The Sins of the Other or Silence of the Self? – Ebola in West Africa

By Alexandra L. Phelan | 21 Aug 14

Even in the twenty-first century, the most vulnerable members of our global society continue to disproportionately carry the burden of infectious disease. The current outbreak of Ebola in West Africa is a compelling example of how inequity, inequality, and injustice are powerful determinants of health.

In August last year, I started my doctorate of global health law in Washington D.C. My research examines how laws impact global health. In particular, whether laws designed to prevent and control infectious diseases are both effective and compatible with human rights.

While the focus of global health is shifting to non-communicable diseases like obesity and diabetes, infectious diseases are far from eradication. New diseases are emerging (like SARS or MERS) and old ones re-emerging (like Polio).

From Local Outbreak to Global Concern

It was early July when I first thought about writing this piece. I was following a growing Ebola outbreak in West Africa closely, but it had received minimal media attention: just another infectious disease, in another post-conflict developing region.

At that time, the World Health Organization (WHO) put the total number of people infected with Ebola in the West African nations of Guinea, Liberia, and Sierra Leone at nearly eight hundred, of which five hundred had died.

But then, over the following month, the total number of Ebola cases jumped. A Liberian man visiting Nigeria died in Africa’s most populous city, Lagos, and two American aid workers were infected.

Western media outlets began to pay attention, and friends started asking me whether we were at risk of Ebola here in Australia.

For Europe, the US, Australia and other developed countries, the outbreak was no longer simply a disease in a far off region; the outbreak had become both a political and a security issue.

On August 8 the Director-General of the WHO declared the Ebola outbreak in West Africa a public health emergency of international concern. The epidemic was now officially a global issue.

As of August 13 there have been 2,127 cases of Ebola, including 1145 deaths. Before December 2013, there were no recorded Ebola deaths in West Africa.

So why did this epidemic become the largest Ebola outbreak in history? And can it change Western attitudes to infectious diseases in developing countries?

What is Ebola and how is it treated?

Like many emerging diseases, the Ebola virus is zoonotic: animals carry the disease and transfer it to humans. Bats – and other “bush meat” animals – are the likely carriers of Ebola; infecting humans that come into close contact with bodily fluids when hunting or cooking.

Once Ebola has infected a person, it can be transmitted between people through direct contact with bodily fluids. Initially, Ebola symptoms are very similar to other diseases like malaria and typhoid fever, causing fever, vomiting, diarrhoea, and in some cases, bleeding (the most infamous of Ebola symptoms). In this current outbreak, the fatality rate is roughly 55 per cent, much lower than the 90 per cent from historical figures reported in the media.

There are no licensed vaccines or therapies for Ebola. Instead, basic supportive medical care is provided, which involves keeping patients hydrated and maintaining blood pressure to prevent organ failure.

While this improves the chance of survival, recent attention has shifted to experimental treatments. Last week, a WHO expert committee concluded that given the severity of the outbreak, and the lack of alternative treatment options, it is ethical to provide early access to experimental drugs.

At this stage it is not clear whether such treatments are safe or effective, and they are not in any sufficient supply to adequately be provided to the number of people infected in this outbreak.

The importance of traditional public health measures

Given these uncertainties, containing the spread of the outbreak quickly is vital. Traditional public health measures are very effective in containing Ebola. In particular, isolation of the sick, quarantine of close contacts like family members, and basic infection controls are highly successful in stopping the outbreak’s spread.

Essential basic infection controls include the use of personal protective equipment, like facemasks and gloves, correct hand washing, and equipment sterilisation and disinfection also work. But in Liberia, Sierra Leone, and Guinea – the West African countries experiencing the weight of this outbreak – effective implementation of even these rudimentary public health measures has been especially difficult.

Western media articles covering the outbreak have put the cause of this difficulty down social factors; sensationalising the role of religion, culture, and traditional beliefs.

“While it is tempting to dismiss religion in West Africa as promoting ignorance,

its broad influence can be harnessed

to engage with and provide education to local communities.”


The Role of Religion, Culture, and Traditional Beliefs

Religion is powerful in West Africa. In Liberia, overt Christianity mixes freely with local beliefs, including black magic. As a result, God is seen as both the cause and the solution to the current outbreak.

In August, religious leaders from the Liberia Council of Churches passed a resolution stating that Ebola was sent as a plague to punish Liberians for “corruption and immoral acts (such as homosexualism) that continue to penetrate the society”.

Pastors offered prayer as the only effective ward against Ebola, referencing Psalm 91 of the New Testament:

I will say of the Lord,
“He is my refuge and my fortress,
my God, in whom I trust.”
Surely he will save you
from the fowler’s snare
and from the deadly pestilence.

While it is tempting to dismiss religion in West Africa as promoting ignorance, its broad influence can be harnessed to engage with and provide education to local communities. In Sierra Leone, Christian and Islamic religious leaders have used their influence to lobby the government to take action against Ebola. Church and mosque services are also now used as opportunities to educate their congregations about the disease.

Ebola’s disproportionate impact on healthcare workers

But beyond formal religions, fear, mixed with traditional belief and mistrust, has influenced community responses. During this outbreak, healthcare workers have suffered disproportionately: roughly 145 African healthcare workers have been infected, with 80 deaths. If the Ebola outbreak ended today, it is predicted that it will take years for Liberia to replace the healthcare workers that have died; including roughly 5% of the country’s physicians.

Still, the correlation between healthcare workers and the disease is not interpreted as evidence of a completely overwhelmed and under-resourced health system. Instead, healthcare workers have been attacked and blamed for causing or bringing the disease to communities.

In some areas, doctors have been accused of abducting and killing patients under the pretence of Ebola to sell organs, blood, or body parts for cannibalistic black magic rituals.

Following attacks on their clinics, Médecins Sans Frontières and other aid groups have pulled out of communities for safety reasons. To respond to this, riot police now accompany many teams sent to collect the bodies of the dead, and the WHO has called for police and security forces to be dispatched to protect healthcare workers.

Recounting such events carefully walks the line between victim blaming and providing a legitimate insight into understanding community reactions – and therefore, how to tailor effective public health responses.

“ ‘Otherness’ is an easy way of ignoring underlying

global inequities that led to this outbreak.”


Repeating History: Viewing Ebola as a Disease of the “Other”

Throughout history, sensationalising the “other”, and its role in infectious disease, is common. “Asiatic” cholera outbreaks in London and Europe in the 1800s were blamed on inherent “characteristics” of immigrants, motivated by racism and prejudice.

At the turn of last century, outbreaks of plague in San Francisco occurring in the densely populated Chinatown were attributed to “Asiatics or other races particularly liable to the disease”, rather than as a result of the city’s failure to provide sewerage, clean water, or other basic public health facilities in Chinatown.

Even in recent times in Australia, public health has been used to provide a false legitimacy to harsh immigration measures, which may have a limited basis in protecting health.

In 2012, then Shadow Minister for Immigration and Citizenship, Scott Morrison argued for harsher border protection laws, stating “when illegal boats turn up in our waters there will always be the risk that people on these boats will carry serious communicable disease”.

Importantly, “otherness” is an easy way of ignoring underlying global inequities that led to this outbreak. The truth – decades of civil unrest, entrenched corruption, war crimes, non-existent education, and underfunded health systems – is much more complex.

Australia, the United States, and many European nations are in a much better position to prevent a possible Ebola outbreak not because of a lack of religion, but because there is significant government investment into education, democratic systems, and public health, including clean water, sewage, and basic infectious disease control.

The Importance of a Human Rights Based Approach to Public Health

With governments struggling to rely on basic public health approaches, they have begun invoking state of emergency powers, which can override human rights protections. Unfortunately, laws that appear to benefit public health at the expense of civil liberties may actually result in worse health outcomes.

For example, Liberian President Ellen Johnson Sirleaf recently warned Liberians that “anyone found or reported to be holding suspected Ebola cases in homes or prayer houses can be prosecuted under the law of Liberia”.

The President also announced compulsory quarantine for close contacts of Ebola victims. The intention of these measures was legitimate: preventing the possible spread of Ebola during burial or funerary rites in homes or communities, and stopping any further transmission of Ebola from victims’ close contacts.

After this announcement, people fearful of prosecution or being forced into quarantine began removing dead bodies from their homes, and leaving them in the streets.

While Ebola is one of the few diseases where quarantine and isolation is very effective, clearly the approach taken by the government rendered community compliance ineffective.

Extreme public health measures are also being considered, such as cordon sanitaire; a technique not used for nearly a century involving the complete quarantine of an infected area, regardless of whether there are healthy people inside. While arguably very effective at stopping the spread of a disease like Ebola, a cordon sanitaire is likely an illegitimate infringement on individual civil liberties and unethical.

The International Community’s Response

The WHO’s declaration of a public health emergency of international concern has spurred the international community into action.

The United States has announced that it is sending more than 50 disease specialists to West Africa as well as US $7.1 million in additional funding to aid programs in West Africa, the WHO and UNICEF. China has announced US $4.9 million in funding, as well as sending nine disease specialists to West Africa to assist with controlling the outbreak. The United Kingdom has pledged £2 million to partners working to combat the outbreak including the International Federation of the Red Cross and Médecins Sans Frontières.

In contrast, Australia has not publicly committed any foreign assistance – whether financial or technical – to address the Ebola outbreak in West Africa. Australia’s response has been solely domestic: strengthening “border protection procedures” such as screening incoming passengers at Australian airports.

“For Australia to consider itself a responsible member of the global community

the Abbott Government must immediately commit funding or technical assistance

to specifically address the Ebola outbreak in West Africa.”


From Global Concern to Global Action

West Africa needs very basic assistance from the world: they need medical practitioners and epidemiologists to track and treat the sick and potentially infected.

They need personal protective equipment, such as gloves and masks, for healthcare workers. And they need transparent and accountable funding to not only pay their healthcare workers, but to be able to implement adequate and effective infection control in their hospitals.

Importantly, widespread education is essential: not to “correct” local communities, but to empower them to prevent the spread of disease and seek medical attention early. These are all very basic requests, but West Africa should never have had to ask.

The Ebola outbreak is now getting the attention it initially deserved, demonstrating that the health security of Western nations is a powerful motivator for action. However, pro-active action to fix health systems, address corruption, and provide education in West Africa’s post-conflict nations could have prevented the deaths of so many.

As a critical first step, developed countries should immediately invest in fixing the health systems of developing countries so that the mistakes of this outbreak do not happen again.

Importantly, for Australia to consider itself a responsible member of the global community the Abbott Government must immediately commit funding or technical assistance to specifically address the Ebola outbreak in West Africa.

In a globalised world, we must stop responding to infectious diseases as an issue of the “other” – not just for our health security in the West, but for equity, justice, and basic humanity.

Alexandra L. Phelan is an Adjunct Professor in Public Health Law and Ethics, Doctorate of Juridical Science candidate in Global Health Law, and General Sir John Monash Scholar at Georgetown University Law Center in Washington D.C.