Third World Quarterly ISSN: 0143-6597 (Print) 1360-2241 (Online) Journal homepage: http://www.tandfonline.com/loi/ctwq20 Personal Protective Equipment in the humanitarian governance of Ebola: between individual patient care and global biosecurity Polly Pallister-Wilkins To cite this article: Polly Pallister-Wilkins (2016) Personal Protective Equipment in the humanitarian governance of Ebola: between individual patient care and global biosecurity, Third World Quarterly, 37:3, 507-523, DOI: 10.1080/01436597.2015.1116935 To link to this article: http://dx.doi.org/10.1080/01436597.2015.1116935 Published online: 10 Mar 2016. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ctwq20 Download by: [UVA Universiteitsbibliotheek SZ] Date: 10 March 2016, At: 08:56 Third World QuarTerly, 2016 Vol. 37, No. 3, 507–523 http://dx.doi.org/10.1080/01436597.2015.1116935 Personal Protective Equipment in the humanitarian governance of Ebola: between individual patient care and global biosecurity Polly Pallister-Wilkins Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 department of Politics, university of amsterdam, The Netherlands ABSTRACT ARTICLE HISTORY This article focuses on the use of Personal Protective Equipment in humanitarianism. It takes the recent Ebola outbreak as a case through which to explore the role of objects in saving individual lives and protecting populations. The argument underlines the importance of PPE in mediating between individual patient care and biosecurity. In addition it questions the preoccupation with technical ixes; challenges dominant perceptions about the subject of humanitarianism being the victims of disaster; traces the production of a particular politics of life; and explores the individualisation of risk and concomitant processes of labour discipline in the everyday lives of humanitarian workers. received 2 april 2015 accepted 3 November 2015 KEYWORDS humanitarianism technology objects biomedicine biosecurity ebola Introduction Rubber gloves were nearly as scarce as doctors in this part of rural Liberia, so Melvin Korkor would swaddle his hands in plastic grocery bags to deliver babies. His staf didn’t bother even with those when a woman in her 30s stopped by complaining of a headache. Five nurses, a lab technician – then a local woman who was helping out – cared for her with their bare hands. Within weeks, all of them died. The woman with the headache, they learned too late, had Ebola. (Sergeant Kollie Town, Liberia, August 2014)1 Personal Protective Equipment (PPE) has come to symbolise the recent Ebola outbreak in West Africa. Images of humanitarian workers clad in plastic clothing with their faces obscured by masks and goggles have become an easy visual cue for the virus itself and the complexities of the public health and biosecurity response. Meanwhile, international humanitarian agencies trumpet the necessity of PPE and ofer web-based interactive tours of what exactly PPE is and how much it costs.2 This is set against a backdrop of Ebola-afected regions lacking in the most basic equipment, local infrastructures struggling to cope and local health workers having to use plastic bags for protection. All of which, in turn, has necessitated outside, international intervention by those with the capacity and importantly the equipment to facilitate ‘safe’ intervention. CONTACT Polly Pallister-Wilkins p.e.pallister-wilkins@uva.nl Polly Pallister-Wilkins http://orcid.org/0000-0002-4741-613X © 2015 Southseries inc., www.thirdworldquarterly.com Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 508 P. PALLISTER-WILKInS There is a long history of actions designed around the moral imperative to save lives and reduce sufering using tools, technologies, techniques and instruments to make a diference to life-saving endeavours. It extends from Florence nightingale’s famous use of lamps in the hospital wards of the Crimean War, the British navy’s post-abolition use of gunboats to police the Transatlantic Slave Trade,3 the use of quarantine to combat disease,4 and the use of urban planning, mapping and statistics in the governance and ultimate eradication of cholera in European towns to the more recent heraldry of drones and satellite surveillance systems alongside ‘simpler’ technologies such as the Mid-Upper Arm Circumference (MUAC) band, Plumpy’nut and the Peepoo in humanitarian eforts guided by the logics of patientlevel care and the wider well-being of populations.5 This historical symbiosis of technologies, or what Tom Scott-Smith has called ‘humanitarian objects’,6 with humanitarian rationalities concerned with saving lives has been underexplored in studies of humanitarian action. Yet, as we can see, objects play and have played a central role in humanitarianism – or practices that display humanitarian logics – over the years. With this in mind this article focuses on the role of PPE as a mediating device in humanitarian action. It takes the recent outbreak of Ebola in West Africa and elsewhere, in which the use of PPE has been of critical importance in the facilitation of intervention, as a case study through which to explore the intersection of humanitarian and biosecurity actions and the role of objects, or what I will call ‘devices’,7 in mediating such actions. These actions include both individual patient care and corresponding global health management where, the article argues, PPE works to mediate the relationship between the act of individual care giving by humanitarian workers and the management of the spread of the disease at local, national and global levels. This relationship and its tensions have been notably highlighted by the criticisms of some practitioners within Médecins Sans Frontières (MSF) and made public when an internal letter was published in the French newspaper Libération.8 The critics claimed concerns over the risks to humanitarian workers were placed above medical practitioners’ responsibilities to provide the best possible care to their patients. These criticisms were revisited by MSF in its own Ebola report published in the spring of 2015. In this report, Ebola: Pushed to the Limit and Beyond, the concerns over providing individual patient care remain but are joined by competing responsibilities for staf safety and the centrality of human resources in tackling the virus.9 Considering the centrality of PPE in facilitating and mediating the response, the argument takes seriously and aims to contribute to the debates around the reliance on ‘technological ixes’ and ‘technological fetishism’ in humanitarian practice.10 The argument builds on and complicates these debates, focusing on ‘how matter comes to matter’ in on-the-ground humanitarian practice and its interface with wider systems of global health security.11 In the process it ofers a counter-case to those instances where technology is assumed to be a ‘ix’ alone and focuses more on how technology comes to play a mediating role. Further, starting the analysis with PPE itself facilitates an exploration of the politics of devices and their role in (re)producing social and structural inequalities between lives and in the provision of health care. The article proceeds as follows: it starts with a discussion of humanitarianism’s dual role as a provider of individualised patient care and a biosecurity actor in the global health response. It then moves on to consider recent discussions around the role of material objects and technologies in humanitarianism, introducing an analytic of the ‘device’ as a way of exploring the productive work that humanitarian objects do. What follows moves beyond a Foucauldian THIRd WoRLd QUARTERLY 509 biopolitical approach to humanitarian action by considering didier Fassin’s arguments concerning the ‘politics of life’ as a useful way to discern the ways in which humanitarian action produces particular lives that are worthy of being saved or sacriiced.12 After this, the article goes on to tackle the substantive empirical investigation of PPE, exploring the mediating role it plays in managing the continuum of risk as humanitarians move between the demands of individual patient care and responsibility for wider biosecurity. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 Biomedicine, biosecurity, devices and the politics of life Humanitarianism as a technique of government and as a practice centres on the preservation of human life;13 one of the principle ways humanitarian values come to be performed is through medical intervention of some kind. This action is often simultaneously concentrated on the individual patient and the well-being of the wider population. Such tension makes up a central part of humanitarianism as a value system, a technique of government and a practice, and is inherent within the commitment to seeing humanity – a universal subject – as being made up of equivalent individuals. In the provision of medical care this tension is ably captured by what Andrew Lakof has termed humanitarian biomedicine and global health security, and what this article calls biosecurity. Lakof’s discussion of the humanitarian biomedicine and biosecurity approaches is concentrated on how both have contrasting views of health care provision on a global scale based on practices developed in national approaches to public health management. Humanitarian biomedicine is concentrated on providing medical care in contexts of insuficient health infrastructure, where ‘human sufering demands an urgent and immediate response outside the framework of state sovereignty’.14 In contrast, biosecurity is concentrated on the health and well-being of the population at a ‘global’ level and ‘comes from the recognition that existing national public health systems are inadequate for the potentially catastrophic threat of emerging and re-emerging infectious diseases’.15 According to Lakof, both biomedical and biosecurity responses rest on normative and technical elements but they have very diferent views on the social aspects of health care provision and the technical means of achieving it.16 Biosecurity focuses on creating ‘pre-emptive’ systems capable of managing ‘emerging infectious’ diseases at the level of populations and combines a range of technical aspects concerned with ‘surveillance, immediate alerts and immediate responses to disease outbreaks’ especially, in the global context, when the disease has crossed international borders.17 Humanitarian biomedicine, in contrast, while appearing to be more patient-centred, relies on a range of technical interventions such as drugs, vaccines and various objects used to manage public health, such as bed nets to prevent malaria or, in the case of this article, PPE.18 In exploring the particular role of ‘objects’ in humanitarian practice, Peter Redield’s work on MSF’s use of the ‘humanitarian kit’ traces the relationship between humanitarian sensibilities and the material world. In doing this Redield has been keen to emphasise that humanitarian practice itself ofers a ‘unique vantage point that alters the ield of assumptions surrounding biological emergencies,’19 while the perspective of humanitarian responses from agencies such as MSF does a number of things to our ideas of human security more generally: First, it shifts the focus one step away from the nation state, given that intergovernmental and nongovernmental entities play signiicant roles in deining and enacting humanitarian projects. Second, it also moves concerns about people and things one step closer to the domain of 510 P. PALLISTER-WILKInS Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 ethics, to the extent that humanitarian conceptions of sufering commonly and overtly mobilise discourses about good, evil, and moral obligation. And inally, if the horizon is truly global, it both enlarges and diminishes the sense of infrastructure involved, amplifying the degree of mobility essential to achieving care from a distance even as it reduces the sense of ‘life’ to a minimal proportion of needs.20 So humanitarian’s symbiosis with the material world of objects brings normative and political questions into discussions about the productive nature of such objects. Meanwhile it makes us cognisant of the spatio-temporal reach of such practices, suggesting they are simultaneously local and global, happening at the level of local public health management, for example, and at the global level of biosecurity. In addition, Tom Scott-Smith has recently explored the role of what he terms ‘humanitarian objects’ in the management of malnutrition emergencies. Examining the use of Plumpy’nut and MUAC bands, Scott-Smith argues that in such instances these objects have become fetishised and ‘divorced from their contested origins, credited with magical powers and increasingly seen as indispensable in inlexible approaches to relief’.21 Such an argument is a useful starting point for considering the role of objects, urging caution as opposed to hasty judgments about the importance and positive role of objects in humanitarian practice. Further, Scott-Smith suggests humanitarian objects should be considered whole, with histories that place them in complex sociologies and processes of production. As such, the rush to fetishise humanitarian objects works to conceal both their origins and their efects. These recent explorations of humanitarianism and the material used in its practices have tended to focus on those objects used by or on the victims of disaster or disease, such as MSF’s ‘kit’, and those designed to make humanitarian work easier, quicker and more eicient. This has led to the charge of ‘fetishism’, where objects are ‘presented as a miraculous curative’ or a ‘standardised intervention’.22 In the case of PPE any fetishisation of the plastic suit, rubber boots, gloves, goggles and face masks that make up this ensemble would conceal both the history of PPE in military responses to chemical and biological warfare and the wide-ranging efects PPE has on the provisions of individual patient care and the governance of biosecurity in the present. However, a charge of fetishisation cannot be levelled at the object of this article in the same way. PPE’s important role in facilitating human action while mediating between the care of individual patients and the management of wider biosecurity at local, national and global levels means that it cannot be characterised as a ‘technical ix’ alone, even while it was concomitantly presented as central in the response to Ebola. Considering both the productive nature of objects and the problems of fetishisation, the question then becomes how objects in certain instances make humanitarian actions possible and what work they do. This is where turning to devices is useful. Recent work advancing the analytic of devices helps us trace the importance of objects without efacing the often long-running socio-political techniques or rationalities they are created by, work with, or work to bring into being.23 Importantly this enables the avoidance of privileging either the social or the technical. Instead it facilitates questions about the ways certain modes of government, certain sensibilities, structural conditions and social hierarchies are constituted through their relations with objects and how certain objects come to be constituted through particular social relations. In working through the facilitation of humanitarian action made possible by the speciicities of PPE it is important that we think not only about the role of devices, but also about what kind of human action is made possible and what kind of social relations are rendered THIRd WoRLd QUARTERLY 511 visible and enacted by PPE. In this instance, the Foucauldian biopolitics of humanitarian biomedicine and biosecurity are analytically insuicient for capturing the values and meanings that are and come to be attached to human life here.24 In addition to being a biopolitics of socio-techniques concerned with the regulation and well-being of populations, humanitarian intervention is: Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 [a] politics of life as it takes as its object the saving of individuals, which presupposes not only risking others but also making a selection of which existences it is possible or legitimate to save. It is also a politics of life in that it takes as its object the defence of causes, which presupposes not only leaving other causes aside but also producing public representations of the human beings to be defended.25 The question then becomes: ‘what sort of life is implicitly (or even explicitly) taken into account in the political work of humanitarian intervention?’26 A particular politics of life is not only rendered starkly visible through an investigation of PPE but is also produced and consolidated through the provision, use and focus on PPE in the recent Ebola outbreak. This, along with an exploration of the other ways PPE comes to play a mediating role between local biomedical responses and global biosecurity, as well as managing the continuum of risk, will be examined in the following section. The section will focus on the ways in which the speciic characteristics of the virus interact with the speciics of PPE to determine medical intervention, advancing the idea of PPE as an individuated barrier device, exploring what this means for the individual humanitarian workers who had to work with PPE and the wider humanitarian systems in which such care was administered. It also discusses the ways in which a politics of life is produced and consolidated among local and international health workers involved in the humanitarian response, throwing into stark relief the simultaneous discrepancy between the biomedical response and biosecurity concerns. In addition to these explorations, the analysis will aim to further the debates around the role of devices in humanitarian practice, discussing the ways in which PPE is more than a ‘technological ix’, centred as it is on facilitating human interaction and mediating diferent responses to risk. It focuses on the continuum of risk and the humanitarian worker as the potential subject that is simultaneously both at risk and a risk. Here the role of PPE as an individuated device performing biosecurity at the personal as well as the global level will be worked through before attention is turned to the disciplinary efects of PPE and the way the ‘personal’ in Personal Protective Equipment works to individualise the management of risk and bring ideas around labour discipline into the humanitarian ield. Throughout, the analysis draws on the testimonies, relections and critiques of practitioners engaged in the humanitarian and medical response to Ebola, focusing on their experiences of using PPE and the wider structures and politics in which their interventions were situated. Personal Protective Equipment facilitating and mediating the management of Ebola ‘You can’t stop Ebola without staf, stuf, space and systems.’27 According to Paul Farmer, anthropologist, medical practitioner and co-founder of Partners in Health,28 ‘stopping transmission’ was the irst step in governing the virus, bringing it under control and ultimately ending the pandemic. ‘Transmission is person to person, in the absence of an efective medical system, it occurs wherever care is given: in households, clinics, and hospitals, and where the Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 512 P. PALLISTER-WILKInS dead are tended’; this requires ‘uninterrupted supplies of personal protective equipment’.29 Thus the focus of the following section is on the relationship between staf and stuf.30 This focus on PPE is not without foundation. The particular characteristics of Ebola, ‘multiplying as the patient declines and increasingly oozing out in bodily luids’, places caregivers at particular risk of catching the virus and/or becoming vectors of transmission,31 revealing the continuum of risk and how ‘care itself has become a source of existential insecurity’.32 These particular characteristics of the virus are important to consider when working through why PPE played such a central mediating role. Ebola is not an airborne virus, but is transmitted via bodily luids: blood, urine, breast milk, sweat, tears, vomit, semen and diarrhoea. This results in the particular characteristics of PPE as an individuated, bodily barrier which, if used correctly, prevents health care workers coming into contact with the bodily luids of patients. The mode of transmission is also an important factor in understanding how health care workers are not only at risk of falling ill themselves but are also a risk as potential vectors of transmission. As MSF’s report into their Ebola response makes clear: ‘In Ebola outbreaks, health facilities without proper infection control often act as multiplying chambers for the virus, and become dangerous places for both health workers and patients’.33 This risk of infection and the possibilities of transmission result in humanitarians being ‘scared of Ebola as it’s something about the way it is emitted – through the blood, sweat and tears of human beings’.34 Barrier devices Building on this fear, this section analyses the role of PPE at the level of the virus itself and how PPE facilitates the intervention of humanitarian assistance while also managing the continuum of risk. In her work on governing ‘pathogenic circulation’ nadine Voelkner draws our attention to the ‘double bind’ of circulation for human security. According to Voelkner, circulation is necessary for health security but concomitantly a possible source of risk.35 Further, in exploring how this ‘double bind’ is managed, Voelkner argues for the performative role of material objects. PPE is designed to perform security by preventing bad circulation – the transmission of the Ebola virus through bodily luids – and enabling good circulation – the life-giving forces needed by the caregiver, such as oxygen. As such, PPE is a selectively permeable barrier working at both the bodily level of the individual and also at the molecular level, distinguishing between ‘bad’ liquids and ‘good’ gases. This is not an inconsequential distinction but forms an integral part of how PPE works as a life-saving device that takes account of the individual risks faced by the health care worker and the wider risks of transmission that such workers are partly responsible for. In a recent intervention into caring as an existential act of insecurity, Sung-Joon Park and René Umlauf pointed to the way ‘protective gear allows for hermetic isolation of the caregiving individual’.36 While the identiication of care giving as a source of existential insecurity and of PPE’s isolating role is accurate here, the characterisation of protective gear as hermetic isolation reproduces similar mainstream logics around other forms of barrier, focusing on the blockading actions of barrier devices at the expense – in the most extreme of cases – of mischaracterisation of the device itself.37 no barrier designed for wider techniques of government concerned with biopolitical logics can ever perform ‘hermetic isolation’ when circulation is a central life-force. Instead barriers work to mediate between levels of risk. For example, specially constructed infectious disease isolation wards still allow for the movement Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 THIRd WoRLd QUARTERLY 513 of people, caregivers in this instance, as well as things: medicines, food, water and oxygen. These movements are tightly controlled and iltered according to calculations of risk but these units do not prevent movement. The same is true of PPE itself, designed as it is to stop the transmission of Ebola and other viruses contained in bodily luids. It does not seal the wearer in but facilitates good, life-giving circulation through the use of permeable facemasks allowing for the movement of gases – oxygen in and carbon dioxide out – without which the wearer would die. Thus Redield’s more accurate description of PPE as a ‘second skin’ better captures its particular characteristic as a selectively permeable membrane.38 The focus on the passing of gasses through the facemasks of PPE is not a small observation, as it is often the facial areas where PPE is vulnerable as a form of protection and where transmission is most likely to occur. By having to allow for circulation of oxygen and carbon dioxide, PPE has an in-built weakness and can itself become a site of transmission. The need to consider the well-being of the body inside the PPE alongside the ability of the device to stop transmission is highlighted by the secondary ways that PPE, while acting as a device for securing the individual against the spread of particular liquid-borne pathogens, can itself also be a risk to the well-being of the wearer. In such a way PPE becomes a double-sided device or a ‘double-bind’.39 Adam Levine, an emergency medicine specialist treating Ebola suferers in Liberia shows how PPE can become a risk to health and the ability to provide patient care while recounting a story of having to rehydrate an Ebola patient by feeding him rehydration luids by the capful: ‘only a few hundred more capfuls to rehydrate him, but I know that in the stiling heat I am not going to last much longer in my full PPE’.40 As a result, most experts do not think that caregivers should spend more than two to three hours in PPE for their own health and to be able to provide care safely. That being said, when one considers the role of PPE in facilitating individual patient care, it does in certain ways become a barrier mediating between health care workers and their patients, as shown by the experiences of Levine above and outlined by Hilde de Clerck, a doctor with MSF: We have to move and breathe slowly due to the overpowering heat, limiting us to spending an hour maximum inside at a time. Inside the high-risk zone, I have to plan the most crucial activities I can squeeze into an hour. It’s frustrating and upsetting that I can’t spend unlimited time with my patients or connect with them as I usually would, with a smile or a comforting human touch.41 Here PPE may be a selectively permeable barrier but the suits, face masks and goggles act as a barrier between the medical practitioner and the patient, limiting time, physical contact and emotional connections.42 This physical isolation from patients is a source of much discomfort for humanitarians. Furthermore it is diicult to identify the individuals inside the suits, as faces become obscured and bodies become encased in plastic ‘space suits’. Humanitarians have attempted to deal with this de-personalisation for both themselves and their patients by writing their names on their suits, most usually on their foreheads in recognition of the importance of the facial area and eye contact in forging personal connections. In addition to the discomfort with physical and emotional isolation, and the problems of overheating and dehydration, PPE also causes problems for the wearer’s ability to deliver patient-centred care by restricting movement. Frederique Jacquerioz, a doctor and researcher, told the American Society of Tropical Medicine and Hygiene’s annual meeting in 2014 that PPE hindered ease of movement and that movement in the suit was itself an acquired skill, ‘not something that can be learned in 20 minutes’.43 These concerns were also echoed by MSF when faced with time constraints in training new, inexperienced staf in the Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 514 P. PALLISTER-WILKInS realities of working with Ebola.44 In addition, PPE hampers existing skills, making it diicult to listen to the lungs or to put in an IV drip.45 That people have to remove PPE – and have to do this so regularly in tropical conditions – causes additional problems, as the removal of the suits becomes a major source of potential transmission. This along with the problem of overheating, where workers lose up to 1.5 litres of sweat per hour, and other problems with ‘regular’ PPE have been recognised by experts tasked with managing the biosecurity response to Ebola, such as the US Centers for disease Control and Prevention (CdC) and USAId. These problems include 28 possible points of transmission where the barrier functions of PPE are thought to break down around ‘seam zones’. Additionally the time it takes for removal – up to 20 minutes and involving up to 31 steps – has been acknowledged as a weakness in the efectiveness of PPE. A focus on these weaknesses shows how PPE becomes a point of tension itself. Through its work mediating diferent levels of risk it is also a ‘double bind’, leading to calls for a technological ix. Some of those concerned with the technology of global health management believe that PPE can be made to work better to manage the tensions its ‘double bind’ character produces in practice. Such potential technological ixes have been suggested through the ‘Fighting Ebola: a Grand Challenge for development’ competition run and inanced by USAId.46 one of the winners of the competition was the Johns Hopkins Center for Bioengineering Innovation and design, in conjunction with the international health organisation JHPIEGo, which designed a new PPE suit ‘purposefully designed to address safety and climate issues now putting health workers at risk’.47 Here the suit becomes ‘fetishised’ as the ‘thing’ that needs ixing, while the wider underlying structural factors of the Ebola pandemic go unaddressed. Attention is focused on creating the perfect suit to manage this and future outbreaks, instead of addressing the inadequacies of health care systems unable to cope with treating Ebola. In addition, such technological ixes fail to address the already existing problems of inadequate PPE provision. In the recent Ebola pandemic local health care workers were reduced to using plastic bags, and even international humanitarian agencies were unable to provide adequate and efective protection for local health care workers outside the specially built Ebola Treatment Centres. Protecting and producing the humanitarian subject The body inside the PPE cannot be ignored. This section will examine PPE’s role in the production of the humanitarian worker as the subject of protection. Here attention will be paid to the importance of the protection of ‘human resources’ and the responsibility of humanitarian agencies for the protection of their staf on both ethical and practical grounds. Through this focus on ‘human resources’ and the protection of personnel we witness the production and consolidation of a politics of life between those who were accorded the protection of full PPE and those who had to make do with homespun, ad hoc solutions, such as plastic bags, or simply go without. In the process the section highlights PPE’s involvement in wider postcolonial relations and political economies of inequality. In the Ebola outbreak, however, this politics of life was not a politics of neat categories between those lives risked and those saved. Instead, echoing the blurred boundaries of postcolonial relations that challenge the neat categories of ‘self’ and ‘other’, the politics of life enacted by PPE’s mediation of a continuum of risk produced a context-speciic and relationally contingent politics of life. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 THIRd WoRLd QUARTERLY 515 As much humanitarian action occurs within a continuum of risk where its subjects are both at risk and a risk, where they may move between the two and may be both simultaneously, the governance of Ebola and the diference made by PPE in the performance of such interventions complicates the issue of who is the subject of such protection. With humanitarianism’s focus on protecting both the individual and the wider population, the subject is usually presumed to be the ‘victim(s)’ of natural disasters, disease and conlict. However, it has also been recognised that the humanitarian is also at risk through the practice of saving lives, particularly in situations of violent conlict.48 The performance of PPE speaks to this, because the person in the personal protective equipment is the humanitarian worker and not the Ebola suferer. Through being worn on the body of the humanitarian worker, PPE enables said worker to carry out humanitarian tasks and produces the worker as the principal subject of protection. ‘Everything needed to be done by someone and on a massive scale.’49 So having enough staf and protecting them from infection was of critical importance. The issues of human resources and the protection of staf were critical in two ways: so that there were enough people to carry out life-saving tasks; and to avoid deterring potential volunteers.50 Here the role of PPE in protecting and enabling comes to the fore in the central role that human resources played in many organisations’ ability to respond efectively and safely to the pandemic. The speciic experiences of MSF in this regard are illuminating, where again and again the need for staf, their protection, not deterring new volunteers through fear of the virus and the limitations that these created all afected the response. Lindis Hurum, MSF’s Emergency Coordinator in Monrovia in August 2014, had this to say: we are not without limits. And we’ve reached our limit. It’s very frustrating, because I see the huge needs but I simply don’t have the human resources. We have the money thanks to our donors. We have the will. We certainly have motivation, but I don’t have enough people to deal with this.51 ‘MSF does not have an Ebola army with a warehouse of personnel on standby. We rely on the availability and commitment of our volunteers.’52 In addition, MSF felt it was ‘under pressure to set an example and show it was possible to treat Ebola safely, in an efort to mobilise others to intervene. If we took even more risks and too many staf fell ill, we’d be unable to maintain trust with our teams or recruit new volunteers’.53 Furthermore, like other humanitarian organisations, MSF had a duty of care to its staf and volunteers. ‘our duty for our staf is certainly crucial…Though we have invested heavily in personal protective equipment, training and security protocols, we have painfully learned there is never zero risk.’54 When we consider the idea of risk as a continuum rather than a binary relationship, the humanitarian community can no longer be cast solely in the privileged position of saviour. The speciic nature of the Ebola virus and the role of PPE in countering it ask us to recast the humanitarian net to include the humanitarian community itself as not only the providers of protection but also the subjects of protection. In turn, this works in part to privilege issues of the security of particular individuals above and before issues of humanity as a whole and forces us to ask questions about whose security is being considered. It also works, in practice, to entrench the structural privileges of international agencies over more local responses, often along racial lines, while simultaneously working to eface Ebola’s victims. Such an observation is not surprising, when the security of populations clashes with issues of individual security, raising as it does so ethical and risk-based calculations, especially in the ield of humanitarianism where – at least in theory – every individual is said to have 516 P. PALLISTER-WILKInS equal humanity. In other words, these tensions are of particular ethical concern for the humanitarian community itself. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 But in a public health emergency of this scale and danger, patient communication and counselling can be brushed aside under the pretext of urgency. Ebola patients can be considered mere disease-carriers rather than complicated, emotional human beings.55 That being said, the production of the humanitarian worker as the subject raises additional ethical questions around a politics of life and the production of particular ‘hierarchies of humanity’ and moral economies. This was starkly illuminated when ‘the realisation dawned that Ebola could cross the ocean. When Ebola became an international security threat, and no longer a humanitarian crisis afecting a handful of poor countries in West Africa’,56 and a belated global biosecurity response was mobilised. This response was mostly restricted to supporting coordination and logistics and included the building of medical facilities for treating healthcare workers while ignoring the provision of direct medical assistance to local populations.57 However, even with this focus on protecting the humanitarian workers, not everyone was the subject of protection. Instead, in certain instances already existing structural and racial hierarchies between international humanitarian workers and local health workers treating Ebola were reproduced. As Paul Farmer argues, efective PPE is not and was not available to every clinician or to those – usually women – attempting to care for sick family members at home.58 In an attempt to address this inadequacy of equipment and the risks to those caring for their families and communities at home, away from the infection controls ofered at Ebola Treatment Centres, MSF distributed 600,000 ‘home disinfection kits’ in Monrovia in order to reduce infection risk, while knowing that ‘these kits were not the solution’.59 In contrast, those staf ailiated with international agencies had access to equipment such as PPE and medical facilities to treat them if they fell ill. Many international staf were evacuated back to north America and Europe for treatment in state-of-the-art infectious disease units such as those at the Emory University Hospital in Atlanta and the Royal Free Hospital in London, while nearly 500 local medical workers lost their lives, starkly highlighting the structural diferences in public health provision. not only were Western medical and humanitarian workers treated in state-of-the-art units, but they were also the recipients of treatments unavailable in West Africa. In Western hospitals patients were tended to by many clinicians 24 hours a day, while those who fell ill in West Africa were most often treated by their families at home or in Ebola Treatment Centres, where health care workers could only spend a few minutes with each patient and in certain instances were forced to institute drastic systems of triage and limit who they could admit. This ‘meant dead bodies in the homes and lying in the street, sick people unable to get a bed and spreading it to their loved ones and only being able to ofer very basic palliative care’.60 Thus the humanitarian subject was also within speciic contexts and relationships a racialised humanitarian subject, echoing Fassin’s arguments around the difering moral economies attached to values of life for international and local humanitarian workers.61 Personal to global protection equipment The lack of PPE in the zones of the Ebola outbreak highlights the spatio-temporal logics of a technocratic approach to global health that seeks to govern through vertical interventions, technological ixes, ‘benchmarking progress’ and circumventing ‘the messy realities of Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 THIRd WoRLd QUARTERLY 517 international politics and local infrastructures...for more efective results’.62 Throughout this article it has been argued that PPE mediates the relationship between providing a humanitarian biomedical response and managing global biosecurity. This section turns to this relationship in speciic detail, exploring how in the process PPE acts as a barrier device between the personal, local and global, and between the ability to provide individual patient-centred care and the ability to manage biosecurity on a global scale. This in turn uncovers tensions between the two approaches outlined by Lakof in empirical practice, drawing our attention to ‘an impossible tension between curbing the spread of the disease, and providing the best clinical care to each patient’.63 Such tensions generated hard-hitting critiques from within organisations,64 as well as between those practitioners present on the ground and those such as the CdC who were concerned with managing the pandemic and protecting populations.65 What an analysis of PPE and the work it does enables us to see is that, in practice, these tensions are mediated and managed through an imbrication of human action and technologies that leave wider structural causes and inequalities unresolved. By recasting the individual biosecurity of the humanitarian worker as the subject and policing their individual body PPE highlights the personal in biosecurity, but moreover PPE works to police the exterior or the wider population by managing the individual biosecurity of humanitarian workers. By policing the individual body of the humanitarian and the centrality of circulation across space – individual to local to global – in humanitarian responses to Ebola, PPE also works to police the exterior and the security of the wider population. As the humanitarian response to Ebola has been an international one, workers move from areas of infection to other parts of the globe in line with long-standing forms of humanitarian practice. This means they are a risk for transmitting the virus not only in Ebola-afected regions of West Africa, but across the planet. Consequently humanitarian workers must not only be protected by PPE to save their own lives and so that they can perform humanitarian biomedicine, but, as a potential vector of transmission, they must also be protected so that they do not become risks to wider populations. Such logics were on display in the responses to those humanitarian workers who were evacuated to Spain, the USA and the UK in 2014 to receive treatment. Their returns sparked nationally focused concerns about borders, quarantines and light bans. When Craig Spencer, a doctor who had volunteered for MSF in Guéckédou, Guinea, tested positive for Ebola on 23 october 2014 in new York City, after a period of self-monitoring, there were subsequent orders from the governors of new York and new Jersey for the routine quarantining of returning humanitarian workers that resulted in nurse Kaci Hickox being detained at newark airport.66 These calls for light bans, border closures and the enactment of quarantines all failed to consider the necessity of mobility and human resources for an efective response to Ebola. Hickox criticised her detention on the grounds that it would deter people from volunteering with organisations like MSF and carrying out much needed work to ight the disease.67 Additionally, like much of the Ebola response that saw other medical services scaled back or stopped completely, the calls for quarantines and light bans also failed to consider the wider security of the populations of Guinea, Liberia and Sierra Leone, with their already fragile economies. While, as we have seen, PPE mediates the relationship between providing humanitarian biomedicine based on individualised patient-care and wider biosecurity, the case of Craig Spencer also highlights the ways in which individual humanitarian workers were made responsible not only for their own biosecurity but for the biosecurity of whole populations. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 518 P. PALLISTER-WILKInS Through PPE being worn on the body of the individual caregiver, risk, both personal and potentially global, is individuated and embodied at the level of the humanitarian worker and, crucially, is determined by how well they use their PPE. As such, PPE speaks to previous debates around the incorporation of citizens and individuals into the performance of security. However, previous debates have tended to focus on individuals reporting suspicions to institutions of authority, such as UK-based campaigns around reporting potential terrorists and irregular migrants, turning citizens into informants encouraged to police their societies.68 The individualisation and embodiment of risk in the PPE that adorns humanitarian workers casts them as both informant and policeman by enjoining them in a variety of spatial settings to self-monitor, police their bodies and notify the relevant authorities when they detect any change in their body temperature, as indeed was the case with Craig Spencer in new York. Crucially this policing and reporting is not concerned with suspicions of others, but suspicions of the self as a potential biosecurity risk. This is not therefore just about individual bodies being the subject of potential global (in)security, but the subject of security being the self and that same self being responsible for ensuring his/her own security and that of others. As such, processes of discipline and labour play a role in the relationship between humanitarians, their PPE, their capacity to perform individual patient care and the global human biosecurity assemblage of which they are a part. The humanitarian worker must be properly trained in using PPE for it to work efectively, as without proper training PPE can become a hazard, ofering as it does a false sense of security. Here the cases of nina Pham and Amber Joy Vinson, the two nurses who contracted Ebola at the Texas Health Presbyterian Hospital in dallas where they encountered Thomas Eric duncan, the USA’s irst Ebola fatality, are instructive. Pham and Vinson were the irst two people to contract Ebola in the USA (duncan had contracted the virus in Liberia) and controversy raged over whether they had received adequate training in using PPE safely, amid continually changing Ebola protocols at the dallas hospital. Bonnie Costello from the largest nurses union in the USA, national nurses United, accused the hospital of scapegoating Pham,69 while others reported that Pham and Vinson had not had access to any PPE when irst encountering duncan. In handling questions around the transmission of the virus, Tom Frieden, the director of the CdC, emphasised the importance of using PPE safely, in particular the importance of removing the equipment – above all gloves – correctly.70 Meanwhile, in the case of Pauline Caferkey, a British Save the Children worker who contracted Ebola while working in Sierra Leone, Michael von Bertele, the charity’s humanitarian director, said: It’s really important for us to try and understand whether it was a failure of training, of protection, of procedure, or indeed whether she contracted it in some incidental contact within the community, because our workers don’t just work inside the red zone, which is a very high-risk area, they do also have contact – although we are very, very careful in brieing people to avoid personal contact – outside of the treatment centre.71 In these cases it is clear that caregivers in the process of carrying out their duties of employment are disciplined into behaving correctly in order to ensure their own and others’ security. And yet even here we see a global health approach that privileges a ‘technological ix’ for the problems of discipline and the risk individual mistakes in removing PPE can pose. A case in point is the aforementioned new PPE designed by Johns Hopkins to mitigate the risks of heat, as it is also designed to lessen the potential risks in removing the suit. As the Johns Hopkins Ebola Hub says: THIRd WoRLd QUARTERLY 519 The Johns Hopkins prototype is designed to do a better job than current garments in keeping health care workers from coming in contact with Ebola patients’ contagious body luids, both during treatment and while removing a soiled suit.72 Such a ‘technological ix’, while being attentive to the previous deiciencies and weaknesses of PPE, and to the fallibility of its human subjects, creates a suit that circumvents and makes no attempt to address the messy political and structural realities and inequalities that underpin local health care provision in West Africa. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 Conclusion This article has explored the intersections and symbioses of the human and non-human in processes of governance using the symbiotic and historical relationship between humanitarian practice – as a ield constituted around the human73 – and technology, devices and material in performing both individual patient care and biosecurity. In advancing the analytic of the device it has argued for understanding how PPE mediates between on-the-ground humanitarian biomedicine and global biosecurity. PPE here is an important risk-mediator where its wearers are both at risk of catching the virus and simultaneously a risk as a possible transmission vector. Through tracing the work PPE does as a humanitarian device, the continuum of risk faced by many involved in the humanitarian response to Ebola, and the dual role they played, has been highlighted. In exploring how PPE facilitates wider humanitarian techniques, the article has traced the messy networks and worlds produced and consolidated through the use of PPE in the governance of Ebola. It has extended the analytic of barriers concerned with governing circulation to encompass barriers at the level of the individual human body. Meanwhile, it has shown how PPE also challenges the primacy of biopolitics in a biosecurity response concerned with protecting populations by exploring PPE’s role in producing and consolidating a particular politics of life. Here PPE privileges the humanitarian as the risky subject and therefore the subject of protection, recalibrating the relationship between victim and saviour in humanitarian practice and reproducing pre-existing racial and socioeconomic hierarchies between a technically capable West and countries lacking in even the most basic of resources. An analysis of the politics of life produced by PPE leads to much wider questions around whose security was being managed and whose security was being disregarded in the humanitarian biomedical response to Ebola, with attempts to provide patient-centred care while also pre-emptively managing the biosecurity of those populations not afected by the pandemic. The biopolitics of biosecurity, concerned with technical ixes and management systems, is also unsettled through the individualisation of risk and issues of discipline and labour. In doing this, the article has argued that, while humanitarian practice has the tendency to fetishise objects in the pursuit of technical ixes for complex emergencies, objects cannot be considered solely in this vein. PPE works to complicate the idea of the technological ix by making its case as a necessary facilitator of life-saving interventions, while also having its own faults technologically ixed for improved eiciency and risk management. In uncovering what work PPE does, an additional empirical case has been ofered, to add to those ofered previously by Redield and Scott-Smith, to highlight the complex sociologies of devices used in humanitarian practice and wider biosecurity. 520 P. PALLISTER-WILKInS Disclosure statement no potential conlict of interest was reported by the author. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 Acknowledgements I would like to thank the reviewers and editors for their engagement with this piece and the insightful comments and suggestions. I would like to thank those members of MSF-Holland and those in the operational Centre in Amsterdam who shared their experiences and insights with me and listened to my arguments. Thanks must go to Alison Howell, Lee Seymour and those present at the ‘Humanitarianism and Technology: Agents, Actions and orders’ panel held during the 2015 ISA conference in new orleans, where this article was irst presented. In addition, thanks to those at the ‘The ontological Politics of Security: Materialism and discontents’ panel of the 2015 EISA conference in Sicily for their comments, questions and suggestions, with special thanks to Rocco Bellanova. Notes on Contributor Polly Pallister-Wilkins specialises in the intersection of humanitarian intervention and border control. Her current research is concerned with what she terms ‘humanitarian borderwork’ in Europe and builds on previous research into humanitarianism, border policing and the political sociologies of walls, fences and security barriers. Her regional areas of expertise are the Mediterranean, speciically Greece, and the Middle East. Her doctoral research was undertaken at SoAS, University of London and focused on the Security/Separation Barrier in the occupied West Bank and the resistance it engendered among Palestinians and Israelis. Notes 1. Hinshaw, “Ebola Virus.” 2. See MSF’s interactive tour of PPE: http://www.msf.org/article/interactive-learn-about-ourebola-protective-equipment. 3. Blackburn, “Gunboat Abolitionism.” 4. Turner, “The Enclave Society,” 290–291. 5. Redield, “Bioexpectations”; and Scott-Smith, “The Fetishism of Humanitarian objects.” 6. Scott-Smith, “The Fetishism of Humanitarian objects.” 7. Amicelle et al., “Questioning Security devices.” 8. “Ebola: A Challenge to our Humanitarian Identity – A Letter to the MSF Movement,” an internal letter written by nine MSF practitioners to the movement in december, 2014. http://www.youscribe.com/BookReader/IframeEmbed?productId=2541547&width= auto&height=auto&star tPage=1&displayMode=scroll&documentId=2622078& fullscreen=1&token=aJnTPzsW88Pb%2bKLv2wQl6egMIn58L6IVJM wGsoZGenEuoQVCugGs1dfeITn6jz6uIJnT99yY6KhGt13Mn8XtnQ%3d%3d. The letter appeared in Libération, February 3, 2015 . http://www.liberation.fr/terre/2015/02/03/parfoisle-traitement-symptomatique-a-ete-neglige-voire-oublie_1194960. 9. MSF, Ebola. 10. Abdelnour and Saeed, “Technologizing Humanitarian Space”; and Scott-Smith, “The Fetishism of Humanitarian objects.” 11. Barad, “Getting Real,” 108. 12. Fassin, “Humanitarianism as a Politics of Life.” 13. Barnett and Weiss, Humanitarianism in Question. 14. Lakof, “Two Regimes of Global Health,” 64. 15. Lakof, “Two Regimes of Global Health,” 63. Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 THIRd WoRLd QUARTERLY 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 521 Lakof, “Two Regimes of Global Health,” 59. Lakof, “Two Regimes of Global Health,” 67. Ibid. Redield, “Vital Mobility,” 147. Redield, “Vital Mobility,” 148. Scott-Smith, “The Fetishism of Humanitarian objects,” 914. Ibid. Amicelle et al., “Questioning Security devices.” Foucault, “The Birth of Biopolitics.” Fassin, “Humanitarianism as a Politics of Life,” 501. Ibid. Farmer, “diary,” 39. http://www.pih.org/. Farmer, “diary,” 39. However, I do not discount the role of space, such as in the creation of Ebola treatment centres that make use of a range of devices seeking to manage the circulation of patients, staf and systems of triage, and the wider systems of logistics governing the response to the pandemic, or the longer-term viable health systems needed to address the structural factors underpinning the speciics of this Ebola outbreak. Redield, “Medical Vulnerability.” Park and Umlauf, “Caring as Existential Insecurity.” MSF, Ebola, 7. dr. Javid Abdelmoneim, MSF doctor in Sierra Leone, quoted in MSF, Ebola, 17 . Voelkner, “Managing Pathogenic Circulation,” 240. Park and Umlauf, “Caring as Existential Insecurity,” 3. For more on barriers as more than blockading technologies and as selectively permeable membranes, see Pallister-Wilkins, “Bridging the divide.” Redield, “Vital Mobility.” Voelkner, “Managing Pathogenic Circulation.” Farmer, “diary.” MSF, Ebola, 17. dr. Hilde de Clerck, see note 12 above, 17. Radin, “Frozen by the Hot Zone.” MSF, Ebola, 9. Intravenous rehydration through the use of IVs in treating Ebola patients is a source of much disagreement within the medical and humanitarian world. See USAId, Fighting Ebola: A Grand Challenge for Development, 2014, http://www.usaid.gov/ news-information/press-releases/dec-12-2014-united-states-announces-results-grandchallenge-ight-ebola. See John Hopkins’ Ebola Hub: http://hub.jhu.edu/2014/12/12/ebola-suit-design-funding. Fassin, “Humanitarian Reason.” dr Jean-Clément Cabrol, MSF director of operations, quoted in MSF, Ebola, 12. de Clerck, Ibid. Lindis Hurum, quoted in MSF, Ebola, 10. Brice de le Vingne, MSF director of operations, quoted in MSF, Ebola, 9. Hurum, Ibid. Henry Gray, MSF emergency coordinator, quoted in MSF, Ebola, 17. Frankfurter, “The danger.” Frankfurter was a health worker in Sierra Leone. dr Joanne Liu, MSF international president, quoted in MSF, Pushed to the Limit, 11. MSF, Ebola, 14. Farmer, “diary,” 39. Anna Halford, MSF coordinator for distribution, quoted in MSF, Ebola, 18. Rosa Crestani, MSF Ebola task force coordinator, quoted in MSF, Ebola, 10. Farmer, “diary,” 39. 522 P. PALLISTER-WILKInS Downloaded by [UVA Universiteitsbibliotheek SZ] at 08:56 10 March 2016 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. Beisel, “on Gloves,” 2. MSF, Ebola, 19. 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