West Point and the war on Ebola

Posted on May 14, 2015 by Derek Gregory

I’ve taken this map from a Situation Report issued by the World Health Organisation on 6 May, which superimposes new cases of Ebola virus disease (EVD) over total confirmed cases throughout the epidemic in West Africa:

Three days later the WHO declared Liberia to be free of Ebola:

Forty-two days have passed since the last laboratory-confirmed case was buried on 28 March 2015. The outbreak of Ebola virus disease in Liberia is over.

Interruption of transmission is a monumental achievement for a country that reported the highest number of deaths in the largest, longest, and most complex outbreak since Ebola first emerged in 1976. At the peak of transmission, which occurred during August and September 2014, the country was reporting from 300 to 400 new cases every week.

During those 2 months, the capital city Monrovia was the setting for some of the most tragic scenes from West Africa’s outbreak: gates locked at overflowing treatment centres, patients dying on the hospital grounds, and bodies that were sometimes not collected for days.

So it’s high time I redeemed my promise to return to the ‘war on Ebola‘.

In previous commentaries I discussed the militarisation of the epidemic and, in particular, the mission of the US military under the direction of US Africa Command. But the ‘West Point’ in my title is thousands of miles from the US Military Academy in upstate New York… It’s a sprawling informal settlement in Monrovia, the capital of Liberia (below).

In an extended essay in the New Yorker earlier this year, ‘When the fever breaks‘, Luke Mogelson told the story of Omu Fahnbulleh and her husband Abraham. They lived with their three children in Robertsport in northern Liberia. Last summer Fahnbulleh tested positive for Ebola; by the time an ambulance arrived Abraham was sick too, and they were both loaded into the back and driven off.

Fahnbulleh and her husband believed that they were going to a hospital. Instead, several hours later, the ambulance turned onto a narrow lane that ran past low-slung shops and shanties. Fahnbulleh realized that they were in West Point, Monrovia’s largest slum. A police officer opened a metal gate, and the ambulance stopped inside a compound enclosed by tall walls. In the middle of the compound stood a schoolhouse. The driver helped Fahnbulleh and Abraham through a door, down a hall, and into a classroom. A smeared chalkboard hung on one of the walls, which were painted dark blue. Dim light filtered through a latticed window. On the concrete floor, ailing people were lying on soiled mattresses. When Fahnbulleh lay down, she saw that the two men beside her were dead.

This was the only school in West Point, originally built by USAID, and it had been converted into a ‘holding centre’ for Ebola patients; the only ‘treatment’ on offer was provided by a man in a biohazard suit spraying the floor, the walls and the patients with chlorine. Two nights later Abraham died, and as soon as it was light Fahnbulleh – convinced she would die too if she stayed – determined to escape.

At daybreak, after spending the night in the other classroom, she walked out of the school. Policemen loitered in the yard. When Fahnbulleh reached the gate, they let her pass, afraid to touch her.

After several nights of sleeping rough she was taken to an Ebola Treatment Unit at a government hospital, from where she was eventually discharged.

It’s a heart-breaking story, made all the more extraordinary by a photograph taken by John Moore which shows ‘Omu Fereneh’ standing over the body of her husband ‘Ibrahim’ on 15 August in the schoolhouse. The image was widely reproduced – see also here, for example – and raises important questions about the mediatisation as well as the militarisation of the crisis. Moore’s work won him the title of L’Iris d’Or /Sony World Photography Awards’ Photographer of the Year:

John Moore’s photographs of this crisis show in full the brutality of people’s daily lives torn apart by this invisible enemy. However, it is his spirit in the face of such horror that garners praise. His images are intimate and respectful, moving us with their bravery and journalistic integrity. It is a fine and difficult line between images that exploit such a situation, and those that convey the same with heart, compassion and understanding, which this photographer has achieved with unerring skill. Combine this with an eye for powerful composition and cogent visual narrative, and good documentary photography becomes great.

I’m not sure that Omu Fereneh is Omu Fahnbulleh, or Ibrahim Abraham, but it would be a remarkable coincidence if they were not the same people.

In any event, soon after the photograph was taken and soon after Fahnbulleh escaped, the situation in West Point changed dramatically. Realising that their community had become a dumping ground for Ebola victims from all over Liberia, local residents stormed the schoolhouse and demanded it be closed. They ransacked the building, making off with mattresses and sheets, and evicted over 20 patients who they claimed had been brought in from outside West Point.

Two days later the state called in its security forces which had urged the imposition of mass quarantine. Joe Shute takes up the story:

On August 20, President Ellen Johnson Sirlief ordered the only road leading in to the slum be sealed off, and the entire community placed under quarantine. As the army moved in, many of the city’s vagrants who slept in the slum at night were trapped inside.

West Point was surrounded by barricades and barbed wire; police in helmets and riot-shields stopped people going out into the city; gunships patrolled the water front, and a nightly curfew was imposed on the district’s 70,000 residents. There was, Joe reports, ‘a desperate clamour to escape, some people even trying to swim around the peninsula to enter the city’s port.’

The imposition of a militarised quarantine was a double mis-step.

First, it exacerbated the already precarious position of West Point residents. Many of them were refugees and child soldiers from Liberia’s civil wars; they were crowded together in makeshift corrugated-iron shacks, almost all of them without plumbing or running water. The district is threaded by narrow sand alleys – there is only one paved road – and by open sewers. In 2009 the UN Office for the Coordination of Humanitarian Affairs reported there were only four public toilets in West Point; to use them cost 2-3 cents, and many chose to use the beach instead.

Most of West Point’s residents were dependent on access to the city and the ocean for their livelihood, but with the imposition of the blockade food supplies dwindled and food prices sky-rocketed. As the Institute for Development Studies argued in a Practice Paper on ‘Urbanisation, per-urban growth and zoonotic disease‘ earlier this year:

Poor peri-urban residents, with no money to purchase and store in bulk, buy essentials daily. When lock-down, intended to halt disease spread, occurs, shops, markets and transport facilities are closed, reducing opportunities for peri-urban residents to work and earn cash for food. Many of their activities continue clandestinely, undermining the health intervention. During attempts in West Point to contain the spread of Ebola, people found new ways of moving through the area quarantined in August 2014. Their concern was not exposure to Ebola, but their inability to access food and water.

Some bribed the police to let them out; others, still more desperate, even swam around the point. Here is a report from Norimitsu Onishi writing in the New York Times:

“We suffering! No food, Ma, no eat. We beg you, Ma!” one man yelled at Ms. Johnson Sirleaf as she visited West Point … surrounded by concentric circles of heavily armed guards, some linking arms and wearing surgical gloves.

“We want to go out!” yet another pleaded. “We want to be free, Mama, please.”

Quarantine has to be seen as a political, even a biopolitical response. As the IDS insists,

In the face of Ebola, and with the pressure on governments to act, the peri-urban area becomes an attractive place to intervene. The deployment of the military and the police to quarantine the peri-urban is a tangible manifestation of state power that is oppressive for residents. Thus quarantine-related activities fulfil the political role of assuaging the urban elite’s fears of contagion – ‘cleaning up’ the peri-urban by excluding the poor, rather than helping them or addressing the key challenges of the disease.

And, as Onishi also explained, the political implications were not lost on local residents:

“Putting the police and the army in charge of the quarantine was the worst thing you could do,” said Dr. Jean-Jacques Muyembe, a Congolese physician who helped identify the Ebola virus in the 1970s, battled many outbreaks in Central Africa and has been visiting Monrovia to advise the government. “You must make the people inside the quarantine zone feel that they are being helped, not oppressed.”

Not surprisingly, the imposition of quarantine provoked concerted collective protest. Hundreds of young men tried to storm the barricades and force their way through the makeshift checkpoint. Soldiers and police opened fire, killing a fifteen-year-old boy.

As Clare Macdougall reported:

“The force was disproportionate, they were already using batons, sticks, they had access to teargas and equipment to things to control an unarmed crowd,” said Counsellor Tiawan Gongloe, Liberia’s most prominent human rights lawyer. “I find it difficult to believe that there was any justification for shooting a 15-year-old boy who was unarmed. This is not a militarized conflict, it is a disease situation and a biological problem.”

Second, as this implies, quarantine is not an effective counter-measure and may well be counter-productive. Sealing off ‘plague towns’ was a medieval and early modern response to infectious disease – remember your Foucault! – but as one commentator noted, ‘isolating a small group of unhealthy people with a large group of healthy residents can cause more harm than good if they don’t get access to food, water and medical care — all of which are in increasingly short supply.’ In fact, transmission of Ebola occurs through bodily fluids once a patient shows symptoms of the disease, which means that the most effective response is not mass quarantine but the isolation of individual cases. This places a premium on contact tracing (you can find another image gallery from John Moore here, tracking a tracing coordinator in West Point; see also my previous post for more details and links on contact tracing).

Following negotiations with community leaders, the government eventually agreed to lift the quarantine. ‘We are out of jail!” declared one triumphant resident.

People celebrate in a street outside of West Point slum in Monrovia, Liberia, Saturday, Aug. 30, 2014. Crowds cheer and celebrate in the streets after Liberian authorities reopened a slum where tens of thousands of people were barricaded amid the countryís Ebola outbreak. The slum of 50,000 people in Liberia’s capital was sealed off more than a week ago, sparking unrest and leaving many without access to food or safe water. (AP Photo/Abbas Dulleh)

Now people started to mobilise in other ways. In return for removing the barriers and barbed wire, Luke Mogelson explained, community leaders implemented other containment measures:

identifying sick people, removing them from the community, quarantining their houses, tracking down their recent contacts, and monitoring those contacts for twenty-one days—the maximum amount of time the virus has been known to incubate before manifesting symptoms. Previously, all this was the responsibility of highly trained specialists…

In West Point, the job fell to the neighborhood. “We had to guarantee that the things that needed to be done would be done by ourselves,” Archie Gbessay, another local leader, who worked with Martu to carry out the interventions, told me one afternoon in November. We were walking down the main road that snakes through West Point. Gbessay wore a knapsack filled with case-investigation forms and kept his thumbs hooked on the chest-strap clipped across his sternum. He is twenty-eight years old but exudes a quiet force that seems to have accrued over a much longer life; his face quivers with intensity when he talks about Ebola. “If we didn’t do this, nobody was going to do it for us,” he said.

To build a network of active case-finders who could cover all of West Point, Gbessay recruited three volunteers from each of the slum’s thirty-five blocks. Most of them were young and had a degree of social clout—“credible people,” Gbessay called them. The quarantine had done little to alleviate popular skepticism of the government’s Ebola-containment policies, however, and, for a while, hostility persisted. “At first, the cases were skyrocketing,” Gbessay said. “We used to see seventy, eighty cases a day. But by the middle of September everyone started to think, Look, I better be careful. Today, you talk to your friend—tomorrow, you hear the guy is gone. So they started to pay attention.”

Otis Bundor, a contact tracer in West Point, described his day’s work and emphasised the importance of a trust that depended on local knowledge and on being known:

At the beginning of the outbreak, people were afraid to tell us if their family members were sick. They worried about stigmatization, and they were frightened that their wife or sister or son would go to the hospital and never come back. Some people thought that health workers were injecting patients with poison. As a contact tracer, you need to have the intellectual prowess to convince doubters that Ebola is real…

At first, family members hid bodies and buried them under the cover of darkness. This is one of the reasons that the disease became an epidemic. Attitudes changed only when people noticed that in almost all of the houses where someone died, another person later got sick. In one household, more than seven people died after they vehemently prevented contact tracers from entering.

But gradually contact tracing – or, more accurately, the contact tracers – became accepted as something other than policing. By the time Luke Mogelson visited West Point the holding centre in the schoolhouse had reopened as a transit centre:

Now, when residents of the slum felt unwell, they came here to be diagnosed and, if necessary, wait for an ambulance that was staffed by West Pointers and managed by Martu. The average wait time had become a matter of minutes, rather than days.

In September, at the height of the outbreak in Monrovia, the C.D.C. warned that Ebola could infect 1.4 million West Africans by late January. The prediction assumed that no “changes in community behavior” would occur. By November, that assumption was obsolete in West Point. Gbessay’s active case-finders had largely prevailed on their neighbors to come forward with symptoms and observe basic precautions such as avoiding physical contact with each other and washing their hands several times a day at the hundreds of chlorine buckets stationed throughout the city. As a result, cases were waning. “Every day, patients come,” the supervisor of the transit center told me. “But it’s going down. It’s getting less and less.”

And as Lenny Bernstein noted, this turn-around ‘has occurred without the provision of a single treatment bed by the U.S. military, which has promised to build 17 Ebola facilities containing 100 beds each across Liberia.’

The war on Ebola

Posted on October 25, 2014 by Derek Gregory

We’ve been here before – ‘wars’ on this and ‘wars’ on that. It’s strange how reluctant states are to admit that their use of military violence (especially when it doesn’t involve ‘boots on the ground‘) isn’t really war at all – ‘overseas contingency operations’ is what the Pentagon once preferred, but I’ve lost count of how many linguistic somersaults they’ve performed since then to camouflage their campaigns – and yet how eager they are to declare everything else a war.

These tricks are double-edged. While advanced militaries and their paymasters go to extraordinary linguistic lengths to mask the effects of their work, medical scientists have been busily appropriating the metaphorical terrain from which modern armies are in embarrassed retreat.

Yet all metaphors take us somewhere before they break down, and the ‘war on Ebola’ takes us more or less directly to the militarisation of the global response. In an otherwise critical commentary, Karen Greenberg draws parallels between the ‘the war on terror’ and the ‘war on Ebola’:

‘The differences between the two “wars” may seem too obvious to belabor, since Ebola is a disease with a medical etiology and scientific remedies, while ISIS is a sentient enemy. Nevertheless, Ebola does seem to mimic some of the characteristics experts long ago assigned to al-Qaeda and its various wannabe and successor outfits. It lurks in the shadows until it strikes. It threatens the safety of civilians across the United States. Its root causes lie in the poverty and squalor of distant countries. Its spread must be stopped at its region of origin — in this case, Guinea, Liberia, and Sierra Leone in West Africa — just as both the Bush and Obama administrations were convinced that the fight against al-Qaeda had to be taken militarily to the backlands of the planet from Pakistan’s tribal borderlands to Yemen’s rural areas.’

There are other parallels too, not least the endless re-descriptions of terrorism and even insurgency as life-threatening diseases, ‘cancers’ on the body politic. And, as Josh Holmes shows, there is also an entirely parallel (geo)politics of fear in both cases (see also Rebecca Gordon on the racialization of ‘the fear machine’ here). Given the threat supposedly posed by ‘the enemy within’, it’s not surprising that US Northern Command has already set up a 30-person ‘military rapid response team‘ for domestic Ebola cases, and that the Department of Homeland Security has been issuing Biosurveillance Event Reports on the Ebola outbreak in West Africa from the National Biosurveillance Integration Center.

But as I’ve said, Karen’s is a critical commentary and so, before the military metaphors carry us away, her conclusion bears repeating:

The United States is about to be tested by a disease in ways that could dovetail remarkably well with the war on terror. In this context, think of Ebola as the universe’s unfair challenge to everything that war bred in our governmental system. As it happens, those things that the U.S. did, often ineffectively and counterproductively, to thwart its enemies, potential enemies, and even its own citizenry will not be an antidote to this “enemy” either. It, too, may be transnational, originate in fragile states, and affect those who come in contact with it, but it cannot be stopped by the methods of the national security state.

To make sense of all this, I think we need to stand back and start with four general observations:

(1) Modern military medicine has long involved more than evacuating and treating the wounded from the field of battle. It has always had a substantial public health component. Until the early twentieth century, ‘infectious diseases unrelated to trauma were responsible for a much greater proportion of the deaths during war than battle-related injuries‘. As militaries started to pay much closer attention to hygiene and disease prevention, Matthew Smallman-Raynor and Andrew Cliff estimate that the ratio of ‘battle deaths’ to deaths from disease amongst the military population fell from 1:0.4 in the First World War to 1:0.1 in the Second World War; then it rose to 1:0.13 in the Vietnam War but in the first US-led Gulf War (1991) it fell to 1:0.01.

(2) Modern militaries are no strangers to biowarfare either. Both sides in the First World War experimented with chemical weapons, and although the US Army’s explicitly offensive Biological Warfare Weapons Laboratories closed in 1969 the commitment to ‘bio-defense’ and bio-security has ensured a continuing military investment in the weaponisation of infectious diseases (see right). I don’t subscribe to the view that the Ebola epidemic in West Africa is the result of a rogue US biowarfare program – see for example the claims made by ‘Robert Wenzel’ here: and if you want to know why his name is in scare-quotes, appropriately enough, read Chris Becker‘s takedown here – nor to the fear that what Scientific American calls ‘weaponised Ebola’ is poised to become a ‘bio-terror threat’. But I do think it worth noting the work of the US Army Medical Research Institute of Infectious Diseases which has had field teams on the ground in West Africa since 2006, and the importance placed on surveillance and monitoring.

(3) I also think it’s necessary to think through the biopolitics of public health in relation to military and paramilitary violence. This takes multiple forms. It’s become dismally apparent that in many conflict zones hospitals, doctors and other health-care workers have become targets: in Gaza, to be sure, but in Syria and elsewhere too. The treatment of disease has also become a tactical vector: think of the CIA’s use of polio vaccination campaigns as a cover for its intelligence operations and – the conjunction is imperative – the Taliban’s manipulation of polio vaccinations in Pakistan’s Federally Administered Tribal Areas. Think, too, of the way in which the Assad regime has inflicted a resurgent, even counterinsurgent geography of polio on the Syrian people. As Annie Sparrow shows (see also here):

‘This man-made outbreak is a consequence of the way that Syrian President Bashar al-Assad has chosen to fight the war—a war crime of truly epidemic proportions. Even before the uprising, in areas considered politically unsympathetic like Deir Ezzor, the government stopped maintaining sanitation and safe-water services, and began withholding routine immunizations for preventable childhood diseases. Once the war began, the government started ruthless attacks on civilians in opposition-held areas, forcing millions to seek refuge in filthy, crowded, and cold conditions. Compounding the problem are Assad’s ongoing attacks on doctors and the health care system, his besieging of cities, his obstruction of humanitarian aid, and his channeling of vaccines and other relief to pro-regime territory.

Late this summer she provided this update:

‘… nearly all the cases of polio have occurred in areas of northern Syria under rebel control, where the government is seemingly doing everything in its power to prevent vaccination. The Syrian government has appealed to the UN for hundreds of medicines for areas of the country it controls, while largely ignoring the far more dire needs of opposition-held areas. Many children, especially newborns, still do not have access to polio immunization. Daily government airstrikes target the very health facilities that should be the foundation of vaccination efforts, as well as the children who should be protected from polio, measles, and other preventable childhood diseases. As Dr. Ammar, a doctor from Aleppo, said to me bitterly after an April 30 airstrike killed twenty-two schoolgirls, “The government’s polio control strategy for children is to kill them before they can get polio.”’

(4) Finally, biopolitics threads its way from the sub-national and the national to the trans-national and so to what Sara Davies calls, in a vitally important essay, ‘securitizing infectious disease‘. (The link will take you to an open access version, which was originally published in International affairs 84 (2008) 295-313; see also her ‘The international politics of disease reporting: towards post-Westphalianism?‘, International politics 49 (2012) 591-613, and the collection she has edited with Jeremy Youde, The politics of surveillance and response to disease outbreaks: the new frontier for states and non-state actors – due out next year).

In her original essay, Sara shows how powerful states in the global North joined forces with the World Health Organisation to construct infectious disease as an existential security threat that demanded new rules and protocols for its effective containment. Crucially:

‘The outcome of this has been the development of international health cooperation mechanisms that place western fears of an outbreak reaching them above the prevention of such outbreaks in the first place. In turn, the desire of the WHO to assert its authority in the project of disease surveillance and containment has led it to develop global health mechanisms that primarily prioritizes the protection of western states from disease contagion.’

This has a genealogy as well as a geography (or what Alan Ingram once called a ‘geopolitics of disease’). Peter Dörrie notes that on 18 September 2014 the U.N. Security Council declared the current Ebola outbreak in West Africa ‘a threat to international peace and security’, and that this was ‘the first time the U.N. had taken this step in a public health crisis‘ (in fact the Council had previously expressed similar concerns about the impact of HIV/AIDS on ‘stability and security’). Under Chapter VII of the UN Charter this declaration has significant legal implications, as Jens David Ohlin notes here, but what most concerns Peter is how long it took for the Security Council to stir itself. It issued its statement 180 days after the WHO confirmed the outbreak, and over a month after the WHO had declared Ebola a ‘Public Health Emergency of International Concern’, and in his eyes the international system ‘ignored the problem until it was too big for any solution other than full-scale military intervention.’ But I’ve already suggested, it’s wrong to treat the militarisation of epidemic disease as somehow new. Of direct relevance to the present ‘war on Ebola’ is this passage from Sara’s essay:

The United States has been a keen participant in disease surveillance and response since the mid-1990s. The United States Department of Defense (US DoD) has had overseas infectious disease research laboratories located in over 20 countries for nearly ten years. The Global Emerging Infectious Surveillance and Response System (DoD-GEIS) mobile laboratories were set up for the purpose of ‘responding to outbreaks of epidemic, endemic and emergent diseases’, and their location in the DoD, as opposed to the United States Agency for International Development (USAID) or Centre for Disease Control (CDC) demonstrates how seriously the United States views the response to infectious disease as a key national security strategy.

So, four observations about the military-medical-security nexus that provide a context for the ‘war on Ebola’. There are two other issues that should also be on the table before proceeding.

The first involves the imaginative geographies circulating in the global North that (mis)inform public response to the epidemic. Many of them can be traced back to colonial descriptions of the coast of nineteenth-century West Africa (and Sierra Leone in particular) as ‘the white man’s grave’, a form of what in a different context Dan Clayton calls a ‘militant tropically’. The contemporary reactivation of these tropes is clearly a serious concern because it corrodes an effective political response. As geographer Kerrie Thornhill writes,

African and diaspora scholars, already accustomed to the ‘thousand tiny paper cuts’ of casual racism, demonstrate how these (metaphorical) cuts escalate into real fatalities. Writers such as Nanjala Nyabola and Lola Okolosie point out the abundance of racist tropes depicting West African societies as inherently unclean, chaotic, uncooperative, ungrateful, and childlike. This racism reinforces a global culture of disregard for black African lives, and the perception that they are a source of social and biological contamination.

You can find much more on this in Cultural Anthropology‘s brilliant Ebola in Perspective series.

The second is the precarious condition of health care systems in West Africa (Ebola in Perspective is good on this too). Brice de la Vigne, the operations director of MSF, reminds us that ‘both Sierra Leone and Liberia were at war ten years ago and all the infrastructure was destroyed. It’s the worst place on earth to have these epidemics.’ Other critics suggest that these uncivil wars were not the only culprits. In their view, it was the neoliberal economic model forced on West Africa by the global North that was primarily responsible for gutting public health systems:

While years of war played a role in weakening public systems, it is the “war against people, driven by international financial institutions” that is largely responsible for decimating the public health care system, eroding wages and conditions for health care workers, and fueling the crisis sweeping West Africa today, says [Emira] Woods. “Over the past six months to a year there have been rolling health care worker strikes in country after country—Nigeria, Sierra Leone, and Liberia,” said Woods. “Nurses and doctors are risking and losing their lives but don’t have protective gear needed to serve patients and save their own lives. They are on the front lines and have not had their voices heard.”

So – back to the front lines. Despite the geopolitical-military-security back story, it was Médecins Sans Frontières that made the first public call (on 2 September) for military assistance in combatting Ebola.

‘States with biological-disaster response capacity, including civilian and military medical capability, must immediately dispatch assets and personnel to West Africa…

‘Many countries possess biological threat response mechanisms. They can deploy trained civilian or military medical teams in a matter of days, in an organised fashion, and with a chain of command to assure high standards of safety and efficiency to support the affected countries…

‘In the immediate term, field hospitals with isolation wards must be scaled up, trained personnel must be dispatched, mobile laboratories must be deployed to improve diagnostics, air bridges must be established to move personnel and material to and within West Africa, and a regional network of field hospitals must be established to treat medical personnel with suspected or actual infections.’

Ten days later Peter Piot, the Director of the London School of Tropical Medicine and Hygiene and the microbiologist who helped identify the Ebola virus in 1976, also called for a ‘quasi-military intervention’. Although he spoke about a ‘state of emergency’, he too wanted to reverse the response prefigured by Giorgio Agamben in such situations and contract the spaces of exception that were multiplying across West Africa. He had in mind ‘beds, ambulances and trucks as well as an army of clinicians, doctors and nurses.’

What materialised was rather different.

On 16 September President Obama flew to the Centers for Disease Control and Prevention in Atlanta to announce Operation United Assistance. He committed 3-4,000 US troops and $750 million in defence funding to the mission, which is being orchestrated by US Africa Command (AFRICOM) through US Army Africa in concert with USAID. The focus of the US military-medical mission is Liberia. There are close historical connections between the US and Liberia, which originally offered to host AFRICOM’s headquarters in the capital Monrovia; now a Joint Force Command has been set up there. You can find the 75-page AFRICOM operational order here, dated 15 October 2014, from which I’ve taken the ‘common operating picture’ below. The title puzzles me – the only ‘Operation United Shield’ (singular) I’ve been able to find was a multinational operation to evacuate peacekeeping forces from Somalia in 1995. Appendix B is particularly worth reading, incidentally, because it identifies ‘the enemy’: ‘Ebola Virus Disease is the enemy, aided by poor preventive medicine practices in areas where EVD cases are prevalent and difficulties in identifying and treating EVD patients.’

The US deployment is complemented by the deployment of UK forces to Sierra Leone (Operation Gritrock)and French forces to Guinea. In both cases there are also close, colonial connections, and the British-led International Military Advisory Training Team Sierra Leone has been on the ground since 2000 (since last year this has been re-tasked as the International Security Advisory Team Sierra Leone).

(The map above is borrowed from the BBC; in addition, the Guardian has an interactive map tracing the historical geography of Ebola from the first known case in the Democratic Republic of Congo in 1976 to the present epidemic in West Africa here).

These forces differ in more than geographical deployment; their capabilities differ significantly too. The UK is sending 750 troops, including contingents from the Royal Army Medical Corps (notably 22 Field Hospital), who will construct treatment centres (the aim is to add 700 beds to triple Sierra Leone’s existing capacity) and treat doctors and other health-care workers who contract the disease; they are supported by the Royal Navy’s ‘Primary Casualty Receiving Ship’ RFA Argus (which will provide a further 100 beds), and by another 780 volunteer health care staff.

The US has mobilised troops from the 101st Airborne, whose primary mission is to set up 17 Ebola Treatment Units (each with 100 beds); meanwhile the US Air Force’s 633rd Medical Group is establishing a 25-bed Expeditionary Medical Support System field hospital for doctors and other health care workers who contract the disease (below). The US Army has also fielded three mobile laboratories to test samples for the virus, reducing the time to diagnosis from days to hours. According to Pardis Sabeti, who leads viral-genome research at the Broad Institute of M.I.T. and Harvard, ‘the faster you can get a diagnosis of Ebola, the faster you can stop it.’

‘Our enemy is a disease’, declared Lt Col Brian De Santis, echoing AFRICOM’s operational order – but it was quickly made clear that the vast majority of troops will not come into contact with the enemy or any of its victims at all. This is just as well; most of the soldiers have minimal medical training – just four hours from the US Army Medical Research Institute of Infectious Disease – and the Pentagon’s Press Secretary Rear Admiral John Kirby explained that there is ‘no intention right now that [troops] will interact with patients or be in areas where they would necessarily come into contact with patients’:

‘They’re not doctors. They’re not nurses. They’re not trained for that and not equipped for that. That’s not part of the mission. They will be kept in locations where they can do their jobs without coming into contact with patients.’

Andrew Bacevich thinks all this absurd:

‘It’s like the city that spends all its money to raise up a formidable police force only to discover that what it really needs is a bigger sewage treatment plant. Of course, you can always put cops to work burning human excrement but there are better — that is, more effective and cheaper — ways to solve the problem.’

In effect, this is another case of the military preferring remote operations. Here is a telling passage from Sophie Arie’s interview with MSF’s president Joanne Liu:

‘“Countries are approaching this with the mindset of going to war,” she says. “Zero risk. Zero casualties.” Liu describes the current military efforts as the equivalent, in public health terms, of airstrikes without boots on the ground. Pledges of equipment and logistical support are helpful—“The military are the only body that can be deployed in the numbers needed now and that can organise things fast.” But there is still a massive shortage of qualified and trained medical staff on the ground. “You need to send people not stuff and get hands on, not try to do this remotely,” Liu says…’

The primary areas for military operations in the ‘war on Ebola’ to date are surveillance, logistics and containment. I’ll consider each in turn.

Last week Public Intelligence released a series of weekly Security Updates and daily Intelligence Summaries produced by AFRICOM to support Operation United Assistance. These rely largely on WHO reporting to track the spread of the disease.

This is to work at a highly aggregate level. Most public health experts suggest that the key to stopping the spread of the disease is contact tracing – which, in its essentials, is the same methodology used by the military and the intelligence services to track individuals through terrorist and insurgent networks – and has been used successfully in both the United States and in Nigeria (which was declared free of Ebola on 20 October). Ezra Klein describes it as ‘almost ludicrously simple’ and ‘as low-tech as medicine gets’, and so it is in principle.

But its application in much of West Africa is immensely difficult: the UN estimates that only 16 out of 44 zones have adequate procedures and personnel in place. And since many local people are understandably fearful of the consequences of their answers, it is unlikely that military involvement would improve the situation. Here is Elizabeth Cohen and John Bonifield:

‘People are often uncooperative with the tracers, sometimes even throwing stones at health care workers. They fear that they or their loved ones will be put in the hospital; they’ve seen firsthand that people who go there often don’t return.

“The community perceives this as a death sentence,” [Donald Thea, an infectious disease epidemiologist] said. “Relinquishing your loved one is tantamount to death.”

And health care workers have very little to offer people as an incentive to cooperate. “With smallpox, we could offer people a vaccine, a carrot in essence to induce them to be cooperative. With Ebola, we have nothing,” Thea said.’

Logistics is the area where the military comes into its own. MSF had emphasised that its priorities included ‘the mass expansion of isolation centers, air bridges to move personnel and equipment to and within the most affected countries, mobile laboratories for testing and diagnosis, and building a regional network of field hospitals to treat suspected or infected medical personnel.’ Much of the military effort is currently concentrated in these areas, but the other side to mobilising medical personnel, equipment and testing and treatment facilities is, in effect, immobilising the population.

Containment runs the gamut from quarantine through curfews and lockdowns to border closures. Most observers believe that border closures would be counter-productive: if you want to know why, see Debora MacKenzie‘s short essay here. The other, seemingly lesser measures also have their dangers. In its original call for assistance, MSF insisted that ‘any military assets and personnel deployed to the region should not be used for quarantine, containment, or crowd control measures’, and it emphasised that ‘forced quarantines have only bred fear and unrest, rather than stem the virus.’

But others have other ideas. Major Matt Cavanaugh, from the US Army War College, has made an unofficial, back-of-the-envelope calculation of what a successful ‘containment strategy’ for Ebola would require. He is adamant that only ‘boots on the ground’ could do the job, though the nature of that ‘job’ remains elusive in his account. He talks about military logistics – the ability to ‘fix “the last mile” problem’ – but he also notes the need ‘to fill the basic state functions related to health, security, and public order in order to adequately respond to the threat.’ In case that triptych isn’t clear enough, in his subsequent ‘Ebola Manifesto‘ the major declares that ‘There is exactly one organization designed to rapidly hold and control territory and the people on it: the military.’ The figure he eventually arrives at – somewhere between 36,600 to 73,200 troops – is derived from the wars in Afghanistan and Iraq, and suggests that, for some commentators at least, the Ebola crisis is an opportunity to deepen AFRICOM’s investment in what Jan Bachmann calls ‘policing Africa’ [see his ‘Policing Africa: the US military and visions of crafting “good order”‘, Security Dialogue 45 (2) (2014) 119-36]:

‘The spectrum of [AFRICOM’s] activities can be understood most comprehensively through an analytical perspective of policing, in which the aim of establishing ‘good order’ through an expansive regulatory engagement in issues of welfare is applied to contexts of ‘fragile’ statehood and ‘ungoverned spaces’.’

This is not a uniquely American view. The Daily Mail (where else?) reports that one of the options being considered by Britain’s Chief of the General Staff is a full-scale military lockdown of Sierra Leone:

‘From a military perspective ebola is like a biological warfare attack and should be countered accordingly. There needs to be a clampdown on human movement inside Sierra Leone and possibly to and from the country between now and late 2015 when it is hoped that an antidote will have been developed.’

It’s hard to know how much credence this should be given, of course, though the very existence of proposals like these suggests that the ‘soft power’ which Joeva Rock sees in the militarisation of Ebola conceals an iron fist. And Niles Williamson believes that the military-medical missions are a smokescreen:

‘The main purpose of this military operation is not to halt the spread of Ebola or restore health to those that have been infected. Rather the United States is seeking to exploit the crisis to establish a firm footing on the African continent for AFRICOM.’

That may be one of the objectives, but I think it’s a bridge too far to claim it as the main purpose: as I’ve tried to show, the militarisation and securitisation of Ebola has many other geopolitical and biopolitical dimensions. And Nick Turse has revealed that AFRICOM, far from having a ‘light footprint’, has already achieved a remarkably rapid tempo of operations across the whole continent.

Still, even in its less extreme versions, the ‘war on Ebola’ clearly raises urgent questions about the militarisation of humanitarian aid, about what Kristin Bergtora Sandvik calls a ‘crisis of humanitarian governance’, and about the violence that is involved in the production of the humanitarian present.