American Global Health Internationalism and the Ebola Crisis in West Africa

The Ebola outbreak of 2014–2015 was a sub-regional epidemic that was a real threat to residents of Liberia, Sierra Leone, and Guinea. But through a series of events it was magnified into a global security concern. The disease was even characterized as an existential threat to the world’s lone superpower. Despite interest that often-resembled panic, the US had only two active infections during the crisis period. In contrast, the death toll in West Africa was significant—11,300 (Sarukhan, 2016). With that being said the number of casualties was less than that caused by the civil wars that occurred in the region in the 1990s or the impact of other infectious diseases that affected the area during the same period. Despite declarations of dual intent, the West had only one concern. To protect itself. This was securitization of infectious disease for reasons other than direct and immediate threat to the US. But are self-serving motives necessarily a bad thing in the design of US foreign policy? Further, if those motives align with those of the government in which aid is being applied, isn’t that positive impact? If the end result is foreign policy that is more inclusive of the needs of the recipient’s general population, then would that not be good for all parties?

A close reading of how and why this epidemic merited Western, specifically American, attention five years after the West African Ebola epidemic was halted, would have multiple angles through which an examination could be focused. I’ll look at one.  How does what would normally be an obscure event in the mind of the average American rise to the level of being a national concern/fear/obsession/crisis? The global response engineered by the World Health Organization (WHO) was driven by the needs of the West, America in particular. Even if the average American wasn’t aware that such a campaign should matter. WHOs guide to monitoring and evaluating communicable disease surveillance and response systems states the following:

The International Health Regulations (IHR) 2005 underscore the commitment to the goal of global security and request all Member States to establish and implement effective surveillance and response systems to detect and contain public health threats of national and international importance. (WHO, 2006, p. 1)

One must remember that Ebola occurred after SARS, MERS, and swine flu. All had touched the West previously. None with the same impact as the 1918 flu pandemic, but it could be argued that the West was preparing itself for the possibility of such in its handling of Ebola. Regardless of its stated intent. In fact, that argument is really the only one that makes sense. The Ebola epidemic occurred during a growth spurt of social media when any actor with an ability to catch the attention of an audience could transmit information and images globally in a manner that could sway public opinion and policy very quickly.

Global health internationalism was activated to tackle the issue with the aid of the WHO, and international NGOs based in the West. West Africa was considered a subregion with less geopolitical dangers of global relevance. This was absent in pandemics that had begun in the Middle East and China. West Africa was a perfect laboratory to test response to pandemic disease, particularly its threat to the West.

The international attention and understanding that infectious disease is a global problem led to much needed resources being injected into a subregion that would have lacked the means to quickly respond on its own. Foreign policy is driven by self-serving motives. The specific claims of the West in regard to this case, particularly the US, should be unpacked and critiqued.

The US had made ample investments in infectious disease research laboratories overseen by the Department of Defense rather than what would seem a more fitting home such as USAID or the CDC (Davies, 2008, p. 299). Infectious disease was a well-established national security priority in need of a major case study to test the research.

Civil Society as Security Actor

There’s value in understanding how America navigates its security issues. It is far from static. International security as a discipline in the US existed in a tug of war between the academic/bureaucrat and the practitioner/armed service member (Betts, 1997). The application of theory could be found in the use of arms or secondarily the prevention of their use. What was shared by both is that Western need must take precedence over the perceived wants of the developing world. Even if those wants were part of necessary state-building activity. With this in mind, little need be considered if not directly benefiting the West.

The traditional security sector during the Cold War period was one driven by armed conflict and protection, particularly of a united global elite from the consequences of violence (Sachs, 2010, p. vii). The threat of Mutually Assured Destruction (MAD) kept a balance in the global order with the elite being able to not only survive but thrive as long as the world continued to exist and the system protecting its assets remained untouched (Betts, 1997). The end of the Cold War shook that balance. MAD was off the table, but major conflict could be sparked without connection to the global superpowers. Russia, in this new period, was limited to maintaining a hold on its regional connections leaving the US as the only great power with global reach.

There arose counterweights to traditional security networks. The international development sector emerged after the Second World War. The Cold War that followed reached its conclusion in the early 1990s. The development sector began to insert itself into conversations on security with greater authority during this period. War was no longer perceived to be the singular threat to global calm—if calm was even a preference for the elite. Inequality, racism, sexism, public health, the environment, access to technology and the global economy were also issues that if neglected could result in instability in the view of those who championed the strengthening of civil society.

As much as the old guard attempted to push back, there was an irreversible opening of space through which it could be argued that peace and tranquility for the few alone was a threat to the global whole. In other words, if human need were not catered for on multiple levels there would be a very real threat to those who had full access to their needs. Income and other forms of inequality associated with it were as much a threat to democracy, a stated preference of governance by the West, as an armed insurgency led by religious fundamentalists would be (WEF, 2013, p. 10).

As infectious disease became less of a problem in the West, there emerged a global movement for access to healthcare as a human right and a necessary ingredient in democratic formation. The absence of which might be perceived a counter to progress on the goal, no different than the denial of the vote or access to new markets for products made by Western companies in the developing world. There was a need for multiple campaigns to address human need. One of the larger and more relevant to the West was prevention of the spread of infectious disease. That goal did not necessarily rely on strengthening of public health access in the developing world. Even if that were an objective of a limited segment of civil society it wouldn’t necessarily sway a world power, the US, that was among the few developed countries without universal healthcare provided to its citizens. The securitization of infectious disease was focused on containment and prevention of spread to the West.

Protect the West

In his remarks on the Ebola outbreak, US President Obama made the case for intervention in West Africa as he stated the following:

[…] if the outbreak is not stopped now, we could be looking at hundreds of thousands of people infected, with profound political and economic and security implications for all of us.  So, this is an epidemic that is not just a threat to regional security — it’s a potential threat to global security if these countries break down, if their economies break down, if people panic.  That has profound effects on all of us, even if we are not directly contracting the disease. (Obama, 2014)

The same year that Ebola was sweeping through Liberia, Sierra Leone, and Guinea; the most populous nation on the continent of Africa, Nigeria, was in its worse year of an insurgency in its northeast. Instability in the largest nation with the biggest GDP in Africa if left unchecked, had more of a possibility of destabilizing not only Nigeria, but also Cameroon, Chad, and Niger. These were prominent, populous neighboring states covering two subregions— with possibility for further spread of armed conflict beyond their borders. The IDP crisis alone in that region threatened the lives and life chances of close to three million people. This was many scores more lives than Ebola affected in the lower density population areas most impacted by the epidemic. With the Boko Haram case study revealing a much larger threat to security it would be hard to justify robust American intervention in Liberia for the reasons stated by then President Obama. Then if not that, what drove the American response?

The development of global health campaigns was not driven by altruism. The new campaigns shared something with the more traditional security networks of old. Stop the spread. Protect the West. No different than a western democracy fighting an insurgency in the developing world in an effort to prevent war from being waged at home—a stated claim of America’s War on Terror; the need to contain a virus, for instance, was less about the local beneficiaries of that aid, but more importantly containing the spread of the malady before it could reach America’s shores. In the post-Cold War reality, opening of borders to allow for global trade might also allow an infectious disease agent to enter into Western spaces.

The outcome of this has been the development of international health cooperation mechanisms that place western fears of an outbreak reaching them above the prevention of such outbreaks in the first place. In turn, the desire of the WHO to assert its authority in the project of disease surveillance and containment has led it to develop global health mechanisms that primarily prioritizes the protection of western states from disease contagion. (Davies, 2008, p. 295)

The West does robust business with states that ignore or even endanger the health and safety of their residents. If the breakdown of security linked to a lack of healthcare were a real problem, foreign aid would not be linked nor driven by the desire to eradicate a particular disease but rather the priority would be in the creation of healthcare systems able to respond to community need.

Further, the West, and Cold War era powers, export weaponry used in West Africa in the armed conflicts that President Obama alludes to in his message regarding the threat of instability in the countries affected by Ebola. A cessation of arms sales or at minimum greater regulation anywhere in West Africa with its porous borders would reduce mortality and that reduction in violence would support state building. Many have packaged gun violence as a public health concern. Why prioritize one contributor to mortality – infectious disease, over another other – murder? Especially when the spread of violence can affect as many lives if not more than the movement of infectious disease agents in similar populations.

President Obama’s stated rationale for intervention was not as important as that intervention not being blocked by the American public once taken. A healthy dose of American fear would do the trick. Social media broadly and Twitter in particular had begun to shape public policy directly during the latter stages of the Obama presidency. It mattered less what people knew about an issue than how they felt about it. A very public campaign to eliminate Ebola could be driven by real or imagined fears.

Data acquired from Twitter by Time indicated that 10.5 million tweets mentioning Ebola had been sent in 170 countries in the period 16 September to 6 October 2014 alone, with a dramatic spike at the very end of September and the beginning of October (when CDC announced the transmission of the virus in the USA for the first time). Kim Yi Dionne drew an explicit link between this sense of fear and security: ‘Fear of the Ebola virus and an out-of-control epidemic also make it easier for governments around the world to focus on security and military responses to public health solutions’ (McGinnis, 2016, pg. 390)

Obama’s claim of a traditional security threat emanating from West Africa was easier for America to process than one about prevention of infectious disease in the same location. That was not yet a fear that had captured the imagination of the middle-class voter or the elite. But terrorism or something akin to it was very much a part of the American drivers of anxiety about global affairs. Better to use that to move public opinion towards intervention in a part of the world with little relevance to the average American.

Conclusion

While several years after the end of the Ebola crisis, US President Donald Trump’s pronouncement that developing nations in general and African ones in particular were “shithole” countries is not a new belief (Barron, 2018). The need to impose its will on Africa is a direct result of Western perception that the continent is inferior and unable or unwilling to help itself. The conditions were perfect for intervention in the three West African states during the Ebola crisis. Infectious disease in a far-off place could be securitized by America under special conditions.

America has become more insular since the Trump presidency. But it has not given up its role in policing affairs that could threaten its position in the global power hierarchy. It has arguably been less forward-thinking and nuanced in its approach as of late. It has not however abandoned a desire to remain the lone superpower.

In a global economy with worldwide financial linkages and availability of transport networks that can quickly connect the poorest countries—most often represented by the mobile elite within them or migrant labor—with the richest countries in hours rather than days or weeks; a fear of a transfer of contagion into a western city was a nightmare scenario worthy of intense study.  US presidents’ Bush and Obama, each serving during global pandemics, understood this, and planned accordingly. They recognized that infectious disease could be as detrimental to the lives and life chances of the US or its Western allies as any armed state or non-state actor driven by anti-western ideology.

The response to Ebola is an effective example of the securitization of infectious disease by America. It was not an instance of the prioritization of public health as a deterrent of a security threat as packaged by the Obama administration. For the West, this particular intervention was an opportunity to apply theory to a problem that was predicted to eventually threaten its well-being and global standing.

Acceptance of the global health narrative that clearly illustrated “shared risk from infectious disease” was a positive partial result of the securitization of the Ebola epidemic by the US (McInnes, 2016, p. 387). What the response failed to do was to adequately address the underlying causes that led to Ebola’s spread. It was a response that did not engage the foundation of the problem. This omission meant that conditions that either triggered outbreaks or prevented them from being easily contained were abandoned after each case was solved only to reappear soon after as policy and response was only designed to engage the problem at surface level.

But is it the job of America to be the health care provider for the developing world? Especially considering that it has not addressed its own sad state of healthcare provision for its own citizens. If the US is to address infectious disease as a security threat it will have to apply the same or greater aid to healthcare systems as it has to preparing its allies in the developing world for warfare. The successes of programs such as PEPFAR were not achieved through surface level fixes. America will have great difficulty being the hospital and the gun shop for the global South. Perhaps it is time for it to re-examine its approach and re-order its priorities.   

References

Barron, L. (2018), “A new low. The world is furious at Trump for his remark about shithole countries”, Time, 12 December 2018. Available from: http://time.com/5100328/shithole-countries-trump-reactions/ [Accessed 18 April 2020].

Betts, R. (1997) Should strategic studies survive? World Politics, 50 (1) 7- 33  https://www.jstor.org/stable/25054025  [Accessed 18 April 2020].

Davies, S. (2008) Securitizing infectious disease, International Affairs (Royal Institute of International Affairs 1944-), 84 (2) 295-313, https://www.jstor.org/stable/25144766 [Accessed: 18 April 2020].

McInnes, C. (2016) Crisis! What crisis? Global health and the 2014–15 West African Ebola outbreak, Third World Quarterly, 37 (3) 380-400, Available from: https://doi.org/10.1080/01436597.2015.1113868

Obama, B. (2014) Remarks by the president on the Ebola outbreak. Available from: https://obamawhitehouse.archives.gov/the-press-office/2014/09/16/remarks-president-ebola-outbreak [Accessed 18 April 2020].

Sachs, W. (ed.) (2010) The development dictionary: a guide to knowledge of power. London: Zed Books

Sarukhan, A. (2016) Ebola: Two years and 11,300 deaths later. Available from: https://www.isglobal.org/en/ebola [Accessed 17 April 2020].

WHO (2006), Communicable disease surveillance and response systems: Guide to monitoring and evaluating Available from:  WHO_CDS_EPR_LYO_200_6_2.pdf [Accessed 13 April 2020].

World Economic Forum (2013) Global risks 2013 Available from: http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2013.pdf  [Accessed 13 April 2020].


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