On the off chance that war doesn’t change everything: more on Ebola

I’m trying not to make my commentary about the current Ebola outbreak about representation, but I’ve been a bit troubled by the political analyses accompanying the epidemiological and health systems ones. Specifically, I want to talk a bit about how Liberia’s and Sierra Leone’s civil wars have been deployed by these analysts to understand the response to the outbreak and how explaining existing tensions requires some deeper knowledge about local context.

Laurie Garrett’s recent opinion piece on CNN and her appearance on Melissa Harris-Perry’s show are both examples of this kind of minimally informed political analysis. There is nothing unique about her stance, I suppose. We see this sort of “war changes everything” or “war happened, therefore…” logic quite a bit. But because she is such a well-respected journalist — I loved The Coming Plague in college and became interested in public health because of that book — I think it’s worth discussing here. As much as I have admired her work, I am beginning to see how her analysis, combined with a reputation for producing compelling journalistic accounts of global health problems, may successfully reproduce the tropes that make for interesting and juicy news, but may not help the cause.

One reason it is useful to understand the context is that even reading newspaper editorials requires some knowledge of existing tensions and conflicts. Yesterday, Garrett tweeted a link to an Awareness Times editorial, focusing (in her short Twitter allotment) on the ignorance of a “very important citizen” who underestimated the threat of the disease publicly. While this may very well be one of the points the editorial was making, I think Garrett’s tweet might be missing the point. It helps to know that the Awareness Times is a paper through which Sylvia Blyden, who has been very vocal and critical of the government response to Ebola from very early on, is communicating her disapproval of the government response to the epidemic.

It is also helpful to know that she has ruffled some feathers on many political matters. According to another Facebook friend, Blyden traveled to the Canada some months ago to collect donations for protective gear to help stop Ebola from spreading. Sylvia Blyden’s critique of this “very important citizen,” therefore, must be understood as a critique of the official response to the disease and elites’ repeated claims that rural people are uneducated and ignorant when it comes to assessing their risk for disease. Rather than simply demonstrating ‘ignorance’ of an elite class, then, she is also criticizing complacency and inadequacy of official response. She is disparaging their assessment of rural people.

In her CNN opinion piece, Garrett reminds of us all the backlash against health workers within these Ebola affected communities. She recounts the story of the woman with Ebola whose family removed her from the hospital and was “brought to a traditional healer.” “Brought to a traditional healer” is usually code for ‘culture’ and ‘tradition’, which tend to be, well, euphemisms for ‘backwardness.’ But any medical anthropologist or most undergraduates who have taken an introductory medical anthropology course, for that matter, knows and understands that an individual’s therapeutic itinerary is often related to perceived efficacy. Put more simply, folks’ quest to get better often means looking in multiple places for cures. In the case where biomedicine can’t get the job done, or you’re seeing people enter hospitals and not coming out, where would you go?

Certainly these protracted conflicts have done their damage, but it has been noted that some of the causes of the war were, indeed, the perceived failures of the state and the mistrust engendered in the late 1970s and early 1980s. These were tales told to me by older politically involved individuals whom I encountered during fieldwork in the mid-2000s. One friend, an anthropologist currently in Liberia and who lived in Sierra Leone before and during the war, described how people use the war to explain current problems, when she had observed the same misfortune and problems those years before the war. She wrote, “I remember driving along the Kamakwie road with someone who was saying what a shame the war had destroyed the road. I said, actually, this is pretty much exactly what the road was like before the war too.”

I am sure that if you asked any anthropologist who happened to work in Sierra Leone in the 1980s about changes, they would see little change on some issues, but radical changes in others. Because time has passed. Moreover, war does not affect everyone the same. During one of my first interviews for preliminary dissertation research in 2005, I remember a cousin of a friend telling me, “We were very comfortable during the war. We stayed in a nice little place on the outskirts of Freetown and were very safe.” Her story wasn’t exactly typical, but it was not unusual either for a specific class of individuals. If anything, we might ask how intervention has been naturalized under these narratives about ‘failed’ and ‘fragile’ states, as my friend Susan Shepler has said. It also appears to naturalize the outbreak and responses to it: “well, they’ve experienced so much in war that this can only breed distrust.” The distrust and suspicion were there all along, albeit expressed in other forms. I would argue, too, that if war has changed anything, the incredible influx of humanitarian interventions and aid workers during the war and its immediate aftermath — where outsiders and their local cronies seemed to benefit openly from others’ suffering — has also engendered suspicion that has helped fuel the backlash against local and international health workers.

On Ebola and the pathological movements of Others

This morning, I woke up to two emails about the most recent NYT article about the Ebola outbreak in West Africa. Having worked in Sierra Leone on a range of health issues, I have been a recipient of these kinds of messages at least a few times a week. I’ll just comment on this article because it best articulates a number of trends that I am seeing in these articles.

From Guinea, Adam Nossiter writes:

Eight youths, some armed with slingshots and machetes, stood warily alongside a rutted dirt road at an opening in the high reeds, the path to the village of Kolo Bengou. The deadly Ebola virus is believed to have infected several people in the village, and the youths were blocking the path to prevent health workers from entering.

“We don’t want any visitors,” said their leader, Faya Iroundouno, 17, president of Kolo Bengou’s youth league. “We don’t want any contact with anyone.” The others nodded in agreement and fiddled with their slingshots.

Singling out the international aid group Doctors Without Borders, Mr. Iroundouno continued, “Wherever those people have passed, the communities have been hit by illness.”

What I find intriguing about this piece is that it’s one of the first to make explicit people’s mistrust of international health workers and their motivations. Implicit is, as Susan Shepler notes, a related mistrust of government officials and the perceived competence of government officials to manage an epidemic, have shaped local responses to this outbreak. Add to this that hospitals are widely perceived to be a place where people become sick or die — not simply in West Africa, but elsewhere, too — and we’ve got ourselves some moral panic. (It bears repeating, too, that Ebola was previously unseen in the region and looks like a lot of other endemic diseases in its early stages. Where I previously worked,  Lassa Fever, a hemorrhagic fever with which many Sierra Leoneans are familiar, was also endemic, raising questions for me about whether they used those lessons to address Ebola.)

So, back to the NYT. Young men are trying to bar MSF from their village. Yet, in the paragraph following this vivid description, the analysis falls back on pathologizing the movements of West Africans:

Health officials say the epidemic is out of control, moving back and forth across the porous borders of Guinea and neighboring Sierra Leone and Liberia — often on the backs of the cheap motorcycles that ply the roads of this region of green hills and dense forest — infiltrating the lively open-air markets, overwhelming weak health facilities and decimating villages.

In short, foreigners should move and have unfettered access to ‘Africa’, but these same (literally pathological) movements of foreigners — certainly not all white and Western, but at least symbolically so — are pushed to the background, while the usual movements of West Africans are pathologized. They must stay in their rightful place.

This is not to say that epidemics aren’t traveling “on the backs of cheap motorcycles,” but these young men suspect, as many others in the region do, that (1) the disease may also be traveling with the foreign health workers who move fairly easily across international borders and who are at greatest risk for contracting the disease; (2) that there was a slow and inadequate government response upon initial rumors of the outbreak; and (3) the arrival of Ebola to West Africa is not a simple matter of chance, porous West African borders, ignorance and ‘local traditions’, but one embedded in a range of biological, political, economic and cultural arrangements that have put entire communities at risk. These at-risk communities are having a hard time building trust with people who have failed to control Ebola.

Blurred lines: development, human rights, humanitarianism

Last week, we read Bornstein and Redfield’s introductory chapter to Forces of Compassion. In it, the authors outline a distinction among development, human rights, and humanitarianism. The temporal orientation, disciplinary foci, and the professions associated with each of these forms of social action seem to distinguish them from each other. The authors state, for example, that development is associated with economics, livelihoods and poverty, and are progressive/future-oriented, while human rights organizations are concerned with law, and correcting past wrongs. Humanitarianism is medical and preoccupied with the present, the ‘right now.’ They draw this distinction, I think, because there’s a group of anthropologists who have lumped the work of improving and ‘saving’ lives under ‘humanitarianism’ — the suggestion here being that humanitarianism’s particularity is rooted in a particular conception of ‘humanity’ and ‘life’ and an ethos or structure of feeling, rather than professional and bureaucratic categories. The authors note that their three-pronged schematic is crude, but I think it is telling that they need to provide this schematic at all. Again, I think it lies in humanitarian and development professionals’ clarity about what distinguishes them from each other, and the kind of ethics and professional practice these different kinds of intervention entail. Yet the institutions engaged in these forms of social action not only perform many of these functions at once, but also find themselves using multiple frames simultaneously to justify and continue their work.

As a kind of thought exercise, I went to several international non-governmental organization (iNGO) websites and looked at the short program publicity reports to see how well Bornstein and Redfield’s categories hold up in ‘practice’ — or at least in the routine NGO practice of describing projects for a general audience. I cut and paste these excerpts into a quiz and asked students to identify whether they described humanitarianism, development or human rights programs, as defined by Bornstein and Redfield. Although I was sure to pull excerpts that generally fit the descriptions provided by the authors, students still had some trouble placing the quotes into categories: could the participatory health program that held health facility managers accountable be considered a human rights  (on the issues of participation and rights-oriented language) and a humanitarian (for its medical orientation) program? Of course, the crude association of categories of intervention with professions and disciplines was perhaps less useful than the more analytical move of highlighting the temporal and ideological orientations that we associate with these approaches.

To drive the point home that these distinctions are quite blurred in practice — and manifest in different framing of social problems and, therefore, programs — I asked students to look at the websites of five different organizations (two human rights iNGOs, two development/relief iNGOs and a UN agency) and see how each organization addresses water issues. Of course, many of the largest iNGOs, like CARE or Oxfam, which are firmly situated in all three traditions, describe the problem in multiple ways; they have ‘cornered the market,’ so to speak. On CARE’s water website, for example, they use the language of emergency and crisis; that of long-term investment; and of public health and rights.

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A search for ‘water’ on two human rights websites, Human Rights Watch and Physicians for Human Rights, framed the issue much differently. In addition to suggesting that access to water was a human right, most of their reports concerned water access issues in terms of violations: police crackdowns on water access protesters; shaming mining companies that polluted water sources or displaced people from clean water; disease outbreaks due to poor prison conditions, etc.