Ebola Exceptionalism?: Situating Epidemic Ebola in 2014
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Paper presented at the Annual Meeting of the Association of American Geographers in Chicago, IL - 22 April 2015. Contact: mmw36@uw.edu
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Ebola Exceptionalism?: Situating Epidemic Ebola in 2014
- 1. Ebola Exceptionalism? Situating epidemic Ebola within 21st century global health Maggie Wilson University of Washington Department of Geography
- 2. Overview • Emergent global health: A brief history • Emerging infectious diseases as 21st century security concerns • Placing Ebola within global health • Exceptional Ebola in 2014?
- 3. Global health and the era of MDGs • The Millennium Development Goals: global agenda-setting for the first fifteen years of the new millennium • 2002: Global Fund to Fight AIDS, TB, and Malaria • 2003: PEPFAR • 2008: Consortium of Universities for Global Health • Crane (2013): Academic global health and HIV treatment MDG 4: Reduce child mortality MDG 5: Improve maternal health MDG 6: Combat HIV/AIDS, malaria, and other diseases
- 4. Development Assistance For Health, By Channel Of Assistance, 1990–2013. Joseph L. Dieleman et al. Health Aff doi:10.1377/hlthaff.2013.1432 ©2014 by Project HOPE - The People-to-People Health Foundation, Inc.
- 5. Global health as biopolitics • Fassin (2007): humanitarianism as biopolitics and a “politics of life” • Management of life-at-risk, and saving of lives-at-risk; “making a selection of which existences it is possible or legitimate to save” • Qualification for targeted interventions determines which lives will be saved/protected • Nguyen (2009): African HIV treatment programs as “therapeutic domination” • American and European NGOs/universities/hospitals with powers of life and death over HIV+ Africans • Hinges on the framing of the HIV epidemic as a humanitarian emergency
- 6. Emerging infectious disease in the 21st century • 2003: global outbreak of SARS, a novel coronavirus • Cooper (2008): the “biological turn” in the war on terror; drafting of International Health Regulations • 2004-2007: outbreaks of highly pathogenic avian influenza (H5N1) • Lakoff (2008): flu preparedness as “vital systems security” • 2009: H1N1 influenza pandemic • 2013: identification of MERS coronavirus
- 7. 21st century global health …as development • Concerned with places of poverty • Targeted (often disease-specific) interventions • Vulnerabilities of poverty …as biosecurity • Concerns about globalization and interconnection • Systems of reporting, surveillance, and preparedness • Vulnerabilities of modernity and mobility (C.f. Lakoff 2010)
- 8. …but what about PHC and health systems? • 1978: Declaration of Alma Ata and the universal primary health care movement – “Health for All by 2000” • Never realized: replaced in the 1980s with child-survival and other more targeted programs • PHC and health systems not part of the core global health agenda in the MDG era
- 9. Major 21st Century Outbreaks of Ebola Virus Disease Year Location Cases Deaths 2001 Uganda 425 224 2002 Gabon Rep. of Congo 65 57 53 43 2003 Rep. of Congo (x2) 143 35 128 29 2004 Sudan 17 7 2007 DRC 264 187 2008 Uganda 149 37 2009 DRC 32 15 2012 Uganda DRC 11 36 4 13 2013 Uganda 6 3 2014 DRC 66 49 ongoing Guinea, Sierra Leone, and Liberia 25,826 10,704 Source: Ebola Situation Report – 15 April 2015, WHO
- 11. Why was 2014 different? • MSF (March 30, 2014): Geographic spread unlike any previous outbreak • Many simultaneous small, rural outbreaks, plus spread to major cities • Undetected for several months after the index case in Dec. 2013 • Ungoverned, porous borders in the tripoint zone • Weak public health systems • Lack of HIV/polio infrastructure?
- 12. Reactions • The UN Mission for Ebola Emergency Response (UNMEER): First UN emergency health mission • WHO declares “public health emergency of international concern” (August 2014) • Product of the International Health Regulations created in response to SARS • Previous: 2009 (pandemic H1N1 influenza), 2014 (resurgence of wild poliovirus)
- 13. Dr. Margaret Chan (Director, WHO) address to UN Security council, 18 Sept. 2014 “WHO has successfully managed many big outbreaks in recent years. But this Ebola event is different. Very different. This is likely the greatest peacetime challenge that the United Nations and its agencies have ever faced.”
- 14. Christine Lagarde (Director, IMF) remarks at World Bank event, 9 October 2014 “It is good to increase the deficit when it’s a matter of curing the people, of taking precautions to actually try to contain the disease. The IMF doesn’t say that very often.”
- 15. Ebola and the IMF • Lancet (2015): the IMF should recognize its role in the conditions that made the epidemic possible • Guinea, Liberia, and Sierra Leone receive conditional support from the IMF • IMF conditions for financial support have involved cutting government spending (weakening social services and health systems), wage caps for public sector employees (leading to a healthcare worker shortage in public facilities), decentralization of public health.
- 16. Humanitarian governance of Ebola • Medicins sans Frontières (and other humanitarian organizations) as first responders • Experience containing previous outbreaks; early recognition that the outbreak in Guinea exceeded their capacity • “We have been calling for help since March.” • WHO’s inadequate response – failure by design? • Systematic underfunding and limitations on the capacity of the WHO • Insufficiency of current decentralized approaches to global health for this type of crisis
- 17. Alternatives: Return to PHC? • Rebuilding health systems in Guinea, Liberia, and Sierra Leone • Health systems strengthening as a trend in large-scale global health initiatives • WHO call for a return to the principles of Alma Ata (2008)
Editor's Notes
- Work-in-progress talk: situating questions rather than coming to conclusions I want to talk about is the context of the epidemic of EVD in West Africa within the dominant discourses and approaches to global health. The unique characteristics of this epidemic have inspired an enormous amount of fear and concern worldwide, and discourses about Ebola often emphasize superlatives: it has been by far the largest, most deadly, and most geographically widespread outbreak of the disease in recorded history. But other ways of thinking about the epidemic challenge its characterizations as an exceptional event. Instead, the epidemic can highlight inequalities, gaps, and problems in the systems and structures of global health that produced the conditions that made epidemic Ebola possible.
- --Overview of the dominant paradigms and priorities that have shaped the way we understand global health over the past 15 years—framings of global health in terms of development and in terms of security, how different from PHC etc. The ongoing Ebola epidemic has unfolded within this landscape of global health governance, financing, and obligation. So situating Ebola within the world of global can tell us something about both of them.
- --the past 15 years have been transformative for what we call “global health” --MDGs were crucial—v. influential in priority-setting --three health-related --[skip to the scale-up] --using the language/tools of development (legacy of the 1992(?) WB report on health-wealth) --focus on “headline” diseases/problems and siloing --the global health scale-up --emergence of global health as a discourse, as a “set of problems” (Farmer et al.), and an academic discipline: creation of university global health departments and institutes
- Development Assistance For Health, By Channel Of Assistance, 1990–2013 --2000-2010: the global health scale-up. Driven largely by HIV interventions: PEPFAR, Global Fund. Also PPPs (like Gavi) **over 40% to AIDS, TB, and malaria --Maternal/neonatal/child health also a large %age --MDG-focused programs: almost 70% of DAH
- --Biopolitics in addition to geopolitics of (this part of) global health --biopolitics: of management of life-at-risk at the population level; politics of life thru saving lives, “making a selection of which existences it is possible or legitimate to save” --Nguyen: treatment regimes led by NGOs/universities/hospitals with powers of life and death --Biopolitical regimes dominated by a decentralized, increasingly privatized aid and development industry
- Concurrent with the emergence of global health as we know it: renewed securitization of infectious disease (and especially of emerging infectious disease) Punctuated by global disease emergence events --Cooper: the “biological turn” in the war on terror --Lakoff: systems v. populations, preparedness v. prevention Creation of formal US preparedness plan in 2005 for avian flu
- --Lakoff’s “regimes of global health” --Both of these central to discourses about epidemic Ebola
- Neither attempts to answer the call for “health for all” Another less visible approach to global health – largely incompatible with the other two
- Also concurrent with the GH scale-up: another global-health related history --During the same period as the GH scale-up, the biological “turn” in the war on terror – regular Ebola outbreaks in Central Africa --Largely managed by medical humanitarian orgs (esp. MSF) --None more than a few hundred cases, none lasted longer than 3 months --Current epidemic: month 17 since the index case in Dec. 2013 --No clear end in sight: very low caseloads in Liberia and Sierra Leone, but no such decline in Guinea The numbers certainly indicate that in 2014, something went very wrong. --The epidemic has revealed much we don’t know about EVD, but one thing that is quite well known is how to contain outbreaks of the disease.
- After the very first documented outbreak in 1976, WHO report stated that protective equipment, isolating patients, and safe disposal of contaminated material would “almost certainly…” Other outbreaks have been contained not with high-tech tools, diagnostics, drugs, or vaccines, but through basic public health and preventive strategies—exactly what the health systems in the high-transmission countries were not capable of providing.
- Many factors—difficult to fully explain Failures of prediction: WHO/CDC’s early claims of victory; ProMED Mail post in early April praising Sierra Leone’s preparation before the first cases there Nigeria: contact-tracing systems for polio eradication programs
- Delay in global response, but since summer 2014, it has been framed unequivocally as a humanitarian emergency, an exceptional event that calls for extraordinary measures.
- With a bit of French understatement, Christine Lagarde highlighted the highly unusual position of the IMF: advocating for deficit spending
- What Lagarde doesn’t address, however, is the IMF’s longer-term entanglement with the epidemic. Lancet editorial….
- The Ebola epidemic has also highlighted structural shortcomings of existing systems of global public health. In particular, the months-long delay before a global, centrally organized response likely contributed to the length and severity of the epidemic. The MOHs in the high-transmission countries lacked the resources to effectively control the spread of the virus on their own. MSF asked to lead response before formation of centralized UN response, but they recognized early on that the response that medical humanitarian organizations would be unable to contain the outbreak. By early September, MSF made a public plea for military intervention to contain the crisis—not something that they say very often at all, either. The WHO has received heavy criticism for its failure to quickly and adequately respond to the epidemic, but in part this can be attributed to systematic underfunding, and intentional limitations on its authority. All of this would seem to indicate that for this particular type of crisis, the current decentralized model of global health is simply insufficient.