Getting to Zero

Ebola and the politics of disease elimination

Jun 06, 2022

In March 2015, I spent eleven days in Sierra Leone conducting research for an oral history project on Ebola.1 My objective was to interview key actors in the epidemic response and capture the voices of witnesses to what was, at the time, an unprecedented global health emergency.

My first port of call was the National Ebola Response Centre (NERC) in Freetown. Located in the old Special Courts Complex where rebel Army officers were prosecuted following the end of the country’s brutal eleven-year civil war, the NERC directs Ebola command and control operations throughout Sierra Leone and is home to more than 200 officials from some twenty international agencies. It is also here that every evening Sierra Leonean and British military officials gather to hear the latest Ebola situation reports and plan the next day’s actions.

My arrival coincided with a renewed drive to stamp out Ebola in and around Freetown and Port Loko, a 2,000-square mile district to the north of the capital scored with swamps and rivers perfect for evading the Ebola control measures. The drive had assumed a new urgency following the pledge on 15 February by Sierra Leone’s president, Ernest Bai Koroma, to eliminate Ebola from Sierra Leone within 60 days as part of what the United Nation’s was calling its ‘Getting to Zero’ strategy

‘Getting to zero’ disinfectant bucket outside National Ebola Response Centre, Freetown.

Drawn up in boardrooms in Geneva and Washington in 2014, the strategy was meant to focus attention on Ebola ‘hotspots’ and clusters of infection that were impeding the resumption of normal economic life and the repatriation of international health workers from the Ebola zone. The problem was that while the World Health Organization (WHO) and the United Nations had flooded Sierra Leone with thousands of contact tracers, cases of Ebola were continuing to occur in individuals who did not appear on the official contact lists. As Jim Yong Kim, the president of the World Bank, explained in an op-ed in the New York Times, in order to get to zero it was imperative to ascertain if these were people who had previously been identified as contacts of Ebola patients but whose names had somehow been overlooked by contact tracers, or whether the new cases represented ‘unidentified transmission lines’.

“This will tell us whether we are winning or losing,” explained Kim. “Right now, in all three countries, we have only partial data on this particular indicator.”

Ebola zero infection campaign, Freetown.

Koroma responded by invoking the image of ‘Mama Salone’ – the maternal symbol of the nation - and issuing a statement that it was every Sierra Leonean’s duty to comply with the Ebola measures for the sake of the country.

Under the Krio slogan ‘Leh we tap Ebola (‘let us stop Ebola’), Koroma explained: “Each of us must make a commitment to do whatever it takes to get to zero.

Unfortunately, not everyone viewed compliance as their national duty. A few weeks before my arrival, for instance, a Port Loko fisherman infected with Ebola had ignored the official requirement to report to an Ebola assessmen centre and had persuaded three colleagues to ferry him to a remote island in the Rohmbe swamps. There, he had consulted a traditional healer before continuing by sea to Freetown where he alighted at a wharf in Aberdeen, a stone’s throw from the Radisson Blu Yammy, the city’s premier hotel. By now the fisherman was a walking virus bomb and on disembarking made straight for an Oxfam-built toilet block where he vomitted haemorrhagic fluids on the floor. As a result, 20 villagers living nearby were also infected with Ebola, prompting the quarantining of the Aberdeen community for 21 days and causing panic in the adjacent Radisson, then home to scores of international health workers including more than 50 employees of the CDC.

A fisherman sets sail from Sussex, near Freetown.

In theory that should have been the end of the transmission chain but despite the best efforts of contact tracers one of the fisherman got away, hitching a lift on a motorcycle to Makeni, three hours drive from Freetown, where he infected three more people, including a local healer. All four were eventually traced and taken to an Ebola treatment centre run by the International Medical Corps. However, once there, I was told, several of the patients had refused treatment, fearing that staff were trying to murder them with what the healer called their ‘Ebola guns’ – a reference to the hand-held electronic thermometers that nurses use to record patients’ temperatures.

In recent years achieving an end state of zero has emerged as an important policy goal for a series of 21st Century challenges, ranging from poverty reduction to the elimination of nuclear weapons. This zero rhetoric has proved particularly beguiling to global health policy makers eager to build humanitarian constituencies for the elimination of infectious diseases such as malaria and polio. In 2011 the phrase was even adopted by UNAIDs as the theme of international Aids Day and to call for ‘zero discrimination’ of Aids patients.

At a time of growing global insecurity, where outbreaks of infectious disease in previously remote parts of the world are increasingly seen as a collective threat to health, this eradicationist rhetoric has immense moral and political appeal. Little wonder then that as emerging and re-emerging infectious diseases such as SARS, bird flu, MERS and Ebola have risen to global prominence, so global health policy makers have seized on the rhetoric of getting to zero to mobilize multilateral support for ever more complex medical and technical interventions.

While ‘getting to zero’ may motivated by a politics of medical humanitarianism, however, it can also inscribe a very different kind of politics. This politics draws on historical memories of colonial encounters – encounters that resulted in the extraction of minerals, blood, and other precious resources from indigenous populations – as well as present tensions between urban elites and rural populations in the affected countries. These tensions are arguably heightened by the internment of patients in Ebola holding units and the rapid disposal of the dead, measures that frequently provoke further breakdowns in trust and the imposition of even more draconian measures against rural populations. Indeed, as The Lancet acknowledged in a special report on Ebola, to invoke the idea of global health security today “risks giving permission to more authoritarian minded governments to use health crises as justification for sometimes extreme curbs on liberty or the political, economic and social rights of citizens.”

The Lancet had in mind the Liberian President, Ellen Johnson Sirleaf’s decision in August 2014 to order the containment of suspected Ebola patients in an ill-equipped holding centre in the West Point district of Monrovia – a decision that prompted widespread rioting among the shanty town’s 100,000-plus inhabitants and shocking scenes of police brutality that culminated in the death of a 15-yr-old boy, Shakie Kamara. However, The Lancet’s comments could apply equally to the three-day nationwide lockdowns in Sierra Leone in September 2014 and March 2015 – lockdowns that resulted in the similar clashes between police and protestors in Freetown.

As Médecins Sans Frontières has argued, such heavy-handed interventions may not only be undemocratic but counter-productive, driving Ebola patients underground and undermining trust in international health providers and medical interventions designed to curb the epidemic. Indeed, the Getting to Zero strategy was born in part out of the WHO’s recognition that its initial focus on containment and the rapid disposal of corpses in violation of traditional burial practices may have alienated local communities, particularly in Guinea where community ‘resistance’ was perceived to be especially marked, and might be causing people to stay away from Ebola treatment units. Nevertheless, it is striking that even where the WHO and other agencies have sought to persuade people to act in their own and other people’s collective interests by, for instance, engaging directly with community leaders in an effort to accommodate traditional customs, people have been extraordinarily resistant to the public health messaging.

Beginning with the smallpox eradication campaign in India in the 1970s and concluding with a survey of the Ebola elimination efforts underway in Sierra Leone today, this lecture traces some of these ‘resistances’ by focussing on patients at the sharp end of these interventions. In so doing, it is not my intention to detract from the evident achievements of these campaigns: no one would deny that the eradication of smallpox – an ancient, deadly and often blinding disease – was a hugely desirable outcome, removing a source of suffering for millions of people across the globe. Nor would I wish to see Ebola become endemic to West Africa, though that may well be the direction in which social and economic forces and host-virus interactions are leading us.

However, I do wish to point to the tensions between medical humanitarianism and the very different ethics and logics that drive global health security – tensions which are arguably reflected in Ebola’s shifting construction as an ‘emerging infectious disease’ and potential bioweapon threat on the one hand, and as a neglected tropical disease on the other. And I wish to question some of the assumptions behind the eradicationist impulse – in particular, the extent to which vertical campaigns that aim to halt or eradicate disease transmission should be regarded as desirable in and of themselves, regardless of the collateral damage to trust and support for other forms of health intervention. These considerations apply particularly to Ebola, a virus that, unlike smallpox, is presumed to reside in an animal reservoir between epidemics, and which could re-emerge at any time.

Finally, this talk can also be seen as a contribution to the on-going debate about whose security is really at stake in these interventions and the extent to which Western biomedical values and global health regimes may clash with and override traditional belief systems. In short, I wish to describe a very different history of getting to zero from those usually highlighted in retrospective accounts of humanitarian medical ‘successes’.

***

The concept of getting to zero can be traced to the smallpox eradication efforts in the 1970s, in particular to the campaign ‘Operation Smallpox Zero’ launched in Bihar and Uttar Pradesh states in India in January 1975. This effort, which lasted four months and entailed 130,000 contact tracers going door to door to identify unreported cases of smallpox for vaccine containment teams, has been identified as a key factor in the isolation of the last case of smallpox in India in May 1975 and the worldwide drive to zero which culminated in 1980 with the WHO’s declaration that smallpox had been eradicated worldwide.

I will return to the Indian campaign in a moment because it was during Operation Smallpox Zero that many of the methods and techniques that have now become standard in eradication campaigns were first deployed on a large scale and in many ways the Indian smallpox campaign can be seen as a model for the Ebola elimination drive underway in Sierra Leone and Guinea today. Before doing so, however, I wish to point out that medical dreams of eradicating infectious disease have a long history. In particular, it has been argued, it was the discovery of the mosquito transmission of malaria and yellow fever in around 1900 and the wider deployment of pesticides and therapeutic drugs such as quinine that first put the medical control of infectious disease on a rational basis. In the Americas and the Caribbean these measures proved largely successful; in Africa and Asia less so.

But running alongside with and complementing these measures has also been another technology of intervention: namely, disease surveillance. Indeed, without an accurate method of counting cases, it is impossible to measure morbidity accurately and to know if a disease is on the path to being eliminated, much less to being eradicated.

Now, eradication and elimination are slippery terms which, even now, can mean something slightly different according to the ecology of the microbial pathogen in view and what sort of interventions are available or deemed sufficient for its control. However, whatever definition is adopted, it is surveillance that makes the eradication of disease theoretically possible by enabling epidemiologists to track the incidence of infections to a zero end point.

In her history of the CDC, Elizabeth Etheridge has argued that a key conceptual shift in surveillance occurred in around 1950 when Alexander Langmuir, the director of the epidemiology branch of the National Communicable Disease Center in Atlanta, the forerunner of the CDC, introduced an innovation into the case reporting of malaria.

Suspecting that the incidence of malaria was being over-reported in the United States, Langmuir insisted that instead of merely reporting cases of malaria doctors should also supply the names of infected individuals. Langmuir would then dispatch an ‘epidemic intelligence’ team equipped with sophisticated diagnostics to investigate whether the reports were accurate, after which a decision could be made as to whether additional control measures were required. Langmuir dubbed this new mode of investigation ‘the surveillance of disease’ and under this system was able to demonstrate that, as he suspected, the incidence of malaria in the US had been over-estimated.

Etheridge and others have argued that Langmuir’s innovation marked the emergence of a new rationality in public health – the transition point, if you will, from the old statistical approach of measuring the incidence of disease across populations, to the surveillance of disease itself.

However, this focus has tended to obscure the extent to which Langmuir conceived of disease surveillance as part of the wider practice of ‘epidemic intelligence’. Founded in 1951, the Epidemic Intelligence Service was originally established to train CDC epidemiologists in the detection of biowarfare threats. However, under Langmuir’s direction it soon developed into a fully-fledged cadre of disease detectives. Today, the EIS are considered the CDC’s ‘boots on the ground’ and the first responders to infectious disease outbreaks, with a duty not merely to investigate disease but to contain outbreaks. In this respect epidemic intelligence can be seen as the bridge between disease surveillance and command and control operations. Indeed, it could be argued, that from an eradicationist perspective the two functions are inseparable, for without an accurate measure of the incidence of a disease – of who is and who is not infected – containment and control cannot proceed on a rational basis and gaining the support and trust of target communities becomes that much harder.

Langmuir understood this perfectly, hence in an influential 1963 paper entitled ‘The Philosophy of Disease Eradication’ published in the same year that he outlined his new philosophy of disease surveillance, Langmuir sought for the first time to define eradication as a zero transmission state. Thus, whereas control designated the ‘purposeful reduction of specific disease prevalence to relatively low levels of occurrence’, Langmuir argued that eradication was the continuation of the same process ‘but to the point of continued absence of transmission within a specific area.’ Langmuir’s point was that in either case success depended on the application of the same surveillance tools for measuring reductions in case transmission and that ‘if this reductive process continues until the number of newly transmitted cases reaches and remains at zero, eradication of the disease has been achieved.’

Interestingly, even as he outlined this new philosophy of zero transmission Langmuir was cognisant that his formulation might not meet with universal acceptance, hence his observation at the end of his paper that

We suspect that the possibilities of local failure are more likely to derive from problems of logistics and of inadvertent offense against the mores of primitive peoples than from purely technical considerations. [my italics].

By drawing attention to that pregnant phrase, I do not wish to imply that surveillance regimes that aim at eradication are necessarily coercive. However, my argument is that, far from being inadvertent, these offenses are intrinsic to the rationales that underpin disease surveillance and the logics of command and control.

Take smallpox. The official histories tend to ignore the fact that the surveillance teams tasked with identifying the last cases of smallpox often met with outright hostility. Indeed, Sanjoy Battarcharya has rejected any inevitability toward smallpox zero, arguing that by 1974 the campaign was ‘faltering’ due to the combination of community resistance and bureaucratic conflicts between Indian officials and the WHO in Geneva. Arguably, it was only when Indira Ghandi’s government declared a state of emergency in 1975 and the usual democratic processes were suspended, that Donald Henderson, the chief architect of the WHO’s eradication campaign, was able to complete the job by employing more coercive measures against the target populations.

These measures included the confinement of infectious patients in their homes against their will and the vaccination of anyone entering or leaving, regardless of whether or not they had been vaccinated before. Eventually, the containment was extended to whole villages as the WHO abandoned individual contact tracing as ineffective and adopted a ring vaccination approach instead. As Stanley Music, a senior WHO epidemiologist, recalled, the policy required ‘an almost military style attack on infected villages’:

In the hit and run excitement of such a campaign, women and children were often pulled out from under beds, from behind doors, from within latrines…. [Attempts were made to secure the cooperation and ‘blessing’ of village headmen… however, headmen’s authority did not extend into individual’s homes…] Almost invariably a chase or forcible vaccination ensued in such circumstances… We considered the villagers to have an understandable though irrational fear of vaccination… We just couldn’t let people get smallpox and die needlessly.

Music was not the only person to find such scenes disturbing. Another young WHO epidemiologist, Larry Brilliant, who would go on to a distinguished career in global health, expressed similar misgivings about the actions of the Indian vaccination teams, describing how in one village in Bihar he had observed a middle-aged couple being dragged from their home by a government squad and vaccinated against their will. Afterwards, Brilliant described how the husband had shown great dignity and adopted the moral high ground by invoking the South Asian concept of ‘dharma’, an ethical code that he argued transcended Western values and norms of medical conduct. Addressing the vaccination team, this man stated:

My dharma [moral duty] is to surrender to God’s will. Only God can decide who gets sickness and who does not… Daily you have come to me and told me it is your dharma to prevent this disease with your needles. We have sent you away. Tonight you have broken my door and used force. You say you act in accordance with your duty. I have acted in accordance with mine.

Similar clashes between scientific and traditional belief systems have bedevilled the Global Polio Eradication Initiative. Since its launch in 1998, efforts to eradicate polio from the last remaining centres of endemic transmission – Afghanistan, Nigeria and Pakistan – have stalled to the point where in 2012 the WHO declared polio eradication a programmatic emergency. In many cases, opposition has been driven by the belief among some Muslim populations that the Koran forbids vaccination. But in other cases this opposition appears to be motivated by politics and a history of structural violence in polio endemic countries. Thus in 2012 a leader of the Taliban in North Warzistan called for a ban on polio vaccination until the US stopped visiting drone strikes on the area, arguing that such strikes kill and cripple more civilians than polio ever could. In both Afghanistan and Nigeria, this suspicion of international vaccination squads has also led to conspiracy theories that the vaccines are a ploy to sterilize Muslim women. While patently false, such beliefs are not helped by the disclosure that during the hunt for Osama bin Laden a Pakistani physician working for the CIA obtained DNA from children in Abbottabad using the ruse of a fake immunization campaign. But perhaps the more fundamental reason for the stalling of polio eradication is simply the fact that the campaign has gone on too long and people are fed up.

***

In the last part of this talk I want to turn to the Ebola elimination campaign and the disjunction between the rhetoric of humanitarian assistance and people’s experiences of these security interventions on the ground. In Sierra Leone, as in Pakistan, people are also becoming fatigued with elimination efforts. Moreover, in these countries, as in other parts of Africa, there is a long history of uneasy encounters with medical researchers – encounters that have made indigenous populations wary of European scientists and the pharmaceutical industry more generally.

This distrust of Western biomedicine was arguably exacerbated by the WHO’s belated response to the outbreak in Guinea and its decision to prioritize the disposal of the dead and the rapid isolation of infectious patients at the expense of contact tracing as part of what it called its ‘70-60-60 plan’ (70 percent safe burials and the isolation of 70 percent of those infected with Ebola, all within 60 days). In practice these targets were impossible to meet, particularly in Guinea where burial teams encountered fierce resistance from communities convinced that Ebola was a ploy by their government to garner international aid funds. Another area of contention were burial edicts requiring the rapid disposal of infectious cadavers – edicts that left little time for mourning or traditional burial routines.

But perhaps the biggest reason for the widespread distrust of government and its international partners was that, in the initial stages of the epidemic at least, most people entering Ebola treatment units were never seen again. Coupled with the sight of Western health workers being airlifted to the US and Britain, where they generally enjoyed much better clinical outcomes and access to experimental drugs such as ZMapp, it is little wonder that many Sierra Leoneans came to view the contact tracers and Western medical teams with suspicion. As a villager in Kailahun, one of the first and hardest hit districts in Sierra Leone, put it:

Because so many people died at the Ebola camp in Kailahun, we assumed that as soon as someone was put into an ambulance they would die. We also thought that the contact tracers were working with the authorities to get our blood or kill us.

This distrust was exacerbated by the unequal management of the living and the dead. For instance, during my visit, I heard several stories of how those with the means and connections were able to obtain preferential treatment for sick family members or exemptions for private burials. Meanwhile, patients without money or influence were sprayed with chlorine before being placed in decontamination suits and herded into ambulances for gruelling four-hour drives to the nearest Ebola treatment unit.

By October, the WHO was beginning to realise that its 70-70-60 policy was inadequate and that it needed to pay more attention to contact tracing. Indeed in informal discussions with the WHO’s director general Margaret Chan, advisors urged her to adopt the same contact tracing model that had proved successful during the smallpox vaccination campaign in Calcutta in the 1970s. This was the beginning of the Getting to Zero strategy.

By the time I arrived in Freetown in March, the campaign was in full swing and the harsh measures that had characterized the initial response to the epidemic had given way to a more consensual approach. Nonetheless, widespread suspicion remained that containment was not being applied equitably and that the Ebola restrictions were being used to settle political scores.

On the day after my arrival, for instance, demonstrations erupted outside the Connaught Hospital in Freetown in protest at the NERC’s decree that a prominent representative of the opposition Sierra Leone People’s Party (SLPP) be removed to the municipal cemetery in Freetown for burial. The decree was seen as politically motivated as the politician, Musa Tamba Sam, was aged 89 and had died of natural causes, not Ebola. In this highly charged situation it mattered little that the NERC was insisting there had be the same rule for everyone. In the atmosphere of distrust and conspiracy pervading Freetown, the decision to hand the elder statesmen’s body over to an Ebola burial squad rather than to allow his family to convey his remains to his home district for traditional funeral rites was seen as a provocation and a sign of ‘disrespect’ to the SLPP.

A few days later, Koroma used section 41b of the emergency regulations to fire his own vice president, Sam Sumana, who was in the middle of a 21-day quarantine at his home in Freetown following the death of one his bodyguards from Ebola. The announcement, which came in the midst of a parliamentary inquiry into the alleged misappropriation of funds for the purchase of ambulances, was interpreted by the government’s opponents as an example of Koroma’s arrogation of power and abuse of constitutional processes. Though widely reported in Sierra Leone, it goes without saying that these incidents warranted barely a mention in the international press or the weekly Sitreps issued by the WHO and UNMEER.

These snapshots – and I stress they are only snapshots – go some way to explaining why Sierra Leone has yet to reach to zero and why officials are growing increasingly frustrated at those sections of the community that continue to flout the Ebola regulations. In an attempt to reach these resistant elements, NERC officials have appealed to the country’s paramount chiefs, asking them to use their authority with village headmen to pass on information about secret burials and suspicious individuals from other districts. However, while in many parts of the country this reporting system has been successful, in Port Loko there have been several cases of headmen concealing Ebola patients and turning a blind eye to secret burials. The result is continuing outbreaks in villages where it was thought Ebola had been eliminated.

One of the most revealing moments came when I was allowed to sit in on a meeting between paramount chiefs and DfID officials at the District Ebola Command Centre in Port Loko. Like their Sierra Leonean counterparts, the DfID officials were concerned that despite social messaging and the best efforts of contact tracing teams, cases were still occurring beneath the radar. As one official put it, venting his frustration:

When I took up this post I made a promise to you that we would isolate the sick within 24 hours and give them a safe and dignified burial (pause). We have done that but I’m sorry to say we are not at zero yet, we are not even close (pause). There is nothing more that I and my colleagues in this control room can do (pause) We are looking to you – the paramount chiefs – to lead the next stage of this fight.

This speech was followed by a presentation by a WHO official of a typical transmission chain with coloured blobs marked ‘SB’, ‘HM’ and ‘TH’ – WHO code for ‘Secret Burial’, ‘Head Man’ and ‘Traditional Healer’. The idea, presumably, was to draw attention to entrenched behaviours and practices that, in the WHO’s opinion, were continuing to fuel clusters of infection. But, if so, the message backfired. As one of the paramount chiefs sitting next to me put it: “We should flog them. Believe me, if we flog these people they will not do it again.”

Paramount chiefs outside the District Ebola Command Centre in Port Loko prior to meeting with officials from DfiD.

The remark caused the DfID and WHO officials to shuffle their feet awkwardly, but at that moment it was hard to resist the conclusion that the paramount chief had grasped the coercive intent of the containment measures better than they had.

To conclude. It is probably too early to write a history of getting to zero in West Africa – although the WHO declared Liberia free of Ebola on March 9, in the past three weeks 76 new Ebola cases have been recorded in Guinea and Sierra Leone, leading Bruce Aylward, the WHO’s special envoy for Ebola, to remark that the virus ‘will not go quietly’.

However, I hope that in this brief review I have pointed to some profitable lines of inquiry and to some gaps in the historiography. In particular I think historians need to revisit the early days of the Epidemic Intelligence Service and look at how Langmuirs’ concept of disease surveillance developed as the EIS service expanded and became increasingly involved in command and control operations. In short, we need a better understanding of how EIS disease detectives also became marshals for disease elimination. And we need officials involved in these interventions to reflect on the tensions their dual role as emissaries of humanitarian biomedicine and global health security and the sometimes invidious position this places them in.

There are signs this process may now be underway. In May I went to see Kevin DeCock, who directed the CDC operations in Liberia, speak at the London School of Hygiene and Tropical Medicine. DeCock spent three tours of duty in Liberia and was in Monrovia in August when the Liberian capital felt – as he put it ‘like a city under siege’.

He soon realised that to get on top of the epidemic Liberia needed a better disease incidence management system with clearly demarcated lines of command and control. However, the CDC’s efforts were not universally appreciated and DeCock related how at one point an incensed relative of an Ebola victim had invaded the offices where the CDC had installed a state of the art management system and tried to set light to it.

Community hostility, he observed, could “turn in an instant from scepticism that Ebola was not real, to resentment that more was not being done.” But the fiercest confrontations he had witnessed had been with the burial teams. At first this had surprised him, until a colleague explained that for many Liberians being buried in the correct, i.e. traditional manner, was more important than death and the loss of a loved one to Ebola. In other words, the religious and moral values that mattered most to Liberians were not the same as those that mattered to the CDC, or indeed to the WHO and UN.

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