to believe that the “basketcase” state of their health systems were either natural or inevitable, like a typhoon. They should have been in a better position to deal with this outbreak. It is true that the scale of the outbreak today, or even back in July, would have swamped all but a well-developed nation. But we must assess matters earlier in time, when the basics of good case management and information flow could have prevented the outbreak from escaping control. What shocked me the most is that so many of their own citizens so distrusted these governments that Ebola was first seen as a ploy to attract and embezzle aid. The abundant health education message of EBOLA IS REAL makes me want to cry. How to stop an outbreak if that is where you begin?

And yet I heard Sirleaf Johnson blame the miserable state of her country’s healthcare system on a war that ended eleven years ago. Perhaps I missed her explanation of what happened to the considerable aid sent to Liberia to rebuild. Ditto for Sierra Leone or Guinea. As Human Rights Watch notes: Endemic corruption, including in health services, has long plagued the governments of all three countries and contributed to years of unrest and lack of development. It is in the first instance not the rich governments of the world who decided to leave millions of West Africans without adequate healthcare or basic outbreak response.

Governmental failure is a matter foremost for civil society. West African voices can already be heard. See, for example, this blog post, questioning poverty in the face of mineral riches and offering judgment on governance: It is not good enough for the Deputy Minister of Foreign Affairs of Sierra Leone Ebun Strasser – King to note that Ebola “took us by surprise and met us when we were ill prepared for it”. Or Abdul Tejan-Cole, speaking eloquently on seeing “civil society step up when government institutions have crumbled or not addressed the crisis”, not because of poverty but because of poor management.

Beyond governments, will heads roll in any aid NGO or agency aside from (presumably) WHO? What of those agencies who have spent years claiming to develop health capacity in West Africa? What of those who have raised money by declaring themselves leaders in global humanitarian emergency health? Where are their beds and nurses and doctors? And where were they when the epidemic could have been controlled? The WHO was silent and even downplayed the gravity of the situation. Did they own the only working phone in West Africa? Aside from MSF, where were the alarm bells from other agencies with health teams already on the ground? Are board members going to resign in disgust? Or is everybody too busy ramping up activities to respond to Ebola the cash cow in addition to Ebola the virus?

There are those who argue that now is the time for action, not recrimination. That is the pragmatic voice of the aid establishment. And that is sweet music for those responsible, who do not in any way fear the hand wringing and promises to do better in the future which have long served to excuse failure and defuse calls for change. To delay accountability now is to reinforce this entrenched pattern of inertia tomorrow.

As did the global political elite know and ignore brewing famine in south central Somalia a few years ago, as did they know and ignore the mounting crisis in Syria, so did they know and ignore the burgeoning Ebola crisis in Guinea, Liberia and Sierra Leone. This is the new world order, in which the most powerful are either unwilling to meet their international obligations, or incapable of doing what is right and what is human until direct self-interest and fear muster the political capacity to act.

Ebola: Three Ideas (continued)

[Originally posted October 2 and lost due to website issues. Apologies to those whose comments have been lost as well.]

Part 2. Ill-suited for outbreak response

And now, for something completely unoriginal: fear of Ebola is doing as much damage as the virus, maybe more. Yes, you knew that. Many have called fear a primary driver, a vector not just of the epidemic but of “collateral” deaths as well. Vox populi across Guinea, Sierra Leone and Liberia confirm a frightening view of humanitarian aid – hospitals are seen as a mixture of deathtrap and house of horrors, the people trained to treat the disease as transmitters or killers. As Jeffrey Stern concludes in his excellent Vanity Fair article, the outbreak would have been contained early on, but people took Ebola underground due to fear and distrust; it later emerged a multi-headed Hydra.

I remember similar issues arising in 2005, when a major outbreak of Marburg haemorrhagic fever had Angolans in the town of Uige running away from – you guessed it – space-suited health workers and afraid to enter hospitals. There too, insensitive burial of the dead sparked anger (so MSF began involving family members in a safe way, allowing them to see the corpses of their loved ones for themselves, stifling wild rumors).

Fast forward to frequent stories of healthcare teams being attacked (e.g., eight Guinea village health workers hacked to death only last week, month nine of the outbreak) that signal an almost primordial reaction. And there should be no comfort in believing such fear only happens in oogabooga land; that these West Africans are depraved, brutal, and primitive. Spielberg, no stranger to scaring us, had space-suited agents invade Elliot’s house to capture ET. Why? Because they breathe like Darth Vader, walk like Frankenstein, and frighten the bejesus out of us (check out the clip). Recall also the hysteria and even violence surrounding HIV/AIDS in the US. Or current scares for Ebola zombies. Or the fact that the discovery of one Ebola patient in the USA wiped billions of $$$ off the value of airline and travel stocks.

From an intellectual perspective, the nature of Ebola has a lot to do with the fear. It’s an exceptional combination of fatal and gruesome. More viscerally, though, the terror of Ebola is epitomized by the protection-suited doctor or nurse. Part hazmat worker, part astronaut, part faceless invader. They walk like robots. Part alien, part monster, part inhuman.


Thus far, the suits seem an unavoidable measure to protect healthcare workers, although some claim such measures are both costly and counterproductive (see here or here). Even if proven that the suits are necessary, we must recognize and combat their perverse impact in driving epidemically dangerous behavior. Hiding from assistance, spreading the disease to family, neighbors. Or maybe the family throws stones to chase away health workers. A fear so strong it permits murder.

But if the suits are necessary, and if they engender such fear, the next question is one I do not see debated: Should treatment and the use of protective suits have commenced so swiftly? Does rapid mobilization cost more lives than it saves in certain outbreak situations? Are there times when the outbreak response – almost universally a model calling for speed in gearing up treatment/vaccination– needs to slow down, at least in terms of the HazMat invasion, to allow populations to be prepared?

Stern: The foreigners [treatment and sensitization teams] had come so fast that they had actually out-run their own messaging. After the Marburg outbreak in Angola, there was even talk of getting the outreach workers and psycho-social experts onto the ground in the first plane, in addition to prioritizing the deployment of infectious disease specialists (see here for old but insightful MSF lessons learned).

Beyond big picture questions, what about the small-focus, right at the point where doctor meets patient? Or, more accurately, where they don’t meet. Those protective suits do more than spread fear and distrust. They are transformational, diminishing treatment to its therapeutic minimum, leaving doctors dehumanized and detached from the people they are attempting to heal.

Here’s MSF’s Dr. Gabriel Fitzpatrick on not being able to comfort a sick, solitary child: The child was clinging on to the nurse, searching and hoping for comfort in a place which does not allow direct skin-to-skin contact. As a father myself, this image stuck in my mind. Heart wrenching. Here’s Dr. Douglas Lyon: In my spacesuit, I won’t be able to connect and provide reassurance with a smile, body language or a concerned look.

On the flip side, patients remain gravely ill, isolated and terrified. Imagine not knowing what your doctor or nurse looks like. There is a need to insert some human into humanitarian, to enhance the human touch. Design changes in treatment centres are a good step, like using a double line of fences to create a safe distance for viewing and talking. Here’s an idea from Dr. Leslie Snider: How about a book or a doll to show children (adults too!) the person underneath a HazMat suit?

Here’s another idea: What if somebody made transparent protection suits? Until that time, though, what about attaching a big photo of the doctor or nurse to the front of the suit? In other words, pasting a smiling human over the alien invader; allowing the Ebola patient to look his or her doctor in the face.Put a name on it (Dr. Marc!). (How about a flip book with several photos in it? – reassuring, sympathetic, happy, sad, sweaty mess, hugging a cured patient...). One small step towards treatment based on a more human doctor to patient contact. One medium step away from zombie therapeutics.

Ebola: Three Ideas You (hopefully) Haven’t Read

[Originally posted September 26 and lost due to website issues. Apologies to those whose comments have been lost as well.]

Part 1. The Ebola crisis is in part the self-fulfilling prophesy of the way we think about Africa.

The Ebola crisis in Liberia, Sierra Leone and Guinea consumes no shortage of attention in mainstream Western media. Other African crises like CAR, Libya or Sudan, let alone success stories, should be so lucky. Then again, maybe attention isn’t such a good thing after all. Some of it quite responsible, much of it still trades in outworn stereotypes of a continent awash in warlords, loin cloths and killer microbes.

Hooray for resistance to sloppy Ebola storytelling, for example Dionne and Seay’s nailing Newsweek‘s sensationalist cover story. Or earlier this week Sierra Leonean Ishmael Beah skewering the way lopsided Ebola reporting reinforces the role of Africa as a foil, as a continent whose dismal failure reaffirms our superior Western civilization.

But why dump all the blame on the media? NGOs and the UN – the foreign aid establishment – surely merit some credit for perpetuating the popular notion that Africa is a cauldron of tribal brutality, a crucible of scary diseases and a reservoir of primitivism, all rolled into one waiting-for-a-savior basket. (Not to mention the rather stock idea that Africa is a country. On that geographical malapropism, see this great blog.). The point is firstly one of principle: NGOs should be truthful in their communications. Easier said than done. They appear locked into an audience (the home society public) that demands such a stereotype in order to feel compelled to donate (see e.g., my previous blog on this).

We’ve heard criticism of this stereotyping before, often from within the aid and Western media communities. Is there hope? Importantly, Beah published in the Washington Post, bringing his views to Western eyes. If only for a moment, his piece shakes our monopoly over the narrative. As I’ve written before, these stereotypes will come under increasing pressure as internet media expand access to Western debate and discussion. The question: Is the aid industry simply (!) a promoter of the distortion, or an addict as well? But that is for another blog.

The main point here is that the degree to which the monotonous, stereotyped portrayal of Africa gives rise to the conditions in which Ebola outbreaks occur. Persistent underdevelopment, bureaucratic inertia, low foreign investment, unresponsive government, the cycle of waiting for crisis rather than building systems, dependence on the foreign aid community, etc. These ills are all either caused and/or reinforced by the inaccurate portrait of a continent, in this latest episode with a virus as the star in a long line of unabated indigenous catastrophes. NGO action may be vital in combating Ebola, but aid agencies themselves helped weave the very “basketcase” to which they would nowadays respond.