4

RE-THINKING THE GLOBAL HEALTH

EMERGENCY
Power at work in making and shaping global
health crises

Sometimes it felt like we were being forced to sing a song no one had any interest in singing.
– Marc, Interview

In the middle of writing this book, the world was stopped by a global health crisis
continually described as unprecedented. Coronavirus-19 or more widely known as
COVID-19 was not, however, the first virus of this type to breach the zoonotic
barrier1; however, the pace and rate at which it spread across much of the planet
drove a much quicker move to declare it a public health emergency of international
concern (PHEOIC) on 30 January 2020.
The last time a PHEOIC was declared was during the 2014 West African Ebola
Crisis. Ebola, a hemmoragic fever caused by a filovirus, is named after the river
Ebola which travels through the north of the Democratic Republic of Congo.
Ebola has a high mortality rate, claiming the lives of around 50% of those who are
exposed to it, though recent WHO statistics suggest that rates of death in various
outbreaks range from 20% to 90%. There are five known subtypes, each named
after the geographical location where it emerged: Zaire, Bundibugyo, Sudan,
Reston and Taï Forest, though the largest outbreaks have been linked to Zaire
and Sudan streams (WHO, 2017). Though its symptoms are similar to Malaria
and the Flu in its initial onset, its progression is far more severe – with patients
experiencing severe diarrhoea, dehydration and death within days of contracting
the disease.
During the 2014-16 outbreak, the language of emergency was heavily leveraged
to mobilise a global response to what was, at the time, the worst Ebola outbreak in
history, resulting in more than 11,000 deaths (Chérif et al., 2017). The language of
emergency helped to raise more than 459 million dollars for the Ebola response

DOI: 10.4324/9781315623788-4
This chapter has been made available under a CC-BY-NC-ND 4.0 license.
60 Re-thinking the global health emergency

(WHO, 2016). But by 2017, Ebola emerged again, in Democratic Republic of

Congo (DRC), an outbreak that has continued till 2020. Though the DRC
outbreak was the second largest in history, the language emergency was not
leveraged to the same extent – despite arguments that the DRC, a country
plagued by civil war, has been in a state of crisis since 1997. In 2022, Ebola
appeared again, this time in Uganda and eastern Africa, a region where inter-
national engagement is longstanding. Who and what has the power to determine
what counts as emergency? What bodies and places are deserving of our inter-
vention? What does the power at work in ‘emergency’ contexts produce? To
explore these questions in more depth, this chapter turns to the 2014–2016 Ebola
outbreak in West Africa, and the story of Marc, an advisor working for Medicens
Sans Fronteirs.

Life after Ebola? Undertanding the ‘original’ emergency

Marc*,2 arrived in Sierra Leone in 2018, in the wake of the Ebola pandemic. ‘It was
a hard time to join the ranks – everything was in transition’ he told me in an
interview, in early 2020. During the height of the outbreak Sierra Leone was a site
where multiple Medicines Sans Frontieres (MSF) branches were situated; Spain,
Netherlands and Belgium, each with varying inputs and responsibilities. However,
by the time Marc had arrived, Spain and Netherlands had begun to pull out, leaving
the Belgian section behind. To their credit, the desire to remain was, as Marc put it,
a reflection of the ‘tensions’ within modern humanitarian practice in health. During
our conversation, he noted the mood at the 2017 UK general meetings reflected
similar interests.

There were a lot of internal discussions as to what the, MSF presence in Sierra Leone
would look like in the post Ebola periods … I recall going to one of the MSF UK annual
general meetings.. in which there was a very clear commitment was made to continue to
work in Sierra Leone … a certain sort of moral obligation that had developed because of
[Ebola] to the Ministry of health, and people felt very strongly that we should maintain
some long term commitment.

What this equated to for MSF (Belgium) in Sierra Leone was a renewed focus on
health systems investment, linked directly to his role to expanding and deepening
investment . Of course, this is a step in the right direction. A major reason why the
outbreak was thought to have spread so rapidly was the weakness of health systems
in these west African countries, legacies of conflict and state failure. In an analysis of
Ebola as a complex emergency, Piot, Muyembe and Edmunds (2014) identify a
perfect storm of conditions driving the rapid spread of the virus in 2014: decades of
civil war leading to a low level of trust in authorities despite their efforts to
reconstruct the country; dysfunctional health services and health worker scarcity
(particularly in Liberia and Sierra Leone). On the cultural side, they noted strong
 Re-thinking the global health emergency 61

traditional beliefs in disease causation and denial of the virus’ existence; high-risk
traditional funeral practices that amplified transmission, including recent healing
where the bodies of patients with Ebola are touched. Finally, in the global domain,
a slow and inadequate national and international response and high population
mobility across borders.
However, nowhere on this list appears any mention of the systemically imposed
underdevelopment of these three countries, mediated through structural domains of
power driving globalisation processes. The International Monetary Fund has pro-
vided support to Guinea, Liberia and Sierra Leone, for 21, 7 and 19 years,
respectively, and at the time of the outbreak, all three countries remained under
IMF programmes. Such lending comes with strings attached – so-called ‘condi-
tionalities’ – that require recipient governments to adopt policies widely criticised
for prioritising short-term economic objectives over investment in health and
education. As many have pointed to, these structural adjustment policies have not
equated to improved economic performance in many spaces, but have created the
crumbling of health and social welfare systems (Hickel, 2016).
Kentikelenis et al. (2015) reviewed the impact of a series of IMF-advocated
policies from the 90s on establishing health systems fragility in the region, con-
cluding it contributed heavily to the rapid spread of the illness. For example, they
note that the prioritisation of debt repayments at the expense of public spending
resulted in missing targets for social spending (on key areas such as health) in 2013
prior to the first outbreaks of Ebola. These strategies also impacted on health
workforce spending – where in Sierra Leone, for example, IMF-mandated policies
explicitly sought the reduction of public sector employment. Between 1995 and
1996, the IMF demanded retrenchment of 28% of government employees. The
limits placed on wages continued well into the 2000s, and in 2004, they noted that
the country was spending less on wages than the average in Sub-Saharan Africa.
Figures like this make the temporary infrastructures associated with humanitarian
health interventions all the more heart breaking – the graveyards of ambulances that
countries don’t have the money to maintain after an organisation has left; the empty
lots of land where temporary health sites once stood. These become the remnants of
international investment once an emergency has been ’solved’, once cases recede
and life begins to return to normal. Its as though there is a collective amnesia, a
forgetting, that the ’normal’ returned to in many places where emergency resides, is
nothing but. It is not normal for a country of 7 million people, to have fewer than
200 doctors (0.04 per 1000) (McPake, Dayal & Herbst, 2019). With each inter-
vention, there is a hoping for more - but what transpires is rarely that. In Laurie
Garrett’s account of the 1995 Ebola outbreak in Zaire(now DRC), a similar process
of hoping for more is cristalised in the following quote:

When the international response came we were happy. We knew WHO came here to save
our lives … In that time the entire world community came here to Kikwit, and [it] became
the centre of the world. The population believed that because of the terrible disease a health
62 Re-thinking the global health emergency

infrastructure would be developed … but everything has returned to square one, where
people are suffering to find medicine and medical support. Everything is forgoten. Could it
happen again? For sure! There are no changes – Lusilu Manikasa, Nurse, Zaire (DRC).
(Garrett, 2014, p. 104)

In my conversations with Marc, he recalled coming across an ‘ambulance grave-

yard’ in his first few days in country - more than 20 years on. . In light of these
histories, Marc’s accounts of the new phase of work entered into by MSF, their
interest in health systems strengthening and improvement, are welcome, and long
overdue. In the region prior to this, very few organisations worked in models that
focused on strategies of long-term engagement and development, and those who did,
represented the few success stories from the crisis. In fact the success stories of Ebola
revolve around the practices that do the opposite to traditional humanitarain practices.
For example, Partners in Health (PIH) was also based in Serria Leone during the crisis.
Evidence suggests that their strategies, rooted in a biosocial approach to health that
attends to the social, political, ecological and economic drivers of poor health, were
able to manage the emergency while holding an eye to the future. Cancedda and
colleagues’ (2016) account of PIH work in four highly affected districts signified a
commitment to health systems development during and after the crisis. First, they
opted to reinforce ongoing government efforts, working to support capacity and
resource gaps beyond human resources and medical supplies. By strengthening pol-
icies and procedures for health service delivery, and redevelopment of existing
government facilities instead of building new temporary structures, they reflected a
concerted effort to reject the paternalisim that drives much securitised and humani-
tarian approaches taking place at the same time.
And yet, despite the emergence of a new discourse guiding the practices of MSF
in Sierra Leone in the years post Ebola, remnants of this old practice remained. As
we neared the end of our interview, Marc mentioned that part of the local efforts he
saw there involved the construction of a new hospital. I was delighted, excited and
hopeful. The project had been planned during the height of the Ebola period, a
response to shortages in addition to community outreach initiatives. In response to
my question about where it was being built, he paused a smile in his voice ‘a project
built from scratch, on an empty plot of land about 10 km away from Kenema city where there
is, of course, already a functional government hospital’. This decision, in a context where
92% of doctors and 72% of nurses reside in urban areas, but only 18% of the
poulation does (McPake, Dayal & Herbst, 2019), beggars belief.
As Marc and I continued our discussions, the challenges behind the planned
centre for excellence around issues linked to longer wave investment in the local
health system development emerged. An emphasis on pediatric care and reducing
maternal mortality within this new site is exciting. Sierra Leone has a maternal
mortality ratio of 1 in 75 pregnancies resulting in maternal death (The World Bank,
2015), which is one of the highest in the world. . But the historical backdrop to this
tale seems inescapable. A specialised center, in many ways overlooks other health
 Re-thinking the global health emergency 63

challenges that faces citizens of Sierra Leone. The recent World Health
Organisation country cooperation strategy identified that only 13% of the popu-
lation had access to adequate sanitation facilities (WHO, 2017), which have knock
on consequences for a range of infectious disease burdens. Furthermore, the rem-
nants of the temporality driving humanitarian engagement were also painfully
evident: even in attempts to engage in structural advancement, a hospital is built in
temporal ways. Marc described the use of technologies that on one hand, minimise
transmissions of infections via easy to clean surfaces, but on the other, only have a
lifespan of only 10–15 years. The temporality within emergencies remains a posi-
tion that seems hard to shift.
Many have struggled to make sense of what exactly went wrong in managing the
2014–2016 outbreak. Before the west African outbreak, MacNeil and Rollin (2012)
suggest that Ebola should belong to the category of conditions called ‘neglected
tropical diseases’ given it’s comparatively rare presence in the global health arena,
and it’s disproportionate impact on the poorest countries and most under resourced
health systems. However, post-2014, there is little possibility it could hold such a
label. A Lancet editorial published at the height of the 2014–2016 outbreak
Professor Peter Piot argued that Ebola was no longer simply a disease outbreak, but
now a humanitarian emergency of a global scale. Piot argued that this was the world’s
first ‘global health humanitarian crisis’ . Unlike previous Public Health Emergencies of
International Concern, governed by the International Health Regulations (IHR)
such as Swine Flu (2009), and the Zika virus (2016), the realities of the location of
the pandemic, the region’s geopolitical histories and contemporary realities created
a ‘perfect storm’, where public health concerns intersected with humanitarian
discourses of emergency, aid appeals and securitisation (Piot, 2014; Nunes, 2017).
At the peak of the two-year response, academic and media outlets attempted to
grapple with the ‘how’ of this particular outbreak, in the wake of what many called
a failure of global systems of monitoring and response. For example, critical global
health scholar Laurie Garret has argued that the response was badly mishandled by
the WHO, most clearly in its delayed declaration of a PHEOIC, which didn’t occur
until 8 August 2014, many months after the first cases were identified. In a world
that is, at most times, in most places, experiencing some sort of emergency, why
didn’t we act sooner, and why weren’t we, as a global community better prepared?
A collage of reasons have been offered, most of which, like Garrett, focus on the
mechanisms of global health governance, which resides firmly in what Collins
(2012) defines as disciplinary spheres of power. Global health governance is a complex
space of actors, institutions and processes that, when working effectively have
the ability to promote the achievement of good health. The rules, regulations
and practices established by these actors work within, and across national and
regional boundaries, though some factors and determinants also also understood
to operate transnationally (Dodgson, Lee and Drager, 2002; Kickbusch and
Szabo, 2014). For example, Clare Wenham (2016) argued that a general lack of
64 Re-thinking the global health emergency

preparedness and coordination at the global levels of the WHO contributed to

challenges in the response, shaped by limitations of country level reporting from
countries at the epicentre. However, Joao Nunes of MSF (2017) positions failures
more widely in the hegemonic and structural domains of power; reflecting on how
norms around securitisation processes within the global health space limited local-
level action.
Unfortunately, fewer explorations into the ‘how’, ‘why’ and ‘what next’ of the
Ebola response focused explicitly on power relations beyond the domain of gov-
ernance. Linked to this is the underestimation of the importance of understanding
power at work when organising action under the idea of the ‘emergency’ in the first
place. Ideas and ideals (or discourse) exists within the domain of hegemonic power,
which intersect with and are maintained by structural types of power anchored to
legacies of colonial rule and oppression. As the world continue to grapple with
‘emergencies’ in various forms, it is worth considering what is gained and lost in use
of a discourse of this nature in the global health space.
The rest of the chapter proceeds as follows. First, we explore an account of the
history of the ideal of emergency in humanitarianism and global health, tracing the
power dynamics that anchor it to global health and humanitarian and practice.
Then, it reflects on how this language of emergency manifests in framings and
shaping of further ideas, actions and practices. It suggests that Stephen Lukes third
form of power, defined as, ‘the ability to decide what can be decided’, is more than just
politics, and that decision-making power in this context is inseparable from the
normative power of the idea of emergency itself. This in turn is supported by
constellations of other power forms, such as paternalism. What this produces by way
of validation or invalidation of local knowledge and governance systems is critical to
global health and worthy of our attention.

The power of an idea: The global health/humanitarian emergency

The idea of the ‘emergency’ holds great power. In fact, how many everyday people
make sense of the purpose and content of humanitarian and global health work is
linked to this imaginary. It is a concept that calls people to action, building on a
social and moral code which demands that a particular event, and its consequences ,
must be responded to. In his 2004 work ‘A world of emergencies’, Craig Calhoun
argued that ‘emergency’ is a way of grasping problematic events. It allows us to
imagine them in a way that focuses attention to features such as their
unpredictability, abnormality and importantly, their brevity, which means they can
and should be managed. When one mentions international emergencies, many
international organisations responsible for this management easily spring to mind;
MSF, World Health Organisation (WHO), Oxfam. But in making sense of where
and how these associations emerge, we need to examine one of the key premises at
the heart of global health and humanitarian responses under the umbrealla of
emergency: the right to interfere. According to Allen and Styan (2000), the right to
 Re-thinking the global health emergency 65

interfere became synonymous with humanitarian and NGO practices through a

complex process, where interventionism in the name of humanitarianism became
more explicit. Specifically, they link it with the establishment of the most well-
known international humanitarian agency, MSF.
In reflecting on Bernard Kouchener’s work during the early years of the estab-
lishment of MSF, Allen and Styan (2000) clearly illustrate the power of a devel-
opment industry that marshals the idea of emergency defined by Calhoun (2004).
The transition between pre- and post-cold war politics signalled a transition in
thinking about aid and responsibility and moral obligations. Pre-cold war politics
was a period of development that focused on larger systems change; the overhaul of
politics, systems and structures to align them with principles of communism or
capitalism. In this era, large-scale development, projects and visions looked very
different to the post-cold war environments that dominat the first few decades of
global health and humanitarian practice. Now, the preference is short-term projects
that prove ‘success’, through focus on discrete outcomes and individual impact.
Within global health, this transition is embodied in the difference between the
hope, and reality of Primary Health Care. At the 1974 World Health Organisation
Alma-Ata meeting a dream to create Health for All through community and country
level action and social change targeting social and political drivers of poor health
never materialised. (Rifkin, 2018). Instead, the establishment of vertical health
interventions targeting specific health conditions, such as immunisation pro-
grammes and breastfeeding emerged, based on the arguments and interests in
advancing western donor progress (such as vaccine development) rather than local
‘action’ (Burgess, 2022).
These core national interests among donor countries coincided with a global shift
towards the ‘necessity’ of interference in humanitarian spheres. Doctor Bernard
Kouchner was working for the International Red Cross at the time of the Nigerian
civil war, established MSF in response to the failures of neutrality by organisations
during that period. Alongside colleagues he spoke publicly about atrocities hap-
pening in the country and formed MSF as a testament to the importance of acting in
response to the needs of people, rather than governments. By 1988, the right to
interfere was written into UN constitution with the passing resolution 43/131,
which, affirms the sovereignty of states on the one hand, but allows organisations
and actors in other countries the ability to act in ways that promote the survival of
victims, to preserve life and dignity (Allen and Styan, 2000, p. 831).
Though arguably pushed forward in part by one man’s politics and political
positioning, the idea of foreign government intervention to save lives has shaped an
entire field of practice. As time passed, development organisations working in low
resource settings globally contributed to the advancement of the pillars of short-
term and rapid interventionism (HPN, 2015). In Vanessa Pupavac (2006) neccessary
account of humanitarian emergencies and practices, she views short-term inter-
vention projects as anti-development. The humanitarian emphasis on survival in the
short term over a longer-term vision also contributes to a process of supporting the
66 Re-thinking the global health emergency

neo-liberal policies that embed countries in poverty, and promote development of

wealth in former colonial countries . For example, instead of widespread poverty
alleviation programmes orchestrated by state level intervention (such as debt relief),
sustainable development projects and associated humanitarian endeavours calls for
people to ‘end poverty for themselves’ through micro-finance schemes and small-
scale enterprises. Parts of this critique have been taken to heart by many humani-
tarian agencies; MSF being one such actor. In his chapter reflecting on the Ebola
Response, Nunes (2017) describes a ‘misrecognition’ of Ebola as a humanitarian
crisis, in direct contrast to Piot’s (2014) assessments. Nunes argued that this con-
tributed to the deployment of technocratic responses. This is a challenge for both
global health, and humanitariansim, which has been hard to shake, as it is emebdded
within the very ideas that establish the field in the first place.

Who knows best? Quick fixes, paternalism and the global health
emergency
The right to interfere embodies a form of power that is marshalled through inter-
personal and structural domains: paternalistic power or authority. Buchanan (2008)
defines paternalism as the removal of the decision-making power of individuals along
three pathways. First, by preventing them from doing what they desire; second, by
interfering in how they arrive at their decisions, or substituting one’s judgement for
theirs, in the name of improving their welfare. Debates on paternalism are no stranger
to the public health landscape. For example, Bartlett (2018) explores these dynamics
within the space of non-communicable disease prevention, reflecting on the ability of
policy actors to actively manipulate and frame ideas often away from public interest.
Childress and colleagues (2002) suggest that the management of illness or social threat
which poses a high probability of harm warrants paternalistic control. Thus it comes
to occupy a central space of global health governance, particularly within the contexts
of global health security interests, as seen within the COVID-19 debates.
Unsurprisingly many global health governance spaces struggle with this tension of
care and control, particularly in an era where power inequalities between nations,
states and legislative bodies are continually being debated. The interests of public
security continually misalign with public interest (Barreto, 2017). Still, within the
global health space, the emergency discourse is sustained by the fact that action is
driven by resource rich actors. If they view a context as ’emergency’ then they have
the access to structural and economic power that ensures their view, determines
action. Ultimatley, they that their decide what is to be decided.
To overcome this, humanitarian scholars like Dorothea Hilhorst highlight the
importance of viewing humanitarian spaces as dialogical, with a range of re-
lationships between key actors (donors, agencies, recipient countries and commu-
nity members) negotiating across varied aspirations meaning and assumptions about
target communities (Artur and Hilhorst, 2012; Hilhorst, 2018). While this has
resulted in governance spaces that argue for national-level led action on the crisis
 Re-thinking the global health emergency 67

itself, an interest in ‘state led’ responses have rarely translated into action that ad-
dressed the wider needs of that state, or local communities. For example, prior to
the Ebola outbreak in west Africa, policy and governance spaces have acknowl-
edged the devastating impact of structural adjustment policies on health-related
infrastructure (Heymann et al., 2015). However, global, or health specific invest-
ment in that region had not been directed towards redressing these challenges in the
lead up to or following the crisis. For example, according to the 2020 Financing
world health report data (IHME, 2020), DHA allocated to Sierra Leone in 2010
was 74 million. By 2015, one year after the outbreak began, this increased to 581
million. Much of this was targeted directly at Ebola activities. In 2022, Sierra Leone
recieved addtional $20.8 million as part of IMF facilities to support economic
programems that could make progress towards sistainable and improved macro-
econoimc growth. The reccomended ’growth enhancing reforms’ are focused
specifically on ’monetary tightening’ (IMF, 2022). These terms are in direct conflict
to the stated needs for health care stability and reform called for by the WHO,
which call for increased investment in the health workforce in the next few decades
(Boniol, Kunjumen, Nair, et al., 2022).
Paternalism and it’s impact on the failures seen during the West African crisis em-
bodies the tendency for humanitarian and global health disciplines, and the wider
structures that sustain them, to doubt the capacity of communities to lead responses to
their own crises. Paul Richard’s (2016) work on the outbreak details successes achieved
by rural communities in Sierra Leone who, in the weeks and months prior to the arrival
of external intervention, rapidly adapted and deployed their own practices to protect
themselves and loved ones, linked to traditional ethics of care. Richards refers to the
subsequent erasure of local practice by western actors and systems in the name of care, as
the growth of ignorance (p. 8) a social process, initially described by Mark Hobart as the
purposeful cultivation of ignorance as a form of protectionism by certain actors.
This resonates with Stanley Cohen’s writing on Denial (2013), who argues that the
inability of the human conscious to absorb the full reality of our environments means
that denial emerges as a logical mechanism for survival – we continue to operate within
the current state of affairs. Within Ebola, Richard suggests that this manifested as the
outright denial of the ability of communities to do home care of any kind during the
outbreak. However, over time, the international response eventually, with focused
lobbying, acknowledged and incorporated their innovations. For example, with
respect to burial practices and home care, Richards focused on the story of the response
to Ebola in Jawei Chiefdom; located in the epicentre of the epidemic in Sierra Leone.
The first confirmed case of Ebola in the country was in May 2014 – but Chief Kallon
were warned about Ebola by the local government much earlier, in March that year.
After falling ill with Ebola himself, he marshalled a local task force of 55 young men
from across his chiefdom, paid for their training in virology and use of personal pro-
tective equipment. Crucially, he revived an old traditional burial practice, which
meant young people managed burials of elders – meaning only young men trained in
safe handling and burial procedures handled bodies in their most infectious stages
68 Re-thinking the global health emergency

(Richards, 2016). Despite the successes seen by these practices in the early stages of the
outbreak, the arrival of international intervention threatened to bring them to an end:

The approach adopted in Jiawei chiefdom later became the model for local Ebola response
throughout Sierra Leone … byelaws were introduced nationally from August 2014 …
security services and other government agencies began to support these local initiatives …
Task forces were initially successful at finding cases, reducing inter-village movement, and
enforcing bye-laws. The Jawei force undertook ‘safe burial’ from the outset, having been
trained and equipped. Task forces were threatened with marginalization after the
militarization of the Ebola response accompanying the international surge from
November 2014. but paramount chiefs successfully petitioned State house not to exclude
chiefdom task forces from the ramped up response.
(Richards, p. 131)

It is not hard to see that denial of local capacity is somewhat inseperable from the
logic of emergencies and humanitarian practice. Recent analysis by Dorothea
Hilhorst (Hilhorst, 2018) explores the tensions between Dunantists and Resilience
based paradigms of humanitarian action. She highlights that, within the latter, which
occupies the current focus of humanitarian praxis, have shifted their commitment to
engagement with community, replacing language such as ‘recipient’ with terms like
clients and survivors. But even within such framing, the outcome created remains
limited by a short-term logic. On the one hand, Dunantist humanitarianism is limited
by an inability to truly view communities on the ground as partners:

Although aid in this tradition is motivated by the desire to relieve suffering and is based on
the ethics of a shared humanity, in practice, it is really delivered on the basis of mistrust of
the society in which it operates, and the local providers of aid and the aid recipients must be
kept under close surveillance.
(Hilhorst, p. 5)

On the other hand, while resilience humanitarianism appears to be better suited

to the social realities of continued and cyclical crisis (p. 9), it also places the burden
of long-term survival on the shoulders of those who are made more vulnerable
through crisis, which individualises and celebrates resilience:

In a world in which an estimated one billion people – migrants and resident poor – are part
of this precariat, refugees may become a hardly distinguishable lot of urban poor, and is
equally left to fend for themselves. There is a real risk that the politics of resilience towards
refugees turns instead to a politics of abandonment.
(Hilhorst, p. 6)

Hilhorst’s vision for a way beyond these dichotomies calls for new ways of
working; that resonates more with longer term investment and engagement in
 Re-thinking the global health emergency 69

spaces before during and after crisis. The West African Ebola crisis has pushed the
need for this transition further, with more classic Duantist organisations such as
MSF picking up this mantle of shifting away from the complexities and limitations
of their work. In 2017, MSFs published an edited volume on the challenges faced
by the organisation during the West African outbreak. A large focus of the book
was an analysis of the impact of a securitisation discourse on their practices, reso-
nating with critiques raised by Harman and Wenham (2018). However, the politics
of fear and the process of securitisation are linked with the push towards short-term
logic and engagements. As Joao Nunes (2017) notes, ‘The politics of fear has lead to
a short-termist agenda focused on crisis management and disease containment’
(p. 19). However, such a claim is rooted in an underappreciation of the ways in
which the entire logic of interventionism in Humanitarianism and global health
more broadly has a propensity for such interventions. It is no surprise, that the
afterlife of humanitarian discourse, is harder to shift than we imagine. This is clearly
embodied in Marc’s story – and an ongoing dissatisfaction with processes that erase
critical local knowledge and learning that could meaningfully contribute to pre-
paring for future emergencies, or better yet, preventing them from becoming
emergencies in the first place.
Another, and potentially more entrenched implication of the paternalism em-
bodied within emergency discourse, is the way in which it shapes relationships
between states and citizens in resource rich countries, and their perceptions of need,
action and responsibility to the majority world. The dynamics and relationships
between states and their own citizens also shape aid practices, and contribute to the
‘politics of fear’ described by Nunes (2017). Broadly, we know that aid is linked to
domestic political ideologies, and as well as the presence or absence of public, or
political will (Wood and Hoy, 2018). However, it would be unwise to under-
estimate how power also works in subtle and overt ways to shape or limit the
political interest in certain stories, and how this determines which ones capture the
notion of ‘emergency’ in the first place.
Stanley Cohen’s 2004 once more provides a valuable platform to interrogate
this nuanced marshalling of paternalistic power within the humanitarian arena. In
making sense of how the denial of certain atrocities is possible for those who
view the suffering of distant others (the external audiences), he introduces the
concept of the bystander state. This concept allows us to understand the role of
governments in enabling citizens to turn a ‘blind eye’; or ‘unsee’, what they
already have partial knowledge of. This could include the ability for states to
deny their understanding of the pre-existing realities within west-African
countries affected by the 2014–2016 outbreak, and how new practices interact
with these contexts. Drawing on examples of previous global health challenges,
including HIV, Cohen highlights how state actors need everyday citizens to be
aware, but simultaneously blinded to complicated truths. In the case of Ebola,
this amounts to the need to limit citizens from understanding the direct and
indirect contributions of rich nations to the current states of underdevelopment
70 Re-thinking the global health emergency

within the epicentre nations – namely previously mentioned IMF policies and
their downstream consequences. But feel the urgency of the current emergency
to contribute to new action they determine as neccesarry.
A mechanism viewed as enabling and benefiting from this partial ‘seeing’ which
happens in global health and humanitarianism spaces are public appeals. Such in-
itiatives draw on the notion of a collective responsibility and ownership of response in
response to crises. A significant portion of Cohen’s analysis focuses on this phe-
nomenon. He postulates, that these approaches are crucial to state mechanisms which
attempt to create the illusion of action in response to crisis. A rapid google search of
the phrase ‘Ebola public appeals’ generated more than 42,000,000 items, reflecting the
various phases of what Stanley Cohen (2011) defines as the appeal dynamic: public
announcement, media response and reporting. The Ebola crisis signified for many
disaster organisations a significant shift in mechanisms for engagement, perhaps for the
first time, wading into the global health sphere as the core definition of emergency.
For example, the Disasters Emergency Committee (DEC) who co-ordinates joint
public appeals bringing together the 14 leading aid agencies working in response to
disasters, identified Ebola as their first ‘health-related emergency’ and through a
combination of public appeals and matched funding, raised £12 million dollars in six
days, raising £6 million in the first 24 hours (Corfe, 2014). The impact of these funds
is rarely explored – often because to do so illuminates the limitations of the current
system, where evidence indicate that these types of bilateral funding arrangements
follow donor priorities, rather than national/community ones (Fuchs and Öhler,
2021). But one clear result is its ability to establish a system of accountability to
everyday citizens, who are unsurprisingly satisfied with ‘quick fixes’ and a focus
specifically on the disease at hand. It is easier to justify spending funds on Ebola
treatment centres, than the building of new permanent infrastructure that could work
across a series of health challenges facing western African countries when you have
never been educated about the ways in which these same countries were prevented
from building permanent structures for the past 50 years.

Conclusion: Where to for the next emergency?

My conversations with Marc are a lamentation from a global health and humanitarian
practitioner on the front lines haunted by the acknowledgement that much of his work
involves the repeated use of tools that are not always fit for purpose. In a highly cited
publication in the New England Journal of Medicine, he predicted the current state of
affairs as the world grapples with its next emergency, COVID-19.

As the Ebola epidemic fades from the world’s attention, we risk missing the opportunity to
learn from it. Even if the system we have today had worked perfectly for Ebola, it would fail to
contain a more infectious disease. It’s instructive to compare our preparations for epidemics
with our preparations for another sort of global threat – war.
(Gates, 2015, p. 1381)
 Re-thinking the global health emergency 71

We were not ready. Not even close. Yet at the time, he drew heavily on the
discourse of emergency and crisis around Ebola to call for the establishment of new
systems of governance, funding and management, and largely around technological
advances. None of the things he advocated for were likely to provide Marc, or
communities at the epicentre of the outbreak, with much solace during COVID. In
fact, many of the successes achived during this outbreak, were established by
National actions, with local paretners taking the lead, and International partners
having more auxillary roles. For example, an International red Cross report on
successes during the pandemic, noted that mobilsing with local chifdoms enabled
critical local action around screening, health communication of risk, and work to
challenge qeustiosn and rumors in early days of the pandemic (IFRC, N.D).
This, is a huge contrast with the action linked to the arrival of international support
in November 2014 in the epicentres, which meant the unravelling of many local
structures.. The assumption of a Tabula Rasa was enabled by paternalistic power
operating across multiple decision-making processes. The wider allure of the emer-
gency idea in the general population will continue to support additional resources being
funnelled into this system. One wonders what might have happened if communities
who had adapted successful practices locally became the starting point for action and
investment. The impact that COVID had in high-income countries meant that foregin
attention was focused internally, leaving space for more independence of local actors in
low resource countries. The disbelief in lower numbers of impact in these countries is
also shaped by this same deinal linked to paternalism: where it is not possible that ‘they’
could survive without our intervention. One could hope that we have turned a new
leaf in humanitarian praxis, as this new pandemic has made clear the possibilities that
emerge when community ownership and expertise is the starting point, rather than the
afterthought in a response strategy.
The main barrier to humanitarian global health spaces seems to be assumptions made
about the goals and the roles of humanitarian interventions. Their short-term nature
means that the emphasis is often rooted in what Nelson and Prilleltensky (2010) argue as
the error of viewing actors primary role in interventiosn as linked to compliance with
the intervention –rather than viewing communities as routes to leading a response to
crisis. As seen in Richards’ (2016) work, what local communities and States are expected
to do is to adhere to the frameworks and strategies established and verified by external
actors. And as Hillhorst (2018) reminds us, this is a problem across the entirety of the
humanitarian and global health landscape. The long-term consequences of assumptions
fuelled by paternalistic power at work across multiple domains are perhaps most painfully
seen in the country at the heart of the case study in our next chapter: Haiti.

Notes
1 The wetlab/ zoontoic barrier is one of multiple proposed theories for the origins of
Coronavirus-19.
2 Name and details changed to protect anonymity.