The Politics of Fear The Politics of Fear Médecins Sans Frontières and the West African Ebola Epidemic EDITED BY MICHIEL HOFMAN and SOKHIENG AU 1 1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2017 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging- in- Publication Data Names: Hofman, Michiel, editor. | Au, Sokhieng, editor. Title: The politics of fear : Médecins Sans Frontières and the West African Ebola epidemic / edited by Michiel Hofman and Sokhieng Au. Description: Oxford : Oxford University Press, [2016] | Includes bibliographical references and index. Identifiers: LCCN 2016027983 (print) | LCCN 2016042202 (ebook) | ISBN 9780190624477 (hardcover : alk. paper) | ISBN 9780190624484 (ebook) | ISBN 9780190624491 (ebook) Subjects: LCSH: Ebola virus disease—Africa, West. | Ebola virus disease—Social aspects—Africa, West. | Ebola virus disease—Political aspects—Africa, West. | Epidemics—Social aspects—Africa, West. | Epidemics—Political aspects—Africa, West. | Médecins Sans frontières (Association) | Africa, West—Social conditions. Classification: LCC RC140.5 .P65 2016 (print) | LCC RC140.5 (ebook) | DDC 362.196/92—dc23 LC record available at https://lccn.loc.gov/2016027983 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material. 1 3 5 7 9 8 6 4 2 Printed by Sheridan Books, Inc., United States of America CONTENTS Preface vii Christopher Stokes Contributors xi Introduction xv Michiel Hofman and Sokhieng Au THE RESPONSE 1. Doctors Against Borders: Médecins Sans Frontières and Global Health Security 3 João Nunes 2. Whose Security? Militarization and Securitization During West Africa’s Ebola Outbreak 25 Adia Benton Vignette 1. A Few Days in July Lindis Hurum THE SYSTEM 3. The “Humanitarian” Response to the Ebola Epidemic in Guinea: Between Routines and Exceptions 63 Jean- Francois Caremel, Sylvain Landry B. Faye, and Ramatou Ouedraogo v vi Contents 4. The Initial International Aid Response in Sierra Leone: A Viewpoint from the Field 85 Thomas Kratz 5. Dying of the Mundane in the Time of Ebola: The Effect of the Epidemic on Health and Disease in West Africa 101 Mit Philips Vignette 2. Treating, Suffering, and Surviving Ebola: The Story of Prince as told to Patricia Carrick Prince Lahai and Patricia Carrick PATIENTS 6. How Did Médecins Sans Frontières Negotiate Clinical Trials of Unproven Treatments During the 2014– 2015 Ebola Epidemic? 133 Annette Rid and Annick Antierens 7. Failing Dr. Khan 175 Tim O’Dempsey 8. Finding an Answer to Ebola’s Greatest Challenge 187 Armand Sprecher Vignette 3. Children in the Ebola Treatment Centers Allie Tua Lappia and Patricia Carrick CONTAINMENT 9. Fear and Containment: Contact Follow- up Perceptions and Social Effects in Senegal and Guinea 209 Alice Desclaux, Moustapha Diop, and Stéphane Doyon 10. Challenges of Instituting Effective Medevac Policies 235 Duncan McLean Vignette 4. Returning to the “Ebola World” Maud Santantonio Index 259 PREFACE With the clarity of hindsight, the word “unprecedented” is now firmly associated with the West African Ebola epidemic of 2014 and 2015. The figures speak for themselves: 25,213 cases were confirmed in the first year of the outbreak and 10,460 patients died. Health professionals deployed by MSF were not immune to the disease either: in the same period, 28 MSF staff were diagnosed with Ebola and 14 of them died. However, these cold figures do not show the tremen- dous impact this epidemic had, not only on those directly infected by the virus, but also on the societies through which the disease spread and on those who responded to the crisis. The world, including MSF, was slow to respond. All of us, without exception, underestimated how rapidly and how far the virus would spread. We also underestimated the scale of the efforts that would be needed to assist those affected and to control the epidemic. Prior to the West African outbreak, Ebola was a relatively rare disease that had limited local impact and that burned out fairly quickly. MSF, as one of the few agencies with direct experience responding to Ebola outbreaks in the past, had built up a level of expertise. As a result, from the first days of the epidemic, MSF found itself at the center of the response in West Africa. Nothing, however, had prepared MSF for what happened next in Guinea, Sierra Leone, and Liberia. The disease not only spread over a wide geographic region, but also, for the first time ever recorded, reached densely populated areas such as Monrovia and Conakry. MSF was severely challenged in recognizing the scale of this epidemic, and subsequently in scaling up the medical and human resources necessary to respond. The impact was profound. Not only did this epidemic push the medi- cal and logistical infrastructure of MSF to the limit, driving personnel at all levels to exhaustion, but it also severely strained MSF’s own ethical values, forcing staff into making daily decisions between poor, bad, and even worse options while lives were at stake. vii viii Preface Under these circumstances the usual cost/ benefit evaluations are worse than inadequate. This epidemic tested the political resolve and operational choices both inside and outside of MSF. It has left a legacy of lessons to be learned in terms of much- needed technical improvements but also forces us all to recon- sider how the world at large deals with transnational health emergencies. A per- vasive factor influencing the decisions made during this crisis was fear. To examine this theme, MSF has sponsored this book and made the unprecedented step of allowing the authors full access to the internal archives of MSF’s Ebola response in 2014 and 2015. The majority of the authors are external to MSF, providing a unique insight into the processes of fear that informed many of the decisions made by the politicians and the responders such as MSF. Not all aspects of the outbreak are covered in the 10 chapters. The authors made their own choices regarding which aspects they wanted to highlight, and most of the chapters will elaborate on the wider response, going beyond the spe- cific role played by MSF. This can give the impression that fear affected only others, while the fearless MSF “heroes” ventured into the epidemic with iron resolve. Nothing could be further from the truth; fear “infected” and partially paralyzed MSF as well. Not only did MSF fail to realize that the epidemic was unprecedented even as it was spreading across multiple, frequently heavily pop- ulated locations, but MSF had difficulty scaling up its response once the disease was recognized as being out of control. As described powerfully in the eyewit- ness account by Lindis Hurum, the moment the first health staffer from a part- ner organization in Monrovia was infected with the Ebola virus, MSF itself was on the verge of deciding the risk was too great and pulling out. On a more institutional level, some of the MSF resources were also paralyzed by fear. MSF is organized as an international conglomeration of five semiauton- omous “operational centers,” each with its own medical, logistical, and human resource capacity to respond to emergencies. As the majority of the Ebola experts were located in the Brussels operational center, the coordination for the response was allocated there. It quickly became apparent, however, that the scale of the epidemic required resources from the other centers as well, but this was slow in coming. Fear was a clear internal factor in this delayed response: fear of staff contamination, fear of lack of expertise, and fear of lack of resources. Finally, the fear of being literally as well as figuratively overwhelmed by the epidemic when it was at its peak in the summer of 2014 pushed MSF to take yet another unprecedented step: to make the first call in the history of MSF for a military intervention in an epidemic response.