Evacuation: a solution to global health crises?

The excellent Humanosphere website recently posted news of an interesting development in global health philanthropy. The Paul G Allen Foundation and the US State Department have co-financed a new way to evacuate infected health workers from the frontlines of global health crises: an airborne Containerized Bio-Containment System (CBCS), the self-confessed “next generation of biocontainment.” Containment overload. That is the rather grand title for something that, in the words of Humanosphere’s Tom Paulson, is “a big white box that looks on the outside like a love child left over after a romantic encounter between NASA and Northern Pacific Railway.” I couldn’t help but think of recent work by Deb Cowen and others on the “deadly life of logistics” and the ubiquity of the container economy — does CBCS represent the containerization of health?

Outside of the big white box (https://edelmanftp.app.box.com/s/oxsb5bspg35xqyhfiqdg1k5g1imihuwp)

The confinement of infected civilians and medical personnel became a source of considerable anxiety during the 2014 outbreak of Ebola cases in West Africa. It became apparent as the outbreak progressed that certain bodies would be contained, treated and even evacuated, while others would be left to the vagaries of non-treatment and hospitalisation in overburdened and underfunded health systems. Of course, these actions are nothing new in the world of public health: confinement, triage and the control of “circulation” being central to the modern government of epidemics and beyond. The cost is a little different though: Reuters reported that each evacuation case cost insurers something in the region of US$100,000. This was said to be discouraging some medical agencies and staff from heading to the region. This, of course, remains a decision to be made by a privileged few; the evacuation of infected Liberians was never considered.

Allen’s financing has created an airborne unit “that supports and facilitates a critical care treatment environment, allowing for the transport and treatment of four critically ill patients infected with a highly contagious pathogen while maintaining full biocontainment.” Like the evacuation of casualties from the battlefield, the system is designed to remove the patient spatially from the “front,” but to what extent is the context of infection addressed? Here, care, for a fleeting moment, is transplanted to West African cities; a patient is then hermetically sealed, lifted into the air, and flown to a safe distance. Care here is not embedded an messy — that, after all, carries the risk of infection — it is a short-term intervention that does not challenge systematic abandonment, but rather perpetuates it.

Big box’s squeaky clean interior (https://edelmanftp.app.box.com/s/oxsb5bspg35xqyhfiqdg1k5g1imihuwp)

Allen has invested a significant amount of his personal fortune in such schemes designed to alleviate the ongoing epidemic. He has been the single largest private donor to the cause, investing more than US$10 million to emergency response, treatment and preparedness infrastructure. The CBCS initiative is a public-private partnership between Allen, the State Department and Kansas City defence contractors MRIGlobal (who, like many defence companies, now have a line in “medical countermeasures” — see Stefan Elbe’s work for more). Here’s the marketing video. Yes. There is a marketing video:

Horrific isn’t it? The way that responses to global health crises have to be hyped and marketed in such ways. Talking heads discuss Liberia from an echoing warehouse and flank a white box prominently labelled with the seal of the United States. This is modern humanitarianism. It is also hard not to be concerned that this represents a further incursion of the military-industrial-philanthropy complex into the arena of global health. Consider, for example, these words cited in the Humanosphere article:

“Today, some of the most dangerous adversaries we face are contagious diseases. These new medevac units are an extraordinary example of partnership and innovation in action,” said Barbara Bennett, president and COO at Vulcan Inc., Allen’s commercial enterprise.

Ebola and other infectious diseases leap off the page here as “dangerous adversaries,” and others (here and here) have already outlined some of the ways in which the securitisation of the disease has already come into play in West Africa and beyond. But, I’d like to close this brief reflection, by identifying a couple of areas that are also troubling me about this case. Firstly, the white US-branded box eerily resembles those USAID humanitarian packages that you see dropped out of the sky during famines; here, the CBCS is also “helping” and that help is equally short-lived, selective and soon to be found seen disappearing over the horizon. Secondly, and coming back to the earlier marketing of the box as a “critical care treatment environment,” there must surely be a concern that the prioritising of evacuation comes at the expense of investment on resilient health systems. These were found to be sorely lacking in the ebola epidemic, and Paul Farmer neatly summarised the situation in a recent LRB piece: “[w]ithout staff, stuff, space and systems, nothing can be done.” Why invest in the long-term, messy work of health systems infrastructure development, when you can drop a box from the sky and ship the important people out for treatment elsewhere? How, then, to invest more in strengthening health systems while avoiding the strengthening of a hierarchy of human worth that is constructed through the evacuation of some?

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