Ebola Exceptionalism?

Situating epidemic Ebola within 21st century global health

Maggie Wilson

University of Washington

Department of Geography

Overview• Emergent global health: A brief history

• Emerging infectious diseases as 21st century security concerns

• Placing Ebola within global health

• Exceptional Ebola in 2014?

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

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.

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

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

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)

…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

Major 21st Century Outbreaks of Ebola Virus DiseaseYear Location Cases Deaths

2001 Uganda 425 224

2002 GabonRep. of Congo

6557

5343

2003 Rep. of Congo (x2) 14335

12829

2004 Sudan 17 7

2007 DRC 264 187

2008 Uganda 149 37

2009 DRC 32 15

2012 UgandaDRC

1136

413

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

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?

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)

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.”

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.”

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.

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

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)