What will it take to turn the “Ebola Fiasco” into a hot crisis?

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The Australian Government is under mounting pressure to step up its response to the international “Ebola Fiasco” – which US President Obama has described as a “growing threat to regional and global security.

New modelling from the US Centers for Disease Control and Prevention shows that reported cases in Liberia are doubling every 15–20 days, and those in Sierra Leone are doubling every 30–40 days.

If conditions continue without scale-up of interventions, the number of cases in West Africa will rapidly reach extraordinary levels, says the CDC report, which gives a “worst case scenario” of  1.4 million cases by January 20, 2015. However, the findings also indicate the epidemic can be controlled.

In a joint statement today, the Public Health Association of Australia (PHAA) and the Australian Healthcare and Hospitals Association (AHHA) say Australia is lagging behind the US and UK in responding to the crisis.

Or, as experts wrote at The Conversation:

“We are all part of a shrinking global village, and right now some of its homes are ablaze. We can and should expect each of our governments to do more than pay someone else to buy, fill and carry a few buckets to throw on the inferno, as the Australian government has done.”

However, those seeking to galvanise the Australian and global response need to take account of some lessons from political science, suggests Evelyne de Leeuw, Associate Professor of Public Health and Health Policy at La Trobe University.

“We should not just call more loudly for action on Ebola and its determinants, we should do it more cleverly,” she writes below.

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The making of hot crises: Is Ebola different?

Evelyne de Leeuw writes:

In a recent blog, Michael Moore, eminent and astute CEO of PHAA and vice-President of the World Federation of Public Health Associations( WFPHA), explains how one overseas catastrophe can yield more domestic political capital than another.

Going to war, he observes, has always been a sly political strategy. But a war should be fought on a different front, too.

Moore calls on our government to do more in the face of the unfolding Ebola drama: we should deploy our military potential to its fullest, mobilise the hugely professional and effective Ausmat health team, and resource the effort more profoundly.

Raising the alarm

There is, of course, a question whether waging a medical war would indeed be the most appropriate response.

Three months into the explosive Ebola epidemic, Medecins Sans Frontieres raised the alarm and said:

“The WHO, the affected countries and their neighbouring countries must deploy the resources necessary for an epidemic of this scale. In particular, qualified medical staff need to be made available, training in how to treat Ebola needs to be organised and, contact tracing and awareness-raising activities among the population need to be stepped up. Ebola is no longer a public health issue limited to Guinea: it is affecting the whole of West Africa.”

It would have been more appropriate to cut that last sentence short: Ebola is no longer just a public health issue. It impacts on basic survival of humanity, peace and security (not just of health personnel) and our collective ability to respond to tragedy on a grand scale. The very global (health) governance architecture is at stake.

WHO was blamed for inaction and inefficiency, with few recognising that the authority and clout of the organisation have in fact been eroded over the last decades.  Through systematic defunding in regular membership fees, with many ‘extra-budgetary’ funds pouring in, WHO core functions have been compromised.

If anything, the Ebola crisis may be our one opportunity to really commit to a value-based global health system that embraces equity, participation, solidarity and sustainability as a guiding principle for health for all.

UNMEER will fail

The recent efforts at the United Nations to establish UNMEER (United Nations Mission for Ebola Emergency Response) are welcomed. I would qualify the enthusiasm.

UNMEER may well further corrode the authority of WHO, may not align with national and global public health infrastructures (deploying military-style temporary interventions) and will – adopting a clinical-technological control paradigm – fail to address the social, political and commercial determinants of this devastating disease outbreak.

The virus might be fought effectively at great human cost, but the debate on the reasons it could emerge and spread in densely populated West African urban environments has yet to appear on the global political radar.

Too little, too late, or too much, too quick?

1. In January 1976 a US soldier returned after a field exercise to his base a Fort Dix with what first appeared a nasty cold. Within days though, he was dead and a few of his colleagues seemed to suffer from the same influenza stream that had caught him – H1N1, or swine flu. In an unprecedented move, President Gerald Ford decided to act on advice provided by CDC and launch a massive vaccination campaign. Millions of Americans were vaccinated (at a cost of over $135M) but the flu never came. The vaccination campaign was stopped. Indeed, there was a serious health cost: there were 54 cases of Guillain-Barré syndrome associated as side effects of the vaccination effort.

2. In June 1981, the Morbidity and Mortality Weekly Report (a publication of CDC) published a report of five cases of Pneumocystis carinii pneumonia (PCP) that were picked up because treatment required release of an experimental pharmaceutical. This was the ‘official’ beginning of the HIV/AIDS epidemic. Public health professionals very soon recognised the potential scale and impact of this new infectious disease but failed to convince policy makers that profound action was required. It took four years and the death of actor Rock Hudson to achieve at least the start of such profound action – which still can be considered too little too late.

3. Ebola is a member of the small family of filoviruses, causing haemorrhagic fevers. A number of smaller outbreaks have been described over the years, mostly in ‘Dark Africa’. The nature of the virus, the course of the disease and transmission modes have been well documented. The public health community has always been highly intrigued by its life cycle, trying to find its reservoir (where it hides when it does not affect humans) and identifying the circumstances under which it jumps to people. Ebola has been used extensively in books and films as one of the scariest diseases on the face of the earth. But beyond capturing the morbid fascination of artists (Disclosure: Evelyne de Leeuw wrote a novel – in Dutch – about an airborne haemorrhagic fever mutation and the global failure of technology to combat it) and movie-goers, no-one ever considered it as an imminent threat to global peace and security. Millions die of preventable causes every year, but the ever-raging epidemics of cholera, measles and malaria have never been constructed in the minds of the global political elite as a peril to stability and economic survival – 2014 is seeing a momentous shift.

Our game: words

The reasons why some issues gain almost instant political agenda status and others do not have continued to elude policy students.

It should be seen as no surprise that the father of political science, Harold Laswell (who defined politics as driven by the questions ‘who gets what, why and when?’) also is credited as the scholarly originator of the political study of propaganda. He wrote:

“At best the propagandist is selective. He discerns a potential reservoir of discontent or aspiration and searches for ways of discharging the discontent and harnessing the aspirations so that they harmonize with his policy’s objectives. The available means of mobilizing collective action depend, in turn, on words and word equivalents whose signification is already circumscribed by the predispositional patterns present in the political arena. Furthermore, the existing predispositional patterns themselves set limits on what can be done.”

The ability to use words and imagery is critical in moving social issues on, or away from, political agendas.

Effective politicians master this art exquisitely, and political scientists and sociologist still struggle to make sense of this elusive talent.

If one could map and describe the metaphors, narratives, synecdoches and other rhetorical tools of the skilled politician, we could plot our counter-moves, feed them our own propaganda, and create a more effective narrative to pursue our own social and political goals.

If only!

It appears that there is more disagreement between policy scholars around the ingredients of this volatile mix than that there are policy options on any given issue. What do we know?

Some of the first authors to explore this question were US political scientists Cobb and Elder. They saw the policy game as depending on the ability of single issue interest groups to expand their rhetorical reach into other audiences (or ‘publics’ as Cobb and Elder call them) and gain their support.

‘Issue expansion’ is dependent on particular representations of reality (in this context, Laswell speaks of ‘miranda’ – doctrines, formulas, and that which is to be admired in the  popular imagination). This is key in the word game of politics: there are no facts or truths, there are only perceptions that may resemble truths.

The ‘sell’ to expand an issue to other ‘publics’ is that the issue expansionist must create a belief that the issue is:

  • defined equivocally
  • perceived as having social relevance
  • presented as a long-term challenge
  • seen as non-technical or non-technocratic; and
  • without too many historical precedents.

Clearly, eloquence and cunning word play become essential in managing issues that seem to be pretty straightforward and not amenable to manipulation to the ‘honest’ technician-professional. We should not just call more loudly for action on Ebola and its determinants, we should do it more cleverly.

From words to frames to packages

Theorists’ words evolve and morph as well, of course. From ‘issue expansion criteria’, policy scholarship moved into ‘framing’ and ‘packaging’.

Framing (cf. Rein and Schön) is usually defined as a way of selecting and organising aspects of complex issues in order to provide guidelines for analysing, interpreting and acting.

Such frames are more complex constructs than the mere rhetorical tools and belief creations associated with Cobb and Elder’s agenda-building theory. Frames integrate (perceptions of) facts, values, theories and interests. This sets the ‘framing’ concepts apart from simple issue expansion, where problems of power differentials were –conveniently – ignored.

Although many frames are shared by communities and societies (as sociological institutions and the tools of multi-level governance), for policy-making conflicting frames are purposely created to allow the participants in the game to not only disagree with one another but also disagree about the nature of their disagreements.

We should not just be clever about our (public health) Ebola frame, we should recognise that our world view may not align with others’ – and reflect on how to find common ground for new directions.

This is not where the game ends, though. Rhetoric and frames come together in even more elusive ‘interpretive packages’.

These packages are powerful and deceptively simple rhetorical tools for complex frames that have the potential to create scares and panics – what Unger calls ‘hot crises’. Interpretive packages are created and perpetuated by the media in its intractable ecosystem with corporate interests, electoral predispositions, and consumer attraction (and perhaps repulsion…).

Hot crisis packages are rooted in panics and scares – but not every crisis leads to panic, and not every panic is based on crisis.

Unger identifies three models. The elite-engineered and interest group-directed model are connected to professionalism and bureaucracy – in the public health field one would typically expect a Department of Health pronouncement to have the potential to elicit an elite-engineered scare, and the Public Health Association to generate interest group-directed scares. The third group of models are labelled ‘grass roots’ scares. Some are harder to create, control, contain or reduce than others, and our understanding of the lives of panics and scares is still emerging.

Panics and scares are no guarantees for institutional or policy shifts – hot crises are. Unger writes:

“hot crises entail dread-inspiring events that are developing in unpredictable ways and are seen as having the potential to pose an imminent personal threat to specific populations. Hot crises are startling, as presumed invulnerabilities appear to be challenged. A palpable sense of menace puts the issue ‘in the air’, as unfolding events are watched, discussed and fretted over.”

From a situation where the locus of control over the issue has been placed in far-away lands where people we do not know are suffering exceptionally from otherwise almost ‘seasonal’ health concerns (or, as both Alexandra Phelan and Unger in his Ebola Zaire assessment find, ‘othering’ the issue), the hot crisis has now reached UN and WHO offices around the world.

To paraphrase Asterix and Obelix, the fearless Gauls: “Around the world? No – a small island on the edge of the world resisted…”

Engineering an Australian hot crisis Ebola package?

The hot crisis package that has been engineered by the Australian government to lead us into a far-away war in Syria, Iraq and Kurdistan depended on a fear-mongering frame about ‘home-grown jihadi terrorism and cruelty’ – with perhaps a different type of war waged domestically. The intensity with which Australians are communicating about Ebola is qualitatively and quantitatively different.

Michael Moore’s call for more and better action on the Ebola front has so far lacked either the appropriate rhetoric, frame, or hot crisis package – there is neither an elite-engineered, interest-group directed, or grassroots founded package that necessitates the urgent and massive humanitarian assistance that ‘the facts’ would dictate.

I would surmise that the key to understanding the difference in action on both crises can in no small part be attributed to the insular nature of Australian geography and politics. We have managed to ‘stop the boats’ on the seas that surround and protect us, and our vigilant customs and quarantine men and women will do wonders when it comes to Ebola; there are no direct flights from any Australian airport to any West African air travel hub.

Looking at the conditions that would further contribute to building a hot crisis Ebola package, it would be necessary to:

  • document and frame a significant number of dramatic precipitating events relevant to large swathes of the Australian populace;
  • describe the potency and vividness of the underlying dread factor (‘drowning in your own blood’ on ‘a massive scale’) and drip-feed this imagery to the media;
  • make the issue of a massive infectious disease outbreak resonate with recent cultural preoccupations of large groups of Australians;
  • manage and locate Ebola as a global threat that has imminence for Australia;
  • pretend there is consensus and coherence on the causes and effects of the hot crisis (‘we are in this together’ and perhaps a ‘global village’ metaphor exploiting the immigrant nature of our population); and
  • monitor and manage news feeds from the fringe into the mainstream and ascertain (unlike the humanitarian disaster of the African World War that has killed millions in Central Africa over the last two decades but was never seriously reported on in Western media) that coverage is constant.

In discussing such a Machiavellian strategy with public health peers and students I found great apprehension – ‘doing no harm’ seems to contradict the intent to create a hot crisis.

I do believe that our purpose and ideals should be to ‘do good’ – not just onto others (in benevolent expressions of humanitarian assistance and mobilising more significant tangible and intangible resources) but also onto ourselves.

There is an opportunity here for Australia to not just step up a public health response, but to impact significantly on a global health discourse that is values-based and not just infectious disease control focused.

Australian public health has major strengths in researching, teaching, developing and considering action on social, political and commercial determinants of health – let’s deploy that capacity to the world as well.

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Further reading