“I guess if Washington Times prints it, it’s not totally baseless?” a colleague tweeted. For the second time in as many weeks, those of us closely following the Ebola outbreak in West Africa had to process the news that another expatriate aid worker had been given experimental Ebola drugs—the “secret serum”—as a part of his treatment while the Liberians he came to treat were denied any such medicine. Adding insult to injury, the seventy-something Spanish priest, like two American missionary clinicians before him, had been evacuated to his home country and lifted above the fray to receive treatment. While the cost of their evacuations and of procuring the experimental therapy were borne by their respective organizations, there was no doubt, within my Twitter community, that this was yet another instance in which the lives of Americans and Europeans were valued above those of the residents of Sierra Leone, Liberia, and Guinea. Among a smaller group of us, the privileging of white lives over black ones reflected a deeper pattern of racism and anti-African sentiment.
Critics tend to approach the decisions about who should be evacuated and who would be able to access experimental therapy—some have called it social triage—from two different but related angles. Perhaps out of a sense of politeness or fear of implication, the disparity between who receives assistance and who does not is often characterized in terms of wealth distribution, rich versus poor. Others have taken their criticism a step further, casting this disparity not only in terms of wealth and inequality between nations but in terms of white privilege. Regardless of how they framed their criticism, most critics of social triage were upset but unsurprised: as Andile noted on Twitter, “2 whites gets ebola and are put on ‘experimental’ drugs. Africans die in huge numbers. Old story. Blacks lives don’t matter.” Humanitarian aid had revealed a troubling set of ethics nested at its core; it has long privileged the safety, security, and lives of foreign humanitarian aid workers above the so-called “local” people they claimed to want to help.
Mistrust of the humanitarian aid industry, in practice, translates to mistrust of institutions and the individuals who represent them. This is not to say that mistrust of foreign health workers reflects mistrust of Western medicine, as so many mainstream journalists have been eager to suggest. When illnesses are shown to have effective biomedical treatments, people are willing to take them, especially if qualified health personnel provide them in well-stocked facilities. Foreign services like MSF often provide just that, and are usually welcomed accordingly. In a New York Times article focusing on attacks on foreign aid workers, MSF’s emergency coordinator himself acknowledged that such attacks were out of the ordinary: “This is very unusual, that we are not trusted.” He attributed the new mistrust to the health workers’ inability to curb the disease.
It is when health services are provided at too high a cost, too low a level of quality, and with limited efficacy, that mistrust arises—not of medicine itself but of government-supported institutions that fail to meet certain standards. Added to this skepticism about public institutions, which are notoriously underfunded, underperforming, and understaffed, a health crisis like Ebola also fosters a lack of confidence in local health workers—who themselves are not always protected and may even help to spread the disease. The characteristics of Ebola itself, which kills quickly and at alarmingly high rates (50 to 90 percent), amplifies this mistrust. The disease affects women who care for the ill; nurses and doctors who treat patients; the individuals who prepare bodies for funerals; mourning relatives; close friends, intimate partners.
A double standard persists in which protection for health workers is not created equal: a Congolese nurse dies in Liberia, but a Spanish one must not be allowed to languish in the same way; a prominent Sierra Leonean physician and virologist dies, but Americans are flown to Atlanta and given a “secret serum.”
It is when health services are provided at too high a cost, too low a level of quality, and with limited efficacy, that mistrust arises—not of medicine itself but of government-supported institutions that fail to meet certain standards.
Mistrust, suspicion, and fear among affected communities, then, reflect the ways in which the disease’s severity and curious appearance combine with a wider history of mistrust of certain institutions—humanitarian and governmental ones among them—and of the motivations for their work. The suspicion is embedded, as I have written elsewhere, in a wider history in which charity and aid appear to enrich some while leaving others high and dry. Both the humanitarian and development industries—although the two operate in different time frames (emergency and long-term social change, respectively)—tend to represent a detached, mobile, even ephemeral presence in the communities where they work. Development agencies may maintain a long-term presence (organizations like CARE have been in operation in some of these countries since the 1960s), but their expatriate staff moves in and out freely.
Humanitarian emergency relief comes and goes even more quickly, swooping in to provide palliatives for communities in crisis and leaving at the whim of international agenda-setters. And even when relief doesn’t “go,” as was the case during the protracted conflicts in Liberia and Sierra Leone, the expatriate staff are quickly rotated in and out with the assurances that they if they do stay on for extended contracts, they will receive ample “R&R” to decompress from the psychological and physical stressors of living under difficult conditions. At the same time, the movements of West Africans within and outside of the region are quite literally perceived to be pathological in nature. The movement of African intellectuals and skilled professionals constitutes a “brain drain,” at “best,” that will ultimately hamper national progress. Health worker migration from Africa to Europe and North America has even been called unethical in scholarly literature. There is a sense that Africans must stay rooted in place or at least be moving in a circular motion, anchored to home, for their movements to be legitimate and relieved of intense scrutiny. A Nigerian friend working on a master’s degree at Harvard lamented that many of the post-master’s fellowships available to him required that he return home upon their completion.
The evacuation of the American and Spanish missionaries brought into sharp relief the prevalence of social triage along racial and geopolitical lines and the undervaluing of African lives. (That Father Miguel Pajares ultimately died in a Madrid hospital does not change this underlying dynamic.) The “secret serum” they had received had come to stand in for the forms of racism and transnationally mediated injustice that consistently estimates certain people’s lives above others. We soon learned that there was nothing “secret” about this treatment; it had been in development for years, funded by U.S. government bioterrorism initiatives. But for careful observers in the region, it seemed to come out of nowhere; it seemed to have made its appearance only when wealthy whites needed it.
Anthropologists have written extensively about the social and cultural significance of secrets: they may be a means of initiation into a select community, and they may also be used for social control. Often the contents of the secret do not even matter; the ability to withhold, to keep and to share at will, in itself represents power, regardless of what is being withheld. The most dangerous secrets may not even be secrets at all—only things everyone knows but no one talks about. In the case of Ebola, as in all times of scarcity and humanitarian crisis, the most powerful but poorly kept secret is that some lives matter more than others.
Adia Benton is an assistant professor of anthropology at Brown University. She has worked extensively in the fields of public health and humanitarianism, and has lived and worked in Sierra Leone. Her book, HIV Exceptionalism: Development through Disease in Sierra Leone comes out with the University of Minnesota Press in 2015.