A disease of the social: resistance, securitization and social scientists in the Sierra Leone Ebola outbreak : reconstructing the 2014 West-African Ebola outbreak response using Actor-Network Theory

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David Benjamin Nieuwe Weme

Supervisor: Dr. Daniel de Vries

Local supervisor: Anthony Mansaray

A Thesis in the Field of Anthropology

for the Degree of Master of Science in Medical Anthropology and Sociology University of Amsterdam

July 2019

A disease of the social: resistance, securitization and social

scientists in the Sierra Leone Ebola outbreak

Reconstructing the 2014 West-African Ebola outbreak response using Actor-Network

Theory

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Nieuwe Weme, David (University of Amsterdam) A disease of the social: resistance,

securitization and social scientists in the Sierra Leone Ebola outbreak. The high rate of social resistance of

Sierra Leoneans against members of the Ebola response teams begged for a new form of addressing this medical humanitarian crisis. This study sets out to tell a story of resistance against a humanitarian medical aid system. Results are based on data from a two month fieldwork period in both urban and rural areas in Sierra Leone. This study aimed to trace back the path of social scientists that led them into the Ebola response. Along the way, I will describe the development of the Ebola response systems and show how the global trend of securitization influenced the social phenomena of resistance. Actor-Network Theory provides the lens through which the data is interpreted. The concepts of translation and problematization are used to make sense of the negotiations of interests that preceded the formation of all three Ebola response structures. Access, the obligatory passage point and transcription provide tools for the reconstruction of the path along which social scientists became part of the Ebola response network. Tracing back the social phenomena of resistance, I argue that an international trend of securitization of global health influenced the architecture of the

response. By introducing a model, I will show how securitized Ebola interventions neglected to take into account the social, human layers that surrounded the disease. People their bodies were

perceived and treated as a vehicle through which the Ebola response had to reach their goal; Ebola. Interestingly, securitization provided the organizational and financial conditions for social scientists to become part of the Ebola response. Their role was foremost informed by the need to solve

community resistance which resulted in the role of ‘firefighters’, a role criticised by many social scientists. Integration of social scientists into the architecture of future infectious disease outbreak responses, I argue, can both limit and effectively resolve resistance.

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Acknowledgement

Two weeks before my two months period of fieldwork started, I was still expecting to be doing this in my hometown of Amsterdam. That situation changed after a meeting with Danny, my always patient supervisor. It turned out that I would spend that two months in Sierra Leone. The chaotic and stressful period that preceded my leave was more than compensated by my stay in that beautiful country. Finding my way to the relevant people and institutions in an unfamiliar country proved to be a great challenge and an adventure at the same time.

This thesis is a homage to all those who have supported me in the writing process. If it was not for the trust and support of Danny, the local expertise of Anthony, my local supervisor, this project would have been much less of a pleasant experience. I also want to express my gratitude to all those who have contributed to this thesis with their interviews, stories and files.

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1. Introduction

Imagine you find yourself in the following situation: You have a family which you feed with what you cultivate on your farm. You live in a small community in which everyone knows each other very well, you share past, present and probably future with them. Suddenly, people in your village start dying, bleeding out of nose, ears and pores. Your family is unaffected, until your wife gets sick and after a week she dies. You are sick with grief and want to give your wife the proper funeral. At the moment you start dressing the body, people you do not know, dressed in space-like suits, come into the village, spraying around some kind of fluid. They tell you to step away from the corps because it is ‘dangerous’. After spraying fluid on the body, the strangers in space suits take it away, put in in an ambulance and drive away. You will never know hear where to go if you want to mourn the death of your loved one (Fieldnotes, April 2019).

If you would be a rural farmer, living in Sierra Leone, Guinea or Liberia, between late 2013 until early 2016, you could have found yourself in this exact situation. Those three West-African countries were plagued by the Ebola Disease Virus (EDV). This disease infected over 28.000 people of which more than 11.300 died. It is, by far, the deadliest Ebola outbreak as of today. More than 30.000 people have been actively involved in fighting Ebola. All these people together formed the Ebola response network, or simply ‘the response’. The strangers in space suits were members of the Ebola response Burial Team, whose objective it was to take away Ebola infected corpses as quick and safe as possible (Fairhead, 2014). For many people living in the affected countries, their first encounter with the response was as described above; there was little understanding between response and people (Laverack & Manoncourt, 2015). The initial reaction from the people against these seemingly rude, incomprehensible interventions imposed by the Ebola response system, was to defend

themselves by resisting to cooperate with the intended course of action (Fairhead, 2016).

While exploring the direction I wanted to take with this thesis, I contacted several UK based social scientists, who had been involved in the West-African Ebola outbreak response. Finding my way into the field of infectious disease outbreaks I found the term ‘resistance’ was mentioned frequently. Every time someone would talk about it, emphasis was placed on the subjectivity of the term, I felt the use of the term ‘resistance’ came with a degree of scepticism. This sparked my interest; the frequency and context in which the term was used, indicated there was an unresolved controversy about it. As I wanted to further explore resistance and the relation of social scientists to it, I realized I would have to go into the field. As most of the social scientists I was in contact with were based in Sierra Leone, I concluded that going there was my best option.

1.1 Background

Both resistance and social scientist activity in relation to infectious disease outbreaks are debated issues. In 1976, the Ebola virus was discovered by Peter Piot and Guido van der Groen, in what was Zaire back then, now the Democratic Republic of the Congo. The virus was named after the relatively short river ‘Ebola’, that starts in the northern region of the country and flows into the Mongala, 250 kilometres down south. Peter Piot turned out to foresee the stigma that would come with the disease and decided not to name the virus ‘Yambuku’, after the village in which the virus was discovered, but after the Ebola river 60 kilometres away (Wodsworth, 2014). Twenty years later (1997), anthropologist Barry Hewlett had his first experience with the virus. In a vibrant account he depicts the social effects caused by the virus as well as the limited knowledge that was available on the disease (Hewlett & Hewlett, 2008). Upon returning from the bush to the capital of Gabon, people would jump back out of fear when they discovered Hewlett had been in contact with Ebola

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infected people. This practical account was followed by a call for the use of ‘critical anthropology’ in infectious disease outbreaks, a call in which Paul Farmer stressed the need to look beyond the ‘dominant analytic frameworks’ (Farmer, 1996). At this time Ebola was a minor, but deadly disease. The fatality rate of all recorded Ebola outbreaks is around 65 percent, reason enough to gain more knowledge on the disease one would think; in 1997 there was almost none (CDC, 2018).

Importance of the cultural aspects related to the disease were first recognized by the World Health Organization (WHO) in its guidelines for preparedness and response regarding the Ebola virus, dating from1997: ‘Special attention must be given to the actual perception of the outbreak by the community. In particular, specific cultural elements and local beliefs must be taken into account to ensure proper messages, confidence, and close co-operation of the community’ (WHO, 1997 as cited in Hewlett & Amola, 2003). It was in 2000 when the first recorded study was conducted that looked into social and cultural factors surrounding Ebola, particulairly on understanding the local perception of the virus (Hewlett & Amola, 2003). Thereafter, the role of socially oriented research on infectious disease outbreaks developed to occupy a permanent place within the ‘social

mobilization’ pillar of the standard WHO crisis response system (Daszak, 2012). Parallel to the increased use of research on outbreak related behaviour and believes, social scientists themselves also became increasingly involved. Whereas initially they had been involved from a distance, they carfully became inolved in WHO crisis response ctivities (Leach, 2008).

Despite recognizing the importance of the socail context surrounding infectious disease outbreaks, the events West-African Ebola outbreak showed that the activity of social scienstis and their

research was still undervalued in addressing major infectious disease outbreaks (Brown, et al., 2015). Several United Nations (UN) agencies translated this realization into recommendations on the role of social scientists and community involvement in the response strategy (UNDP, 2014; UNMEER, 2015; Mercy Corps, 2014). The voices of social scientists would gain volume throughout the outbreak, drawing attention to the fields of social mobilization, risk communication and community involvement. Taking into account all that is known on the importance of behaviour related to infectious disease outbreaks before and during the 2014 outbreak, it is remarkable to find that so little was done to involve the communtities in the design of the response.

‘So, I think there was a real lack of empathy in the early stages of the response across the board and I think anthropologists could have helped enter this into the decision making. What I mean by that is a lot of the policies made no sense from a human perspective. The things that people were asked to do were predictably unrealistic.’

These are the reflections from John who was the lead physician in one of the government hospitals and could frequently be found in the Ebola coordination centre. Looking back, the lack of empathy within the response measures fuelled the local resentment against the response system, causing communities and people to resist the measures.

Resistance, distrust or non-compliance towards health workers is not a phenomenon new to

humanitarian crises responses (De Vries, et al., 2016; Donnelly, 1993). Much research has been done on the reasons why tensions arise between the response and the people it aims to help. De Vries et al. identify ‘insensitivity to local culture’ as well as ‘a mismatch between information circulated and the local interpretative framework’ as causes for distrust and resistance. Furthermore, the WHO suggested that ‘fear and misperceptions about an unfamiliar disease’ was causing community resistance’ (WHO, 2015). Resistance is often explained from the perception of the response which situates resistance within a biomedical framework, thereby characterizing behaviour of

non-compliance as irrational (Waylan & Crowder, 2002; Piot, Muyembe, & Edmunds, 2014; Hewlett & Hewlett, 2008). When Ebola is seen as a biomedical agent which invades the body, destroying the immune system and making it infectious, medical treatment is seen as the only way towards survival

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(Roemer-Mahler & Elbe, 2016). Behaviour which delays the administration of the treatment, thus not directed at the medical perception of survival, is not compatible with the logics of biomedicine (Bolten & Shepler, 2017). This study will situate community resistance against the backdrop of the global trend of securitization, describing how a global trend affects local practice.

Actor-Network Theory

The resistance of communities in Sierra Leone was a reaction against the new values that the

response was trying to impose on their lives. By using Actor-Network Theory (ANT) it is possible to foreground the tensions between the response system and the communities. I got acquainted with ANT around the same time as when I was introduced into the community of social scientists involved in infectious disease outbreaks. For me, the complex organization which constituted the infectious disease outbreak response was perfectly conceivable as an interconnected assemblage of actors; a network. ANT provides a lens through which abstract representations of events and organizations can be observed. This allows for the analysis of complex networks such as the 2014 Ebola response organization.

Developed to analyse scientific and technological issues from a sociological point of view, ANT has increasingly been used to analyse different phenomena like class structures, kinship structures and defining a good tomato (Law, 1999; Latour B. , 1996; Heuts & Mol, 2013). ANT puts emphasis on the relational effects between entities, depicting situations in our world as networks. John Law described ANT perspective as follows: ‘Everything in the social and natural worlds is treated as a continuously generated effect of the webs of relations within which they are located’ (Law, 2009, p. 2). All entities within a network are homogenous, the material is equal to the social. Relations between entities can range from physical relations like money streams, to virtual relations like power and hierarchy. I am specifically interested in those relations that create tensions, cause the network to ripple or change formation (Latour, 2010), as these are the kind of relations that caused resistance during the 2014 Ebola outbreak. By tracing back tensed relations to the nodes they are connected with, the roots of the tension can be laid bare.

In this thesis, I will reconstruct parts of the response network by using ANT. This allows me to answer the following question: what caused the resistant behaviour of the Sierra Leonean people against the interventions proposed by the 2014 Sierra Leonean Ebola outbreak response and what was the role social scientists played in addressing this resistance? I will address this question in three steps. I begin by giving an overview of the dynamics of the response network, introducing the involved entities and the relations between them. Additionally, crucial events and their ramifications for the response network will be discussed. In the second chapter I take a step back to understand how the 2014 Ebola response is influenced by the global trend of health security and how community resistance is understood against that backdrop. Lastly, in chapter three I will trace the ways in which social scientists got involved in the Sierra Leonean response (access in ANT) and how and by who their role was given shape (inscription in ANT). In this chapter I will bring together resistance and social scientists, proposing a model for addressing infectious disease outbreaks which will minimize community resistance.

1.2 Methodology

This study made use of qualitative methods; informal conversations as well as formal interviews provided the largest part of the data. In addition to this data, I analysed Ebola related images and asked interviewees to do participatory mapping. This method asks the interviewee to draw a network in which he or she is the central node of the network (See Appendix 1). Emphasis lies on the nature of the relations that connect the entities constituting the network (Emmel, 2008).

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Informants were recruited through snowball sampling, a technique which is based on acquiring new contacts through already existing ones (Heckathorn, Spiller, Cameron, & Barash, 2011). Table 1 shows in which dimensions of the outbreak my informants had been involved. I have classified them according to the organization that employed them. I had a total of four key informants in the different fields with who I conducted formal interviews as well as ‘deep hanging out’ (Geertz, 1998). This resulted in a total of 19 formal interviews, many informal conversations, four networks maps and several images.

Social scientist Government Officials NGO’s and institutes (e.g. WHO & MSF) Medical workers In depth interview 3 5 6 4 Key informants 1 1 1 1

Table 1 - Interviewee specifics

All the interviews were audio recorded and transcribed, after which I ascribed codes based on reoccurring themes and memories. ATLAS.ti was used to code all the interviews, which resulted in more than 100 individual codes. Using grounded theory, a way of doing research which proposes a constant loop between data collection, data organization and data analysis, I build up the individual codes to overarching themes (Strauss & Corbon, 1994). The themes came forth from the topics on which my interviewees touched and the way they spoke about them. Those clustered ideas resulted in a total of 5 themes: 1) Involvement of social scientists, 2) Research during a humanitarian crisis, 3) Ebola response dynamics, 4) Resistance, and 5) Securitization. By analysing inter-thematic codes, I was able to find overlap in all themes.

My personal access to the network was provided by a UK based anthropologist, who introduced me into the community of social scientists involved in responding to infectious outbreaks, specifically in Sierra Leone. After having decided to go to Sierra Leone, I was introduced to a Sierra Leonean who worked for a Freetown based research institute, specialized in improving health systems. He has been my local supervisor, aiding me enormously in getting access to relevant communities and individuals.

One of the challenges of this study comes forth from the historical nature of the Ebola outbreak, everything happened up to five years ago. How trustworthy are these memories? As ‘process of remembering and forgetting is inevitably selective’ (Rowlinson, Casey, Hansen, & Mills, 2014, p. 441), I had to reconstruct the response network using the overlapping parts of memories. Analysing and following these collective memories allowed me to interpret the discourse of the network and at the same time through which patterns of cohesion were unveiled (Dunn, 1983; Scott, 1988). I found that social relations such as political, cultural and care were remembered more vividly then relations of material such as money and goods. I propose that these were remembered more clearly, as there is more emotion attached to the memory of social relations (Bolten & Shepler, 2017). As memories attached to emotions are remembered more vividly than non-emotional memories, these relations are foregrounded in this thesis (Levine & Pizarro, 2004).

Ethics

After living in the capital of Sierra Leone, Freetown, for one month, I decided it was time to go deeper into country. In the capital I was able to talk to individuals who had fulfilled roles within the Ebola coordination centre, policy makers who could give me insights in how data streams were used to craft interventions. Moreover, my internet was good enough to have several Skype calls with internationals who had worked for UN organizations, the Sierra Leonean government as well as social scientists. In the more remote parts of the country I aimed to acquire knowledge on how

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policy had influenced the response activities on the ground. An ethical issue I encountered here had been lingering inside my head when living in Freetown, however it became more foregrounded when talking to people in the less connected parts of the country. What is my position the field, and especially what does my colour represent and what influence does it have on the people around me and my interaction with them? However crude it may sound, there is no possible way around the fact that I am white and that the white colour is considered to be rich and powerful. I can support this statement with an example from? some conversation. This was a conversation with a Sierra Leonean man, around 35, at a street stall where he sold coffee. Basically, the conversation came down to his last statement: ‘No black colour is not equal to white colour. Do you see that? (he pointed to a car); white people made all of that’. He wanted to go to the Netherlands and asked me if I could take him there. Many similar conversations happened and many times I wish I had black a skin. I guess that is the curse of an anthropologists: Trying your hardest to become like the people within a specific community, but never fully become part of it.

This research got ethical clearance from the Office of the Sierra Leone Ethics and Scientific Review Committee, located in the Ministry of Health and Sanitation (MoHS), who judged the potential risk to the participants as ‘minimal’ (see Appendix 2).

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2. The Sierra Leonean Ebola response network

In March 2014, Ban Ki-Moon, the UN Secretary General at that time, had been in Sierra Leone to close the UN peace mission that had been running in Sierra Leone since the end of the civil war (1991-2002). In that same month, the first Ebola case was identified in Kailahun, a village close to the border with Guinea and Liberia. From that moment, it took around two more years until the country, was officially declared Ebola free. In that period, Sierra Leone saw an enormous influx of organizations and resources, all of which together formed the Sierra Leonean Ebola response network. This chapter will take a close look at the response network, exploring the dynamics of this collective of organizations from within. First of all, I will look at this collective of entities through a lens of ANT, exploring the processes of network formation. By reconstructing the response network and showing how it changed shape throughout the outbreak, I will show who was involved, at what point in time and for what reason. Secondly, I will show how entities in the network were

interconnected by highlighting the effect of specific phenomena on the network dynamics.

An informant of mine told me the following: ‘One of the weaknesses of the response was that the president did not declare a national crisis until the end of July’. This national state of emergency was quickly followed by the international state of emergency, declared by the WHO (WHO, 2014). The first case of Ebola was identified in Guinea as early as December 2013 and in Sierra Leone the first case was found in March 2014 (WHO, 2015). The critique on the tardiness of the initial response is widely known: the action was too little, too late (Benton & Dionne, 2015; Kamradt-Scott, 2016; Tomori, 2015). The visit of the UN General-Secretary to Sierra Leone in the beginning of March illustrates the lack of awareness on the seriousness of the outbreak. In his three day visit to the country, not a word was said about Ebola. Only five months later, the world realized that Ebola was real and scary. I remember my initial indignation at this course of events; how could people not have noticed? However, the cool reactions of my interviewees helped me realize that all discourses can be traced back to a cause. And what better tool than ANT to use for this. What happened in first few months of the outbreak and what caused the world to wake up?

2.1 A network lost in translation

Following ANT, all practices of the world are seen as networks. These networks are the relational atomies behind those practices. These abstract atomies are made up of material and social nodes which can be identified as actors, entities or elements. These entities are interconnected by a great diversity of relations, their nature depending on the characteristics of the nodes. Networks are generated through a process that is called translation, a process in which overlapping interests of certain actors are transformed as a means to achieve a common goal. Together, they form a ‘discourse coalition’ (Hajer, 1997, p. 5). ‘By translation we understand all the negotiations, intrigues, calculations, acts of persuasion and violence, thanks to which an actor or another force takes, or causes to be conferred on itself, authority to speak or act on behalf of another actor or force’ (Callon & Latour, 1981, p. 279). According to Callon and Latour, it is here in this process of translation, that some of the original ambitions and desires have to be adjusted to fit within the bigger picture. Herein lies a literal paradox. Although the term translation has an inherent notion of similarity, it also suggests that the translated product is an imitation of the original one, thus losing some authenticity.

In this process of negotiating interests, tensions arise. Resistance to losing authenticity against an unreasonable price, and being assigned specific roles (Barry, 2013). Take for example the

construction of a chair, maybe the one you are sitting on now, that product is the result of the translated interest of the client, designer, and manufacturer. Maybe the client wanted a leather seat, however for optical reasons, the designer suggested a wooden seat. The manufacturer stated that for practical reasons a leather seat is quite difficult to produce. The client resists removing the leather

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and starts looking for different partners. However, both the designer as well as the manufacturer add water to the wine and propose leather armrests. If the client judges this change as being too deviant from the original interest, the client will resist against this format and step out of the ‘client role’. If the client does agree with the proposed structure, a discourse coalition will be formed and the actors will work towards their common goal of creating a chair with leather armrests. In 2014, the actors involved in the Sierra Leonean Ebola outbreak could agree upon a response structure as the goal that the structure was to serve was not agreed upon.

The attempt to form a functioning Ebola response in Sierra Leone had started as a reaction on the first couple of cases in Guinea. In late March 2014, the National Ebola Task Force (NETF) was set up which was tasked with making the health system prepared for the potential health emergency, as well as with the formulation of a response plan (Figure 1). This taskforce was headed by the Ministry of Health and Sanitation (MoHS) which was consulted by iNGO’s, United Nations (UN) agencies, Médecins Sans Frontières (MSF) and the International Federation of the Red Cross (IFRC). The organogram of the NETF is shown in Figure 1. The strategic meetings that these partners had, would generate policy that was to be implemented and executed by the District Medical Officers (DMO) who headed the District Health Management Teams (DHMT).

The actors in the taskforce were not able to align their interest. It proved especially difficult to align the potential partners who were out in the country, engaged in operational activities such as contact tracing, sensitization and case treatment. Many of my interviewees who had been working in the field were not even aware of the existence of the NETF at the time, depicting the limited influence of the raskforce. A key informant of mine, Anton1_{, gave me a lot of insights into the ways the response}

started out. He works for a renown international research institute that was heavily involved in the Ebola response. Anton is an animated man who understood much of the internal dynamics that are part of the world in which NGOs fight and cooperate in their quest to save and improve human lives. This is what he said about the first months of the Sierra Leonean outbreak.

‘Initially, it [the response] was quite chaotic and everyone was just doing you know, like the typical kind of you know, whatever they could lay their hands on, like ‘Llet's utilize whatever resources we have’. Everyone was doing what they wanted to do. Like different organizations, there wasn't any kind of coordination. There was not any kind of a platform for people to coordinate ideas and do them more constructively. It was more like 'I am in this district and this is what I can do, let me just do it'. And I Figure 1 - Organogram of National Ebola Taskforce (NETF)

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think that kind of chaos created a lot of either duplication of efforts or sometimes resources were crowded in one place and lacking in other places and all that.’

Without proper coordination, the initial Ebola response was fragmented and the stakeholders their interests juxtaposed. In a conversation that one of my informants had with the Sierra Leonean president, they concluded that ‘The EVD was actually overrunning the daily governance of the state’ and that the taskforce was not able to deal with the situation. Shortly after this conversation, in July 2014, the NETF was replaced by the Ebola Operations Centre (EOC). Figure 2 shows that this structure was jointly headed by the MoHS and the World Health Organization (WHO), advised by largely the same partners as the NETF. The district section (gold coloured blocs) of this organogram differed slightly. It had set up 14 District Task Forces (DTF) which ran parallel to the DHMTs. Each of these DTFs had several operational actors which differed per district. However, the new

organization also turned out to be unable to get a grip on the situation. One of my interviewees aptly told me in a striking ANT like description of the EOC: ‘Everyone brought their own interests which were kind of hard to align into specific single objectives, a single purpose.’

2.2 Doctor Khan

The generation of a common goal is a process that is called ‘problematization’ in ANT: ‘The definition of the problem and its solution’ (Horowitz, 2012, p. 809). The first two response

structures lacked a commonly defined problem. Before a shared purpose was decided on, Ebola was not framed as a common concern. Diverging interests were painfully clear, illustrated by events like the call from MSF. The international medical NGO stated in March 2014 that Ebola was already out of control, on which the Guinean government promptly replied that MSF was overstating the issue (BBC, 2014; MSF, 2014). International as well as national concern was only associated with Ebola when the WHO and Sierra Leonean government, in August 2014, decided that a certain threshold was reached, and thus put out statements containing terms like ‘international concern’ and ‘national crisis’. Only when these statements were hurtled into the world, it was clear that the response network had a common goal. Now, there was enough interest to in working together towards a common goal. But how was this threshold breached, what catalysed the process of problematization? During the initial stages of the outbreak, the central node in the network was the Lassa fever clinic in Kenama. Kenama is a city located around five hours from Freetown. The clinic is located within the premises of the Kenama governmental hospital. In the clinic research is conducted on the rare haemorrhagic Lassa Fever as well and they monitor and respond to sporadic outbreaks of the fever. This was the only site in the country where people were working who had experience with virologic

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diseases. Initially, all patients, as well as Ebola mouth swabs, were sent to the Lassa fever clinic from all over the country. Salva, a WHO epidemiologist at the time of the outbreak, was familiar with the clinic: ‘That was where they had the Lasa fever health clinic, there were NGO's who knew how to treat Lasa fever. So, the Lassa fever project was in Kenama, there was were all the people were brought.’

Even though the Lassa fever clinic was not properly equipped, their staff members not trained for treating Ebola and it was lacking the infrastructure to handle the influx of multiple Ebola patients a day, the response network trusted the Lassa fever clinic to take the lead in the treatment of patients and analysis of specimen. Int his way, the responsibility of having contact with contaminated patients was redirected from health facilities all over the country to one place, a distribution of trust and responsibility that placed a heavy weight on the shoulders of the people working within the clinic. When I first lay eyes on the Lasa Fever clinic, it was not like I had expected. It looked more like a research centre. Two container like buildings and one bigger building made up the clinic. I shortly spoke to an American lab technician who had worked at the clinic for over ten years. He told me the clinic had been overwhelmed, even at the beginning of the outbreak, and that soon he and all other international personnel was send home. Someone else who had been working at the clinic during all of the outbreak, Lewis, explained me what he had known about Ebola.

‘You know Ebola was new to Sierra Leone, West-Africa, it was new although we had been reading about it and we had Lassa. But like even the transmission dynamic was like far, far more different then what we were seeing with Lassa, although they were similar.’

Four to five people would be loaded into an ambulance, driving for hours to deliver the patients from wherever they were picked up, before they would be dropped off in Kenama. An ambulance driver, Abdul, who had driven between Masanga and Kenama, depending on the weather a six to nine-hour drive, told me that almost half of all the patients he transported arrived dead. The risk of

transporting infected patients was such that it almost cost Abdul his life. Albeit his protective gear, he became infected and was hospitalized for three weeks. Luckily he survived. After being discharged from the hospital, he started driver ambulances again. His story made me aware of the danger posed by Ebola to health workers. In Sierra Leone, around seen percent of all healthcare workers perished (Evans, Goldstein, & Popova, 2015).

Those who arrived in Kenama alive were received by health staff who were mostly at a loss what to do, as knowledge on Ebola outbreaks on such a scale was severely limited (Bibby, Casson, Stachler, & Haas, 2015). Resting on a fragile foundation, the weight of trust was bound to come crashing down. The crash came on July 29 when doctor Khan, the sole virologist of Sierra Leone working in the clinic, died as a consequence of having contracted Ebola. A shockwave was sent through the country. The relations of trust were broken; trust on the Lassa fever clinic her abilities to treat Ebola patients. But more important, the conviction that the outbreak was under control vanished into thin air (Crowe, 2014; Fofana & Flynn, 2014). The response network became shredded by the fear of the unpredictable, raging disease. If not even the most skilled doctor survives the disease, who could? A UK based anthropologists, Eva, who was present at the Lassa Fever clinic at the beginning of the outbreak had experienced some of the initial fear and chaos. Although she was not present at the moment doctor Kahn died, she had gained a strong impression of the impact of the event.

‘But also, that it caused a huge attack on the population. If the doctors cannot keep themselves alive, what does that mean for us? Every week… and there was one doctor, Dr. Kahn, who was the face of the whole epidemic and who also passed away and within the time of a few weeks.’

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One might wonder if emotions have a place within ANT, an approach that assumes all entities, social and material, to be to be heterogenous. I argue there is. Relations of trust are much discussed within ANT literature (Bardach, 1998; Coleman, 1990; Manoj & Baker, 2007; Kapucu, 2005). Within the Ebola response network, relations of trust can be identified. For example, Connough general hospital in Freetown and the Lassa Fever clinic were linked by, respectively, faith in the capabilities of the other and an attitude of reassurance and affirmation. When the one entity that was expected to perform in a certain way stops doing so, the relation of trust withers away and leaves a gap in the network (Zinn, 2008). In the absence of solid knowledge on how to act, the level of urgency that is associated with this gap is partially determined by the amount of fear, especially when ‘instrumental rationality is of little help’ (Zinn, 2008, p. 446). The relations of trust that disappeared instigated a ripple that stimulated the network to reform. Here, the definition of fear deviates from the classic one which is associated with deep emotions, in the world of ANT fear is a strong driver of change, capable of initiating the process of problematization and translation; the WHO as well as the national government defined the problem as being of (inter)national concern, a week after the death of doctor Khan (resp. July 30 and August 8). Figure 3 shows the linear course of events.

2.3 A New Discourse Coalition: The NERC

In September 2014, the international community stepped in. The UN established the UN Mission for Ebola Emergency Response (UNMEER) and the UK government sent the Combined Joint Interagency Task Force (CJIATF) to aid Sierra Leone in fighting Ebola. Fighting in a figurative as well as literal sense; with the CJIATF came as much as 750 military personnel (Ross, Honwana Welch, & Angelides, 2017). With these operations, resources poured into the response: Military and civilian personnel, funding, materials and expertise. These events made the response network expand considerably. Although these operations also lacked specific knowledge and experience, the resources they brought with them allowed for the creation of interlinkages between entities that could not connect before, thereby strengthening cooperation.

Expertise, resources and knowledge were utilized in setting up a new centralized coordination body: the National Ebola Response Centre (NERC). The NERC became the new central node in the response network. Figure 4 shows the NERC organogram. All who wanted to work within the Ebola response had to be registered and acknowledged by the NERC. All donations, resources and plans had to go through the NERC before they could be rolled out on the ground. Besides the strong Figure 3 - Timeline Sierra Leone Ebola outbreak (March 2014 - end of 2014)

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material leverage that the NERC had on the other stakeholders constituting the network, the organization also had an advantage in that they produced the knowledge on which the overall

response acted. The knowledge production happened in the Situation Room (SR). This was where all the data came in, where it was processed and made available for informing policy. Being fortunate to know his son in law, I was able to interview Samuel, who had held a high position within the NERC. I was impressed by how he came across, his words and actions were very decisive, without much hesitation. Simultaneously, he was very approachable and receptive to advice and questions. ‘The UN had everybody else, UNFPA, WHO, UNICEF, but they were all being worked, they were all working together and being coordinated by us at the NERC. So, the NERC basically took over the entire response.’

After the disappearance of doctor Kahn and the Lassa fever clinic as central node within the network, the network took on a new shape. The NERC, with all incorporated actors, was now the focal point of the network, the ‘translator’ (Law, 1992). Being the translator, the NERC started forging potential alliances with other actors ‘by convincing them to accept the translator’s definition of their identities and desires, to the exclusion of all other definitions’ (Horowitz, 2012, p. 807). The translation was becoming more successful, a coherent system was set up to fight the outbreak.

2.4 Network dynamics

One of the ways of understanding the dynamics of the entire response network was trying to see the response from different perspectives. At the end of my interviews, I asked several interviewees to do an exercise called participatory mapping (Emmel, 2008). This drawing focusses on the position of the

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entities within the response and their relations. I asked the interviewees to focus on their own position within the network, featuring themselves as a central. Figure 5 shows the map that was made by an anthropologist who had worked with ERAP.

Looking at figure 5, the nodes and relations have different colours and shapes. This detailed network includes relations of implementation, money, advise, discussion/expertise and evaluation. The Ebola Response Anthropology Network has a central position on the left side of the map, this is the side in which the activities of social scientists are represented. From the left side of the map, ERAP has several relations to the right side of the map, representing the situation is Sierra Leone. Indicted by the colours, the Sierra Leonean side of the map shows a more operational character then the left side of the map. As can be deduced from the relations on the map, the left side of the map is rather interconnected. However, their connections with the right side of the map are quite separate. This indicates that the relations of social scientists with different parts of the response ‘on the ground’ were quite individually focussed. This map is illustrating how a network could look like. It includes notions of geography information streams and financial streams and it shows how certain entities are connected ad through what means. Looking at this map, one can imagine how the relations can be performed in life, it is the skeleton behind the actions of ERAP during the Sierra Leonean Ebola outbreak.

The relations on paper become reality when looking at events and actions that happened during the Ebola outbreak. What happens when a disease is overwhelming the local public health system and no one comes to aid the overstretched health system? ‘Chaos’ is the word that my interviewees used most and which I found aptly described situation. Chaos is what characterized both the NETF and the EOC. Imagine a three-dimensional network of organizations, people, material, resources and knowledge streams, all hanging together in a distorted cluster, connected through ragged threads of

Figure 5 - The result of participatory mapping, a network representation of the position of ERAP during the 2014 Ebola outbreak in Sierra Leone

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political relations and competition for resources. The discussion of the ‘alarm bell’ can be used to clarify this picture. How could it be that there were so many organizations aware of the outbreak, but that cries for help were not uttered and when they were, were not heeded? Here we can use the event of MSF raising the alarm as an example. MSF called for international action, they urged the WHO to deploy resources that matched the needs of the ongoing international health crisis (BBC, 2014). Their cry for help was rejected by the WHO at the time, labelling MSF as panic-mongers (MSF, 2015). Both WHO and MSF are organizations that address international health issues, albeit from a different perspective. However, it seemed that their interests in ending Ebola were not similar. The WHO, permanently based in many countries, is intertwined in the national health systems, through the appointment of local government officials as WHO representatives (Walsh & Johnson, 2018). Therefore, WHO their interests are medical as well as political. Having worked with the response from beginning to end, John knew much about the internal politics of both the WHO as well as MSF, he had gathered with them in the same room many times. John was fairly critical of the response as a whole, thereby also not shying away from self-criticism. He told me the following about the difference between MSF and the WHO: ‘So I think other issues are that MSF is just more flexible. You know, they have their own funds, they have their own decision making structure. (…) I think the bureaucracy of the WHO makes it inherently harder to change.’ The choice of WHO to contradict the alarming statement of MSF came forth from the political relations it had with government,

specifically the MoHS, of Sierra Leone, Guinea and Liberia. Ebola is bad for business (Business Insider, 2015). The political issue as discussed above greatly influenced the process of problematization. MSF was overstretched, heavily burdened by the increasing stream of infected patients and the WHO had their hands tied due to diverging international and local interests. Foregrounding political relations between entities show how interests conflict and influence the shape of the network.

I often would hear people talk about going into the ‘province’ and I would wonder what that was exactly. Asking someone who was going to Bo, the second largest city in Sierra Leone why he stated that he was going to the province, he simply replied: ‘Everything outside of Freetown is the province.’ Physical distance had turned into a socio-political gap, people who would live in Freetown were often seen as ‘backwards’ and ‘uneducated’. On multiple occasions I experienced that the person I was talking to, would be laughed at by his friends because of his or her English. Talking a broken English would more than once deliver the speaker the nickname of ‘villager’. The politicised, geographical gap between the Sierra Leonean capital and the rest of the country is not a phenomenon unique to the Ebola outbreak response structure. However, during the Ebola outbreak, this gap was foregrounded and its ramifications for the response were felt emphatically. These apparent harmless phenomena are stripped of their innocence once they are embodied within the national institutions, often under the authority of the thin layer of Sierra Leonean elite. This was also noted by John, who was shocked by the rudeness displayed by Sierra Leoneans towards fellow countrymen.

‘Also, Sierra Leoneans would do this. I think some of the people who were most disparaging of community responses were Sierra Leoneans in the Sierra Leonean lead. They would say: 'Who is these stupid people who are not doing what we tell them to do, they are so uneducated and so backwards.’ I think that was an issue, there is an elite layer of Sierra Leonean people that hold many institutions in their grip as they have the lead.’

These institutionalized preconceptions disconnected the strategic lead from the reality on the ground. Not only the conceptions of reality were obscured by how “the province” was perceived in Freetown, there was also a physical disconnection between capital and countryside. This sounds evident, as geographical locations make for a physical gap, however the geographical gap was never bridged by anyone from Freetown, it was assumed that all what was going on in the province was either known or irrelevant. The geographical distance was not only institutionalized, it also worked

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the other way around. Now people would not cross the distance anymore, trusting the province to be irrelevant. John: ‘The minister said: ‘is there anyone ever here ever been to Kailahun?’ The only people who had been there were NGO staff, no SL people were ever been to that rural, faraway place, why would you go there? So, there was a disconnection.’ Not only John, as an expatriate was struck by this. Also, a diaspora woman, Amber, whom I was able to interview commented on this. Amber had come back to Sierra Leone, after living in the UK for some time. When she arrived, she was quite perplexed by the chaos of the response. ‘Everyone tried to understand Ebola and what it was. Initially people managed, but people did not go up to Kailahun, so a lot of things were not clear.’ Geographical aspects had also found their way into the response network, showing how diverse the nature of the entities and their relations was.

It is remarkable to find how framing of a problem influences the action dedicated to it. Starting out, the two initial response structures (NETF and EOC) lacked a common goal and, consequently, could not find a way to align their interests. Manifested through the death of the only Sierra Leonean virologist, the Ebola outbreak became a global issue. The process of problematization was complete and now a discourse coalition was formed, the NERC. Social, geographical, political and material events and actors constantly influence the network dynamics in their own way. ANT traces back nodes and their relations to their origins, showing how the flap of a butterfly’s wing can cause a tornado.

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3. The Ebola response as a circular model

‘It was interesting because of the scale of the response and just the sheer numbers that we were looking at in the beginning as well as the logistics. People just kind of fell back to a de facto position that ‘this needs to be medically led’ and ‘in Sierra Leone, it makes sense for it to be military led’.’

This quote, from Jessy, a Western anthropologist involved in the outbreak response, suggests that this outbreak was of such overwhelming nature that the people involved withdrew to familiar and basic positions in addressing the Ebola outbreak. Adding to the large scale of the outbreak came insecurity; Ebola was a rare disease in West-Africa and the biomedical pathways of the disease were poorly understood. Both limited local experience as well as the inadequate knowledge within the global public health community, left the initial West-African Ebola response at a loss as to what to do. Having to deal with a large amount of insecurity and inexperience, people and organizations first utilized the knowledge, techniques and governing structures that were familiar to them (Dynes & Aguirre, 1991). However, a crisis environment like the Ebola outbreak ‘[C]reates significant problems in the attempt of the community system to provide overall co-ordination’ (p. 323). From this

position, new ways of organization and coordination had to be developed. Moreover, efforts focussed on the immediate, rather than the long term as legion of problems staring the responders right in the face (Roemer-Mahler & Elbe, 2016).

With the arrival of the UK taskforce and other actors like UNMEER, new response methods were introduced in the response. I argue that these methods were, to a great extent, motivated by the trend of securitization. I argue that when this particular approach is integrated in the actions of a humanitarian crisis response, it strongly affects ways in which interventions are given shape. The response relied on biomedical and military solutions, hinged on the motivation to secure. If found these methods allowed little space for the social, the space in which the Sierra Leonean people live. They felt the coercing nature of the response measures, without knowing why they were coerced. As a consequence, they resisted the intervention. To clarify this argument, I will introduce a model which shows why it was so hard for the response to achieve smooth collaboration with the Sierra Leonean population.

3.1 Securitization

Securitization of global health is a trend that has been discussed mostly during and after the West-African Ebola outbreak (Heymann, et al., 2015; Honigsbaum, 2019; Rodier, Greenspan, Hughes, & Heymann, 2007; Roemer-Mahler & Elbe, 2016). However, Emerging Infectious Disease (EID) outbreaks such as the West-African Ebola outbreak and the current outbreak in the Democratic Republic of the Congo (DRC) are of such nature that, according to the WHO, ‘[W]e are entering a very new phase of high impact epidemics and this isn't just Ebola’, a transition related to ‘a very worrying convergence of risks’ (WHO, 2019). In February 2014, the Global Health Security Agenda was established, an international co-operation that aims ‘to advance a world safe and secure from infectious disease threats’, a consortium which talks about infectious disease outbreaks and bioterrorism in the same breath (Global Health Security Agenda, 2014). Framing health issues as a matter of securitization causes ‘a sense of imminent danger that creates a perceived need for

immediate intervention and a quick fix’ (Roemer-Mahler & Elbe, 2016, p. 499). Containment here is a crucial concept, much used in literature to describe the action of preventing a crisis situation to spread internationally (Honigsbaum, 2019; Heymann, et al., 2015). I argue this trend strongly influenced the initial response interventions, actions which in turn created reason for social resistance.

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documented by the response, depicting Sierra Leonean people as resistant, not co-operating with the response system (Fairhead, 2016; Leach, 2015; Laverack & Manoncourt, 2015). Resistance is a term commonly used to indicate behaviour on non-compliance in operations responding to humanitarian crises (Mac Ginty R. , 2011; Mac Ginty R. , 2012; Wilkinson A. , Parker, Martineau, & Leach, 2017). In ANT, non-compliant behaviour is also explained as ‘resistance’, interpreting it as a situation in which actors do not agree with the proposed division of roles, or ‘the social contract’ (Barry, 2013). In Sierra Leone, the Ebola response system proposed a course of actions with which the people did not agree. They resisted becoming part of a network that did not take into account their needs and values, which resulted in both physical, verbal and symbolic forms of resistance (Wilkinson & Fairhead, 2017).

During my fieldwork, I once stepped into the office of a German NGO which had been very active during the Ebola outbreak. After recovering from the outside heat in front of the ventilator for a few minutes, a kind gentleman who was in charge of one of the program sections was prepared to speak to me. He had been leading the distribution of food, water and other basic needs to people who were quarantined during the outbreak, an aspect of the response were cases of non-compliance were frequent. He used the words ‘egoism’ and ‘habit’ to describe people who would not stay in their designated quarantine space. He described escape as a consequence of shortages like cigarettes and alcohol.

While I was making my way into the burning afternoon sun again, I pondered what this man had said. According to his story, people would only comply when enough of their needs were supplied and even then, it would not be sure whether they were taking the reason for the quarantine seriously. However, a few days later I was shown the other side of the coin concerning non-compliance when talking to Samuel, who had been involved in the upper layer of the EOC and NERC. He told me the following:

‘We realized that there was no confidence in our response. When somebody was sick and they would die in their house, you know what Sierra Leoneans would be doing? They would take the dead bodies and hide it under the bed, because they did not want their family to be buried in body bags. Body bags would mean people coming in PPE [Protective Personal Equipment], putting them in a bag without proper shrouding, take them away and dump them somewhere.’

His statement suggested that between the response and the people, there was a major dissimilarity in priorities. The burial team would come in PPE which, according to a member of the burial team, looked like ‘space suits’, and they would take away the infected body. Besides the alienating experience of having a group of non-local men in weird suits coming into your house, spraying everything with disinfectant chlorine, the response deprived the people from a proper burial of their loved one. A good friend of mine explained me the cultural practices behind burials in Sierra Leone. Having lived his childhood life in Sierra Leone, Manzi had moved to London working for the Sierra Leonean government. When the outbreak started, he moved back right away and fulfilled several functions within the response. He had grown up in the country, he knew how people thought, felt and would respond to certain events.

‘Things like burying the dead is an inherent cultural practice in Sierra Leone. Meaning that that is something we really believe in. Like, you don’t mess with that kind of practice here, because it is ancestral rites. Like, if you die, you add to the ancestral powers that I have. So, me burying you in the right place is more of a blessing to me than to others. So, if you take that away and not give somebody their final resting place it’s a curse. No one wants that curse. No one wants to be rubbed with the devil.

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It’s a practice that we respect’ (Figure 6 shows an Ebola Burial team at work in their ‘space suits’).

Although the action of taking away the dead is motivated by the drive to break the chain of

transmission, amongst many Sierra Leoneans this motivation was inferior to a proper burial of their loved one. From the response side, the behaviour of Sierra Leoneans was seen as resistance,

whereas these same Sierra Leoneans would describe the behaviour of the response as coercive. Is it possible to unite the two sides into one? It is, this is what the process of translation is about.

However, this process can be lengthy and complicated. Resisting to be incorporated in a social structure that does not respect the same norms and values as you do is a phenomenon can hardly be identified as irrational. What makes the situation more complex here is that the response system does not accept ‘no’ as an answer, as the circumstances are a literal matter of life and death.

3.2 Biomedicalization & militarization as means of security

Most of my interviewees would talk about infected patients as ‘cases’. An expatriate NGO director told me: ‘When the first cases ended up in Connought hospital in Freetown, those cases who had Ebola or who were suspected to have Ebola, they fled the hospital from the fear that something would happen to them.’ Patients became part of the medical jargon in the first months of the response. Not only on the strategic level, also on the ground. Salva spoke about people like

materials: ‘We wanted to look at the cases, the contacts. Do we need to transfer [them] to the case management team, hospital or holding unit?’ Besides the medicalization of language, epidemiology added another practical layer, widening the wedge between the sick people and those set to cure them. Manzi told me how incongruous he felt when he heard the Ebola update on the radio: ‘Just listening to the radio in the evening like: Confirmed cases Kailahun: 10, Kenama: 15… Ahh quite scary! They will do suspected, confirmed and dead cases.’ By addressing people with Ebola as cases, Ebola and the people became one. Amber had been deeply involved in the social dimension of the Figure 6 - Members of the burial team lower a body into a grave. Note their Personal Protective Equipment (Source: South China Morning Post).

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Ebola outbreak for which she was recognized; she had been awarded a prestigious decoration. She noticed the effects of this biomedicalization at an early stage: ‘Ebola was like a monster, look at what it did to people. It just coordinated the whole place, like 'do this, do that'. Forgetting that they were people.’ Regarding both humans and disease as one and the same had rather harsh consequences for the ways in which the response treated the people.

In his writing on MSF and the political and humanitarian implications the organization has on the environment they work in, Peter Redfield describes how biopolitics is represented by the tented camps of the French humanitarian relief organization. ‘The species body, individually varied but fundamentally interchangeable, grows visible and becomes the focus of attention’ (Redfield, 2005, p. 342). The bodily status is all that became important for the response, ‘dignity and citizenship’ is of no relevance at this moment of crisis. The rules that reign within an MSF camp, according to Redfield, are focussed on ‘the preservation of life’. According to Manzi, the situation in Sierra Leone at the time might actually not have differed that much.

‘So yeah, you know they [the response] used force, they used power. They removed the social construct and made this behavioural change messaging the rules of the day. So, imagine in a normal society, you have these constructs of laws, like 'put your seatbelts on' or like 'drive at 70mph'. Now they have been replaced by public health rules: 'Don't touch that guy, don't shake hands', you know 'don’t bury the dead, wash your hands'. These rules were taking away the very things that made us animals, which is the social construct that we had.’

It took me around three weeks before I discovered that Sierra Leonean schools had been closed for nine months due to Ebola and that presently, the whole school calendar had shifted half a year. At some point people experienced it as normal that schools, as well as businesses, were closed down. It was part of everyday life, a life that was governed by the fear of Ebola and logics of medicine. The ultimate illustration of how social life was brought back to a minimum happened around the end of September 2014. The event was called ‘a psycho-therapeutic exercise’ by interviewees who

supported the event and a ‘three-day lock-down’ by those who opposed it. What actually happened was the following: The whole country was placed under quarantine, no one was allowed to leave their house. During those three days, more than 28.000 health workers would go from door to door. The actual goal of this campaign is subject to public debate. One side would call it ‘educational’, whereas the other side would call it ‘punishment’ and ‘collecting corpses’. In a broadcast of an African news channel, it is told that almost 100 bodies were collected (CGTN TV, 2014). Although seen as a ‘relative success’ by the authorities, MSF criticised the lock down for spreading fear and distrust (TeleSUR, 2014).

Besides showing how far the government was willing to go in their fight against Ebola, the lock-down also forefronts the role of the military in the response. During the lock down, the Republic of Sierra Leone Armed Forces (RSLAF) would patrol the streets; ‘We had to make sure nobody was leaving their homes’, was what a former soldier in Freetown told me. Whereas the local military had been involved for some time, the UK military became involved with the establishment of the NERC. THis coordination centre was led by Paolo Conteh, the Minister of Defence at that time. One of my informants, Sinneh, who had worked with the old response structures before being integrated in the NERC, memorized the changes that came about with the appointment of Conteh as Chief Executive Officer (CEO).

‘Well I think before Paolo took over, we had limited number of military guys in the response. But when he finally took over the response, well, the response got a different face. It was more militant. And maybe one of the reasons why it happened would be maybe.. One of the rationalities behind it was as a result of these things

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[like] refusal, denial... You know, so they wanted to give a military face to the response. For people to comply. That was perhaps, in my opinion, why Paolo was brought in.’

This did not come as a surprise to me. Sinneh had worked in the data processing centre at the NERC, for which he had to attend all daily meetings. Bringing in the military was a means to enforce the biomedical approach the response had taken towards fighting Ebola. Although Sinneh

remembered that with the coming of the military the vigour of the response increased, it gave the response an attitude of ‘If you do not want to work with us voluntarily, we will make you comply.’ I took this information to John, the medical doctor. Besides hospital work, John had also been active on national policy level which put him in a position to notice the altering dynamics of the response. According to him, the language used within the response had taken on a military character.

‘First of all, the language dehumanized patients and communities. It is more the language of vectors rather than people. I think the second thing is that the idea of 'an enemy' somehow created this attitude. Again, I think it was somehow dehumanizing and sometimes it over-operationalized the logistic side of the response. So, the burials became very much about numbers to begin with.’

Now, the response was ‘fighting the enemy’, the enemy being the ‘cases’ who were ‘resisting and fighting back’. They needed to be ‘forced into compliance’.

The people between disease and response

Having spent a lot of time on designing classic network-like structures in my head and on paper, I came to the realization that these visuals lacked something important: unity. When based on ANT, a network will reflect the world as seen from one specific entity, one of many realties. However, I experienced that ‘the response’ was seen as an overarching system, experienced in a similar way by

Figure 7 - Diagram explaining the phenomenon of 'resistance' during the Sierra Leonean Ebola outbreak (2014-2016)

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many of my interviewees and other contacts. They would talk about “the response” as a living, changing entity, which had as ultimate goal ‘fighting Ebola’. Therefore, I found it more fitting to depict the response as a circle which surrounded its goal as a whole, showing how the response had replaced the original social order. Figure 7 shows the dynamics of that unique social situation and how it was possible that human beings became the enemy of a humanitarian intervention.

The figure is made up out of four layers which represent, from outside in, the international health community, the national response organization, the Sierra Leonean population or ‘the patients’ and the Ebola disease itself. The interventions designed by the response, directed at removing Ebola from the environment, are represented by the thick arrows. These interventions were not received well by a large part of the population, especially in the rural areas, and thus tensions arose which are indicated by the red explosive-like shapes (Focus 1000, 2014; Richards, et al., 2015). The reactions of the people against the response as a consequence of these tensions are represented by the thin arrows. Using the model as a basis, I will set forth my argument on how the trend of securitization of global health pushed the response towards a practical, rough approach, thereby causing tensions between the people and the response. By slowly zooming in, the effects of the global trend on local interventions will become apparent.

International concern

An interesting comparison that was made by several people was on the attitude of the international community during the Ebola outbreak and the Sierra Leonean civil war. This civil war was started by the Revolutionary United Front (RUF) with the help of the Liberian warlord Charles Taylor. It started in 1991, lasted 11 years and costed 50.000 lives. My close friend, local supervisor and gatekeeper Jospeh, reminisced the following about the civil war:

‘Because it was only at the later stage that the international community got to know that 'Oh it feels like we need to do something'. These people are talking about their lives and everything that is going down. So, imagine the war started in 1991, the international community did not step in until like 1995. So, years and years of fighting and even when they did, they approached in very different. (…) There is also this argument about, ‘they only took it serious when there were few cases that started popping up elsewhere’. So, Nigeria started to having its first case. All of a sudden there was a suspected case in the UK, someone was held for a few weeks. They started knowing 'OK, so if we don't control this, then it is possible it can just...' – AM Joseph remembers 1995, yet the correct date is 1999. It took the UN eight years to step into a conflict that, at the time the UN started making diplomatique moves, had already taken around 40.000 human lives. It took both the UN and the government of the UK seven months to step in with serious resources during the Sierra Leonean Ebola outbreak (Encyclopedia Britannica, sd). Motivated to secure the situation, the international organizations and aiding governments took with them an agenda of containment. This agenda would strongly influence policy, strategy and the shape of the interventions.

As Haymann writes on the West-African Ebola outbreak, health security is ‘one of the most

important non-traditional security issues’ states: ‘As the Ebola virus crosses national borders, there is clear understanding that the outbreaks in west Africa are a threat to our health security—people with infection have travelled across borders within Africa and to Europe and to North America where they have unintentionally caused small chains of transmission far from the epicentre of the outbreak’ (Heymann, et al., 2015, p. 1884). During the 2013-2016 West-African Ebola outbreak, a few cases of Ebola managed to find their way out of the infected area to the Global West. Spain, the USA and the UK had cases, the first of which was on September 2014 in the USA. One month later, the WHO issued a report on the risk that Ebola posed in Europe in which it stated: ‘As the most