Understanding the Ebola Narrative

BY CLAIRE CHAUMONT

“From now on it can be said that plague was the concern of all of us.”

The Plague, A. Camus, 1947[1]

On 24 January 2014, the head of Meliandou health post, a sparsely populated village in Guinea, West Africa, informed district health officials of five cases of an unknown infectious disease characterized by vomiting, diarrhea, severe dehydration, and a rapidly fatal outcome. Two months later the World Health Organization (WHO) publicly announced what would become the deadliest outbreak of the Ebola virus disease, a rare illness first discovered in 1976 in the Democratic Republic of Congo.[2] By 27 March 2016, the number of individuals affected by Ebola had risen to 28,646, of whom 11,323 had died from the illness.[3]

As the epidemic’s death toll increased, so did its accounts in the Western media. The narrative that soon emerged was a well-known one: Ebola was “the coming plague,”[4] one of the emerging infectious diseases that the world ought to fear. In these anxious descriptions, the media continuously ignored the clear link between Ebola’s spread and the scarcity of basic infrastructure, health care workers, and medical supplies in the world’s poorest countries. Indeed, when infected Western health care workers were transferred to their home countries in Europe or the United States, the disease was rapidly contained.[5]

The narrative around health systems is usually one of discipline and control. From the eradication of polio to the rise of family planning centers, health programs can transform the world into a safer, more controlled place. Their successes are proof that logic and reason can triumph over unpredictable natural phenomena. In this context, the persistence of an “outbreak narrative” centered on fear and loss of control is paradoxical. Its sharp contrast with more traditional narratives of health systems as instruments of control begs an examination of the broad appeal of the outbreak narrative with the media and the public.

Ebola: The Emergence of an “Outbreak Narrative”

Priscilla Wald, professor of English at Duke University, first coined the term “outbreak narrative” to describe the phrases, images, and storylines that are told regarding disease emergence. As she explains in her 2008 book Contagious: Cultures, Carriers and the Outbreak Narrative, scientific and medical ideas about diseases are merged with cultural narratives about patient zeros, hot zones, or microbes, leading to a formulaic narrative that “begins with the identification of an emerging infection, includes discussion of the global networks throughout which it travels, and chronicles the epidemiological work that ends with its containment.”[6] Contrary to the language of public health, characterized by rationality, statistics, and logical arguments, this is a narrative of terror, danger, and survival. These stories abound both in popular fiction and in the news.[7],[8],[9] The HIV/AIDS epidemic in particular incorporates all the markers of the epidemic narrative, sparking what the anthropologist Jean Comaroff calls “a veritable plague of images.”[10] Indeed, observers have described the epidemic narrative as a “throwback to an era when sickness was, by its nature, immutable, mysterious, and fatal.”[11]

The recent Ebola epidemic fits this outbreak plot. First, the disease itself, with its rapid transmission, high fatality rate, and spectacular symptoms, laid the groundwork in the collective imagination for the perfect “modern plague.” Indeed, since its discovery, the disease has been used in books (Richard Preston’s The Hot Zone, Peter Piot’s recent autobiography No Time to Lose) and films (Outbreak, Ebola Syndrome) to capture the public’s curiosity and fear. In addition, the epidemic was unprecedented in terms of scope and speed. Before 2014, the biggest Ebola epidemic, which occurred in Uganda between 2000 and 2001, affected 425 individuals.[12] In contrast, by 19 November 2014, 2,241 cases were reported in the span of three weeks.[13]

This combination of factors led to extensive media coverage of the outbreak. An analysis of four mainstream media sources between December 2013 and October 2014 shows 932 articles about Ebola were published during this period. The media coverage built upon themes of fear and panic, describing the virus as a “festering,” “wily, unfamiliar pathogen,” and a “killer disease.” Fear of its potential spread to other parts of the world was also made clear.[14] This alarming interpretation of the epidemic quickly spread to the public. By August 2014, airlines had cancelled more than a third of international flights to affected countries, despite advice from the World Health Organization that such actions would harm the already crumbling economies of these countries.[15] The same month, some Air France crews refused to board planes traveling to West Africa.[16] In October 2014, New Jersey governor Chris Christie, against CDC recommendations, imposed a mandatory quarantine on a nurse returning from Sierra Leone.[17]

Why Did Such a Narrative Emerge? Two Opposite Hypotheses

Was this “absolute hysteria” justified?[18] We can turn to two alternate hypotheses. The first one explains this hysteria as a real contextual shift: we might truly be observing the rise of disruptive “newly emerging infectious diseases.”[19] In recent decades, several previously unknown diseases have appeared, each with significant global economic and health impacts, including the severe acute respiratory syndrome (SARS) in 2003, the H1N1 influenza in 2009, the Zika virus in 2015, and obviously, HIV/AIDS. If our existing health systems are not properly designed to tackle the emergence of unknown diseases with uncertain outcomes, we should be rightfully worried.

However, a closer examination raises questions about this hypothesis. First, it does not match with long-term trends in infectious disease outbreaks. Between 1980 and 2013, although the absolute number of outbreaks increased (as well as their potential to spread due to increased travel), the ratio of cases per person decreased significantly.[20] An analysis of mortality data in the United States shows a substantial decrease in infectious disease mortality throughout the 20th century.[21] Spectacular progress in infectious disease control, in part due to the development of antibiotics and vaccines, was made throughout the 19th and 20th centuries.

Furthermore, the exceptional spread of the disease can easily be explained by the lack of effective health systems in the countries where it originated (Guinea, Liberia, and Sierra Leone) after decades of colonial rule, conflicts, and poverty. In 2005, Guinea had an average of 10 physicians per 100,000 individuals.[22] By contrast, France, whose health system was ranked first in the world by WHO in 2000, had 319 physicians per 100,000 in 2013. In 2013, Guinea spent an average US$28 per capita on health. That same year, the United States spent US$8,988, or 321 times more.[23] Clearly, the narrative of a deadly, uncontrollable plague does not fit all the facts.

Finally, the outbreak narrative is not new. The myth of patient zero can be traced back as far as Typhoid Mary, an asymptomatic carrier of typhoid fever who was presumed to have infected more than fifty individuals in New York City in the early 19h century.[24] Accounts of devastating plagues can be found in 19th- and 20th-century classic novels, such as Daniel Defoe’s A Journal of the Plague Year or Albert Camus’s The Plague, in which the Algerian city of Oran is devastated by a catastrophic outburst of the bubonic plague. This gives us reason to believe that the narrative occurred in part because of some recurring cultural appeal it may have with the public.

The second hypothesis is that the Ebola outbreak narrative is appealing to the media and the public not because it is rooted in facts but because it plays a role in shaping Western countries’ collective imagination. This argument is grounded in a sociological theory that suggests that narratives emerge as meaningful ways for societies and individuals to produce knowledge, which not only allows them to apprehend the social reality that surrounds them, but also produces this reality.[25] In short, narratives are meaningful because they help societies articulate apparently unrelated events into a coherent knowledge framework.

In the case of Ebola, the outbreak narrative is particularly appealing to the Western media and public for three interconnected reasons: (1) it reinforces national identities in an interconnected world, (2) it strengthens global power hierarchies through structural violence mechanisms, and (3) it legitimizes the use of sovereign power by producing a narrative of crisis.

The Outbreak Narrative as a Means to Strengthen National Identities

The outbreak narrative plays a role in rebuilding social bonds within communities by strengthening the idea of Western nations as unified entities in a diverse, globalized world. Nations are constructed as “imagined [political] communities,” fabricated in a conscious process to develop ties of kinship between individuals who perceive themselves as part of a group.[26] This mythology is constructed in two ways. First, social ties are reinforced by exacerbating the identity of the “self” versus the “other.”[27] Second, nations are presented as homogeneous entities with a clear scope and mandate. But the rise of globalization challenges this concept. Not only do microbes and viruses know no border, but also their spread is enhanced by the interdependence that now exists between nations. Infections sail along trade routes and move with travelers, revealing the porousness of borders and the frailty of migration controls. This new interconnected world, in which no government can tackle an epidemic single-handedly, challenges the sovereignty of nations.

In this context, contrasting the failure of African countries to contain Ebola with the success of their own health systems helps Western countries rebuild social links within their borders. Debates over quarantines and travel bans that occurred during the Ebola epidemic reveal how diseases can reinforce national belonging. This mechanism was also observed in previous epidemics such as the SARS outbreak, the coverage of which was shown to support the view of a “Euro-American-centered world order” by contrasting the perceived mismanagement of the crisis by the Chinese government with the positive role played by other governments.[28] In conclusion, the epidemic narrative creates a moral panic—that is, “an overreaction to a perceived social problem”—which in turns helps reinforce social ties.[29]

The Outbreak Narrative as a Way to Reinforce Structural Violence Mechanisms

The Ebola outbreak narrative helps reinforce structural violence mechanisms at the international level. Analysis of media discourse in previous epidemics shows how news coverage helps divide the world into zones of danger and safety, reaffirming global power hierarchies and positioning third-world populations as “abject, intractable and doomed.”[30] The outbreak narrative also portrays the epidemic as an uncontrollable external force, which reduces individual physiological susceptibility to the disease to a matter of random chance, denying the role of uneven development and exploitation between countries and individuals.

Structural violence—that is, the systemic economic and social mechanisms which lead to extreme suffering—rests upon a differential treatment of vulnerable groups: “[The] poor are not only more likely to suffer; they are also less likely to have their suffering noticed.”[31] In the case of Ebola, the outbreak narrative neglects the structural reasons underlying the spread of the epidemic, including countries’ colonial pasts and the deficiencies of the current international aid system. It reduces the Ebola epidemic to a problem of transmission from developing to developed countries without acknowledging the role of the developed world in perpetuating the unequal economic and social conditions that allow the virus to spread.[32] Furthermore, by neglecting some aspects of the outbreak—for example, the economic impact of travel bans, the long-term consequences of health care workers’ deaths on health systems, or the long-term health effects suffered by Ebola survivors—the outbreak narrative allows the Ebola outbreak to be framed as a single episode that does not require long-term solutions. This helps explain what the New Yorker journalist James Surowiecki has nicknamed “Ebolanomics”: the lack of incentives to develop drugs for diseases that only affect poor people in poor countries.[33] The outbreak narrative helps justify the differential between those who benefit and those who suffer from this unequal power dynamic.

The Outbreak Narrative as a Way to Legitimize the Use of Sovereign Power

Alongside structural violence, the outbreak narrative is used as an opportunity to reaffirm the use of power by governments themselves. Outbreaks can legitimize the use of violence and political interference and give governments powers otherwise prohibited by national laws and international treaties and customs. Framing geopolitics in biomedical terms justifies Western intervention in developing countries, the quarantine of individuals, travel bans, etc. Many observers have noticed the parallel use of the war metaphor to discuss terrorism and infectious disease outbreaks.[34],[35] Stefan Elbe, professor of international relations at the University of Sussex, cites a “biopolitical economy of power” to discuss how biological issues are turned into issues of security in the context of the HIV/AIDS epidemic.[36] The Ebola epidemic was similarly presented in 2014 as a “threat” that required immediate action.[37] In this context, the outbreak narrative creates a state of exception that allows governments to cite a time of crisis to sidestep normal laws and regulations and express their sovereign powers more freely.[38] The salience of health care and diseases in international politics thus mirrors the central role given to public health in strengthening sovereign power at the national level throughout the 20th century.

Conclusion

At first glance the strong appeal of the outbreak narrative observed during the 2014 Ebola epidemic is puzzling. Health systems are usually described as a way to make the world safer, as a triumph of human logic over uncontrolled natural phenomena. What is the role of a narrative built around fear and panic—especially one not entirely sustained by facts?

Some narratives thrive because of their ability to assemble apparently unrelated events into a meaningful framework, ultimately providing meaning to the world that surrounds us. Using this lens, the appeal of the outbreak narrative observed during the Ebola epidemic can be understood for three interconnected reasons: First, by developing a narrative of “us versus them,” it strengthens the social contract of Western nations in a world that is increasingly global. Then, by framing the Ebola narrative in terms of infection and biological susceptibility, it neglects the role of structural health care factors and erases the responsibilities of Western countries for their roles in developing and maintaining structural violence mechanisms. Finally, by creating a moment of crisis, it gives sovereign powers exceptional authority beyond what would normally be permitted by law and custom.

Narratives do matter. In 2014, the World Bank estimated that the loss in GDP for Western Africa could amount to up to US$32.6 billion in 2014 and 2015, and that part of this loss was explained by quarantines imposed on affected countries.[39] In the United States, a review of 179 public opinion polls about Ebola shows the outbreak may have fueled a partisan split across Democrats and Republicans as candidates used Ebola to increase their media coverage.[40]

The Oxford Dictionary chose “post-truth” as its word of the year for 2016.[41] In a moment of intense debate over what constitutes truth in news coverage, it is important not to lose sight of how facts, and also narratives, shape our understanding of the world. Policy makers, analysts, and the media must avoid inaccurate or misleading narratives. Only this can ensure that policies will be designed based on facts, not fear.

Acknowledgements

The author wishes to thank Bridget Hanna, Jason Silverstein, and Parker White for their constructive comments on previous versions of this article.

Claire Chaumont is a second-year doctoral student at the Harvard T.H. Chan School of Public Health. She has spent the last decade working across Europe, Africa, and Latin America on issues related to health financing, health policy, and management in low and middle-income countries. She is particularly interested in the design and implementation of global governance mechanisms for health.