Between Securitisation and Neglect: Managing Ebola at the Borders of Global Health

GRANTI, A DUNCANJ, J. LARSONH. REVISITING THE EBOLA EPIDEMIC IN WEST AFRICA: THE ROLE OF EMOTIONAL DETERMINANTS IN PUBLIC RESPONSES

Background

The 2014-2016 Ebola epidemic was largely restricted to the three nations of Guinea, Liberia and Sierra Leone, yet it tested the world's ability to address a potential global pandemic. This study provides an in-depth examination of the role of emotions in the response to the outbreak and engagement with public health measures, and the contextual factors which influenced them.

Methods

Historical research methods were utilised in the examination of primary and secondary sources. A multi-faceted SPEECH (Society and Politics, Economy, Epidemiology, Culture, Healthcare and Public Health) framework was developed to aid data synthesis and analysis.

Results

The outbreak occurred in a region still reeling from years of civil war, where poverty was widespread and healthcare severely underfunded. Internationally, global health security had been politically neglected. After a slow start, the international response to the outbreak was strong, yet the lack of community engagement and inadequate consideration of local culture and traditional beliefs, fueled fear and hindered engagement with professionals and uptake of public health measures. Improved collaboration and communication with rural communities in the latter phases of the response was crucial in effectively addressing the outbreak.

Conclusion

This study illustrates the importance of effective collaboration between international crisis responders, in-country public health practitioners and local communities in addressing public emotional responses to the Ebola outbreak. It highlights how community engagement and communications tactics can effectively be utilised to soothe and educate the public, abating counterproductive extreme emotional responses, and in turn improving uptake of public health measures.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

CHANS-Law: preventing the next pandemic through the integration of social and environmental law

Zoonotic viruses have sacrificed hundreds of millions of people throughout human history. There are currently 1.7 million unidentified viruses estimated to be circulating in mammal and bird populations. It is foreseeable that in the near future, another of these will transmit to people, heralding the start of the next pandemic-one potentially more deadly than COVID-19. At the core of this article is a call for pre-emptive protection of the natural environment and its regenerative systems as the first fundamental step in the prevention of future epidemics and pandemics. While zoonoses originate in nature, the predominant legal discipline, managing these crises, is international health law which is invoked reactively once an outbreak has been reported. In this paper, we identify the need for a legal shift in epidemic and pandemic responses. In particular, we call for the incorporation of international environmental agreements to prevent the initial viral spillover from animal to human populations. We propose a strategy of strengthening existing agreements and a coupling of legal disciplines, such as health and environmental law, emphasizing the need for synergies across legal disciplines to enhance the emergence and management of future pandemics and epidemics. We introduce Coupled Human and Natural Systems (CHANS) Law to frame the required integration across legal instruments to regulate inextricably human-nature connections and advocate for the development of a Convention on Epidemics and Pandemics.

Global health security and islands as seen through COVID-19 and vaccination

Since the declaration of COVID-19 as a pandemic in March 2020, significant research and attention has focused on countries' abilities and interests in enacting response measures to the spread of the coronavirus including lockdowns, travel restrictions, and vaccination programmes to contain infections, hospitalisations, and deaths. As the pandemic has continued, much discussion has also centred on the ability of islands to control borders, enact public health measures, and keep the virus out or controlled, owing in part to presumed islandness characteristics of isolation and remoteness. Drawing from ongoing empirical examples of island experiences in the context of COVID-19, this article examines to what extent islandness impacts health concerns and health responses within aspects of global health security and health systems. In considering how islands around the world have been implementing health security measures regarding COVID-19, linkages or suggested linkages among islands, global health security, and pandemics indicate the lack of exceptionality of islands and archipelagos. That is, how islandness or lack thereof is managed ends up being far more important for global health security outcomes than islandness itself.

The Epidemic Failure Cycle hypothesis: Towards understanding the global community's recent failures in responding to an epidemic

BACKGROUND

Within a few years, the global community has failed twice in responding to large viral infection outbreaks: the Ebola epidemic in 2014 and the SARS-Cov-2 pandemic in 2020. There is, however, no systematic approach or research available that analyses the repeated failures with regard to an adequate response to an epidemic.

METHODS

For a better understanding of failing societal responses, we have analysed the available research literature on societal responses to epidemics and we propose a framework called the 'Epidemic Failure Cycle' (EFC).

RESULTS

The EFC consists of four phases: Negligence, Arrogance/Denial, Panic and Analysis/Self-criticism. These phases fit largely with the current World Health Organization pandemic influenza phases: Interpandemic, Alert, Pandemic, Transition. By utilizing the Ebola epidemic and the SARS-Cov-2 pandemic as case studies, we show striking similarities in the response to these outbreaks during both crises. Finally, we suggest three major areas to be of utmost importance for triggering and maintaining the EFC. In terms of ecology, zoonoses, supposed to be the main biological origin for virus epidemics, have been largely neglected by politicians, the media and the scientific community. Socioeconomic and cultural conditions such as harsh living and working conditions as well as conspiracy theories hinder effective preventive and counter measures against epidemics. Lastly, in terms of epistemology, the reliance on knowledge about previous outbreaks has led to slow and inadequate decisions.

CONCLUSIONS

We conclude that any current society has to be aware of the risks of repeating responses to epidemics that will fail. Being aware of the societal mechanisms that trigger inadequate responses may help to get to more appropriate decisions in the face of an epidemic.

The Politics of Exceptionalism: Securitization and COVID-19

The suggestion that we “are at war” with the coronavirus pandemic was not uncommon in national representations of the challenge posed by the virus. Such a representation was in turn frequently linked to the imperative of emergency responses, including expanded police powers, national lockdowns, and border closures. For theorists of securitization, this is not surprising. For them, the language of security and existential threat enables extraordinary and exceptional practices. This paper interrogates these assumptions about the performative and enabling role of securitizing language by beginning with emergency measures and asking how these were justified, how they became possible, and how prominent the language of “security” was to this politics of exceptionalism. It examines justifications for emergency responses—national lockdown and/or border closures—in the United Kingdom, Australia, and New Zealand in March 2020. Ultimately, the cases examined demonstrate significant variability in justifications for similar extreme measures. In the process, this analysis challenges core assumptions about the conditions in which extraordinary measures become possible, suggesting, in turn, the need for a context-specific understanding of both securitization and the conditions of exceptionalism.

Establishing a theoretical foundation for measuring global health security: a scoping review

BACKGROUND

Since the 2014-2016 West Africa Ebola epidemic, the concept of measuring health security capacity has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and reducing global catastrophic biological risks. Efforts to regularly and sustainably track the evolution of health security capabilities and capacities over time - while also accounting for political, social, and environmental risks - could help countries progress toward eliminating sources of health insecurity. We sought to aggregate evidence-based principles that capture a country's baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments.

METHODS

We conducted a scoping review of English-language scholarly and gray literature to identify evidence- and practice-based indicators and proxies for measuring health security at the country level over time. We then used a qualitative coding framework to identify recurrent themes in the literature and synthesize foundational principles for measuring global health security. Documents reviewed included English-language literature published after 2001 until the end of the research period-September 2017-to ensure relevance to the current global health security landscape; literature examining acute infectious disease threats with potential for transnational spread; and literature addressing global health security efforts at the country level.

RESULTS

We synthesized four foundational principles for measuring global health security: measurement requires assessment of existing capacities, as well as efforts to build core public health, healthcare, and biosecurity capabilities; assessments of national programs and efforts to mitigate a critical subset of priority threats could inform efforts to generate useful metrics for global health security; there are measurable enabling factors facilitating health security-strengthening efforts; and finally, measurement requires consideration of social, political, and ecological risk environments.

CONCLUSION

The themes identified in this review could inform efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security.

Ebola and Public Authority: Saving Loved Ones in Sierra Leone

It is unclear how public authorities shaped responses to Ebola in Sierra Leone. Focusing on one village, we analyze what happened when "staff, stuff, space, and systems" were absent. Mutuality between neighbors, linked to secret societies, necessitated collective care for infected loved ones, irrespective of the risks. Practical learning was quick. Numbers recovering were reported to be higher among people treated in hidden locations, compared to those taken to Ebola Treatment Centres. Our findings challenge positive post-Ebola narratives about international aid and military deployment. A morally appropriate people's science emerged under the radar of external scrutiny, including that of a paramount chief.