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An emergency of circulation: entry screening in the UK during the 2014 Ebola epidemic
Abstract
The rise of emergency governance in global public health has driven a number of changes in this field. In this article, we investigate one of the practices of emergency governance – border screening – and identify a new form of screening that emerged in the UK during the 2014 Ebola epidemic in West Africa. Analysing the UK’s deployment of Ebola entry screening and the public debate that emerged around it, we show how this technology was constructed to identify potentially risky individuals, assess their risk level and pre-accelerate future response to potential cases. Engaging with Foucault’s notion of a ‘crisis of circulation’, we argue that this approach expresses a response to an emergency of circulation: the alarming prospect of a concrete threat with the potential to infiltrate the population through circulation systems. We show that entry screening, in this case, addresses such a problem by enabling, rather than diminishing, circulation.
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Introduction
In response to the 2013–2016 West African outbreak of the Ebola virus disease (EVD), Public Health England introduced enhanced screening at major UK ports of entry. Our aim was to explore screeners’ and screened travellers’ perceptions of screening as part of an evaluation of the screening programme.
Methods
We undertook qualitative focus groups and semistructured interviews with screeners and travellers who had returned from affected countries before and after the introduction of screening in England. The study was conducted in two airports: one international rail terminal and one military airport. Research topic guides explored perceptions of the purpose and implementation of the process, potential improvements and reactions to screening. The data were analysed using the framework method.
Results
Twenty-four screeners participated in 4 focus groups (one for each port of entry) and 23 travellers participated in interviews. Three themes are presented: ‘Context’, ‘Screeners’ experience of the programme’ and ‘Screening purpose and experiences’. The programme was implemented rapidly, refined over time and adapted to individual ports. Screeners reported diverse experiences of screening including negative impacts on their normal roles, difficult interactions with passengers and pressure to identify positive EVD cases. Screening was considered unlikely to identify individuals with symptoms of EVD, and some participants suggested it was driven by political concerns rather than empirical evidence. The screening process was valued for its provision of information and reassurance.
Conclusion
This qualitative study found that the UK EVD screening process was perceived to be acceptable to assess individual risk and provide information and advice to travellers. Future programmes should have clear objectives and streamlined processes to minimise disruption, tailored to the nature of the threat and developed with the needs of humanitarian workers as well as general travellers in mind.
Governments in Europe and around the world amassed vast pharmaceutical stockpiles in anticipation of a potentially catastrophic influenza pandemic. Yet the comparatively mild' course of the 2009 H1N1 pandemic provoked considerable public controversy around those stockpiles, leading to questions about their cost-benefit profile and the commercial interests allegedly shaping their creation, as well as around their scientific evidence base. So, how did governments come to view pharmaceutical stockpiling as such an indispensable element of pandemic preparedness planning? What are the underlying security rationalities that rapidly rendered antivirals such a desirable option for government planners? Drawing upon an in-depth reading of Foucault's notion of a crisis of circulation', this article argues that the rise of pharmaceutical stockpiling across Europe is integral to a governmental rationality of political rule that continuously seeks to anticipate myriad circulatory threats to the welfare of populations - including to their overall levels of health. Novel antiviral medications such as Tamiflu are such an attractive policy option because they could enable governments to rapidly modulate dangerous levels of (viral) circulation during a pandemic, albeit without disrupting all the other circulatory systems crucial for maintaining population welfare. Antiviral stockpiles, in other words, promise nothing less than a pharmaceutical securing of circulation itself.
The current outbreak of Ebola is the largest and most complex Ebola outbreak to date. Mainly affecting Guinea, Sierra Leone and Liberia, on 8th August 2014, it was declared a Public Health Emergency of International Concern (PHEIC) by the Director General of the World Health Organization (WHO).1 As of 31st December 2014, there have been a reported 20,206 cases and 7,905 deaths, including cases in Nigeria, Mali, Senegal, United States, Spain and the United Kingdom.2 In the United Kingdom, the outbreak has been declared a level 4 incident, defined as ‘public health impact severe. It requires central direction and formal interaction with Government’,3 resulting in increasing financial support, dissemination of guidance, local planning and preparation and deployment of healthcare workers and other personnel to affected areas.
As of 26 November 2014, 15 935 cases of Ebola had been reported to the World Health Organization (WHO), of whom 5689 have died.1 It is widely believed that these figures are underreported and the actual number of cases and deaths is higher.2 Six cases and one death were reported outside West Africa.3 This unprecedented outbreak took professionals and policy makers by surprise as it occurred where it was not expected and developed on a scale that could not have been predicted. Or at least, that has been the accepted view. A consideration of the population affected and the weak health infrastructure of the countries most affected should have led to a recognition that, once a contagious disease such as Ebola developed in this setting, the scope for rapid spread was great, given the high population density and degree of connectivity among the people of the region.4 Unlike previous outbreaks that occurred in remote rural areas of central Africa,5 this developed in a densely populated area and, very quickly, outbreaks occurred in the capitals of the main affected countries (Guinea, Sierra Leone and Liberia). Rapid initial spread was facilitated by lack …
Will it make a difference?
On 9 October the UK government announced that “enhanced screening” for Ebola virus disease will be implemented at Heathrow and Gatwick airports and Eurostar terminals. Details of how this will be done are not yet available, but the objectives presumably are to identify people arriving from Sierra Leone, Guinea, or Liberia who may have been exposed to Ebola, assess whether they have symptoms consistent with Ebola, test those who do, and isolate anyone with positive results.
Several practical difficulties will need to be overcome to achieve these objectives. As most direct flights to the UK from Sierra Leone, Guinea, and Liberia have been discontinued because of the epidemic, passengers will be arriving from various European cities, and itineraries will need to be carefully checked to identify passengers arriving from those countries. Those who are identified will be asked to complete a questionnaire stating whether they have been in contact with sick people or have attended funerals in west Africa, and whether they have symptoms such as fever, headache, diarrhoea, or vomiting. People who answer “yes” to any of these questions will presumably …
Through analysis of preparedness for pandemic influenza in Israel, I explore how future uncertainty is conceptualized and the various practices put into action to deal with it. In particular, I discuss the emergence of a new type of uncertainty—potential uncertainty—and three technologies employed to cope with it: risk technology, preparedness technology, and event technology. Event technology emerges in the preparations for a potential uncertainty event—such as pandemic influenza. In contrast with the other two technologies, it acknowledges the problem of potential uncertainty and retains uncertainty through its action. Thus, uncertainty is not solely linked to the appearance of new risks in the world, which is the basis of the risk society approach (e.g., Beck 1992; Giddens 2000), nor is it related to the impossibility of calculating these risks, as the preparedness paradigm (e.g., Lakoff 2008) and science and technology studies argue. Rather, uncertainty underpins a technology through which the future, although not reducible to calculable forms, can still be governed. Employing the concept of potential uncertainty and considering the various technologies applied to management of the future allow for a more thorough discussion of problems of future uncertainty with which current societies are preoccupied.
Drawing on perspectives from the governmentality literature and the sociology of risk, this article explores the strategies, tools and mechanisms for managing risk in acute hospital trusts in the United Kingdom. The article uses qualitative material from an ethnographic study of four acute hospital trusts undertaken between 2008 and 2010 focusing on the provision of dignified care for older people. Extracts from ethnographic material show how the organisational mechanisms that seek to manage risk shape the ways in which staff interact with and care for patients. The article bridges the gap between the sociological analysis of policy priorities, management strategy and the organisational cultures of the NHS, and the everyday interactions of care provision. In bringing together this ethnographic material with sociological debates on the regulation of healthcare, the article highlights the specific ways in which forms of governance shape how staff care for their patients challenging the possibility of providing dignified care for older people.
This essay concerns the current intersection of national security and public health in the United States. It argues that over the course of the past three decades, a new way of thinking about and acting on the threat of infectious disease has coalesced: for public health and national security officials, the problem of infectious disease is no longer only one of prevention, but also—and perhaps even more—one of preparedness. The essay describes the process through which a norm of preparedness came to structure thought about threats to public health, and how a certain set of responses to these threats became possible. The story is a complex one, involving the migration of techniques initially developed in the military and civil defense to other areas of governmental intervention. The analysis is centered not on widespread public discussion of biological threats but, rather, on particular sites of expertise where a novel way of understanding and intervening in threats was developed and deployed. It focuses in particular on one technique, the scenario-based exercise, arguing that this technique served two important functions: first, to generate an affect of urgency in the absence of the event itself; and second, to generate knowledge about vulnerabilities in response capability that could then guide intervention. More broadly, the scenario-based exercise is exemplary of the rationality underlying the contemporary articulation of national security and public health.
How should we understand the politics of security today? This article addresses this question from one particular perspective, that of 'biosecurity'. It examines contemporary strategies for managing biorisks in three European states: France, Germany and the United Kingdom. We suggest that the framing of threat and response differs, even within Europe, and that one can identify three different configurations: contingency planning, protection and resilience. Each of these embodies a significantly different way of reconciling fundamental imperatives for those who would govern a liberal society today - the imperative of freedom and the imperative of security.
The experience of the 2003 Severe Acute Respiratory Syndrome outbreak in Toronto, Canada provides an important example for understanding how the relationship between national security and public health is being defined in the contemporary context of emerging infectious diseases and the globalization of public health. This paper argues that Canada’s public health legal framework is a critical part of Canada’s practice of ‘biosecurity’ through which an unpredictable and continually emergent ‘new reality’, is mobilized to justify an ongoing state of emergency. Norms about state power and human rights are suspended in the interest of global capitalism and at the expense of those most vulnerable to the short-term and long-term effects of infectious disease.
In this article, we analyze UK global health policy in the light of the 2014 Ebola epidemic. Specifically, we focus on the UK government’s intervention in the epidemic, reflections on the UK’s response in parliamentary committees and government-sponsored forums, and subsequent UK global health policy changes. Post-Ebola, we argue, UK global health policy turned into a pursuit of global health emergency-preparedness through development. This, we further suggest, resulted from what we identify as the specific structure of the UK’s emergency-preparedness configuration that creates a ‘spill-over’ between the immediate event (of emergency) and future preparedness. This configuration transmits problems between different temporalities – allowing immediate, urgent problems to become problems of future uncertainty (and future uncertainties to be enacted as urgent problems). In activating emergency-preparedness, furthermore, self-scrutiny is triggered – prompting the UK to assume responsibility for problems identified as threats regardless of their point of origin, thus internalizing external problems.
Recent years have witnessed an upsurge in global health emergencies-from SARS to pandemic influenza to Ebola to Zika. Each of these occurrences has sparked calls for improved health preparedness. This book addresses the question, how did we become “unprepared?" Emerging disease has only recently come to be understood as a problem of preparedness. Andrew Lakoff follows the history of health preparedness from its beginnings in 1960s Cold War civil defense to the early twenty-first century, when international health authorities carved out a global space for governing potential outbreaks. Alert systems and trigger devices now link health authorities, government officials, and vaccine manufacturers, all of whom manage the possibility of a global pandemic. Funds have been devoted to cutting-edge research on pathogenic organisms, and a system of post hoc diagnosis analyzes sites of failed preparedness to find new targets for improvement. Yet, despite all these developments, the project of global health security continues to be unsettled by the prospect of surprise.
After the Severe Acute Respiratory Syndrome (SARS) outbreak in 2002, legal theorist David Fidler diagnosed the arrival of the 'first post-Westphalian pathogen'. The coinage indicates that the spread of infectious disease transforms the spatial coordinates of the modern political environment. This article analyses this transformation by asking how the legal regime, designed to prepare for the pandemic, envisions the globe as an object of government. It demonstrates that the WHO's International Health Regulations (IHR) articulate a space of global circulation that exhibits two features. First, the infrastructures of microbial traffic become the primary matters of concern. The IHR do not focus on human life so much as they aim at securing transnational mobilities. Second, the IHR circumscribe a space that is fragmented by zones of intensified governmental control at transportational nodal points, such as airports and harbours. In these zones, technologies of screening and quarantine are applied to modulate the connectivity of people, organic matter and things. As a whole, the article investigates how processes of de- and re-territorialisation interact in the context of global health security. In analysing forms of legal worldmaking, it unearths a nomos of global circulation which applies its regulatory force to the post-human materialities of microbial traffic.
The Ebola virus outbreak in west Africa has been described by WHO as the “most severe acute health emergency in modern times.”
In the UK, Public Health England (PHE) has instituted enhanced entry screening for Ebola in passengers coming from Sierra Leone, Guinea, and Liberia. Screening is already in place at Heathrow and will shortly roll out to Gatwick and St Pancras (Eurostar). …
Experts have questioned the effectiveness of the UK government’s announcement that it is going to introduce screening at major UK transport terminals in a bid to intercept travellers with Ebola disease.
The government made the announcement to stem fears over the potential spread of the disease in the United Kingdom, after a man in the United States died from the disease and a nurse caring for missionaries with the disease in Spain became infected.1 2 3 The US has also introduced screening at five major airports.4
Enhanced screening will initially be implemented at Heathrow and Gatwick airports and the Eurostar train terminals and will be conducted by medical rather than border force staff, the spokesman added.
Only travellers from the three affected countries—Sierra Leone, Liberia, and Guinea—will …
This article traces the emergence of human security as a situated political strategy for managing the circulation of pathogens relating to Burmese migrant communities in Thailand. Specifically, it focuses on the intricate and productive interplay of a range of human and non-human elements that helped to bring forth and shape the vernacular micropolitics of human security. The article documents the techno-(bio)political mechanisms of the human security intervention in two of Thailand’s provinces. By enframing, ordering and depoliticizing the complex health world of Burmese migrants in terms of simple dichotomies in which ‘unruly’ nature (pathogens, diseases, bodies) is contrasted with human techno-scientific ingenuity (scientific evidence, technological innovations, managerial effectiveness), these mechanisms render the circulation of pathogens amenable to biopolitical governance. It is here argued that in the struggle to manage pathogenic circulation, human security transforms the issue of migrant health into a technical matter concerned with the (self-)management of bodies and the governmentalization of the Thai state to the exclusion of important but difficult questions concerning a violent politics of exclusion.
Emergency is now a taken-for-granted part of how 21st century life is governed, being applied by states, corporations and non-governmental organisations to a wide range of events. Despite its ubiquity, there are few reflections on emergency itself in distinction from the ‘state of emergency’. In this paper we complement and extend existing work on the legal–political geographies of the ‘state of emergency’, by arguing that distinct versions of emergency are produced in apparatuses of security. We exemplify this approach to the political geographies of security through a case study of the apparatus of organisational forms and techniques through which the UK state responds to a range of events: UK Civil Contingencies. Drawing on documentary analysis, interviews and observation, we show how events are governed in UK Civil Contingencies through a number of distinct versions of emergency that open up a specific field of action: an interval after an event occurs but before that event becomes a disaster. In relation to this interval, UK Civil Contingencies revolves around a ‘state of preparing for emergencies’ and a ‘state of responding in emergency’, whilst the ability to proclaim a ‘state of emergency’ remains in potential. In conclusion we set out the implications of our approach for future work on how events and life are governed.
Tuberculosis (TB) is `re-emerging' as a major public health challenge among marginalized urban communities in London (UK) and other European capitals. With some parts of London experiencing rates `comparable' to those in the `developing South' the emergence of the disease brings into sharp relief the interconnectedness of global concerns, including poverty, inequality and exclusion. This paper analyses the relationship between risk discourses and TB and, in particular, how risk is discursively and institutionally (re)produced within biomedical and public health discourses. Drawing on the `flows of people between richer and poorer',1 it highlights ways in which public health discourses, suffused with structures that are gendered, raced and classed, produce and sustain constructions of the other, through discourses of migration, technologies of risk, classification, `immobilization' and `space confinement'. The paper challenges (the often assumed) essentialized notion of risk categories by suggesting productions of risk are always being reworked and renegotiated because of the different socio-historical and contextual formations of TB.Social Theory & Health (2007) 5, 267-284. doi:10.1057/palgrave.sth.8700098
Drawing on an inquiry into Israel's preparedness for biological threats, in this article I suggest a new analysis of biosecurity events. A complex and dynamic assemblage emerges to prepare for biological threats, one that I call a “pre-event configuration.” The assemblage is composed of three core elements—the scientific element, the security element, and the public health element—each of which diagnoses threats and suggests appropriate solutions. This configuration also determines what will be perceived as an event for which preparation is needed and what will remain a nonevent. I maintain that the constitution of an event takes place beyond the actual time of its occurrence and is determined by the pre-event configuration in the “time of event.” Therefore, a comprehensive analysis of events should combine an examination of actual events and their aftermath with an inquiry into their potentialities as determined by the pre-event configuration. [biosecurity, preparedness, events, disasters]
This article traces the use of managed competition policy to transform the NHS from an administered public service to a set of interlocking markets and contracts. It reviews the overlooked origins of managed competition in the new managerialism and explains the relationship between managed competition and the cost crisis of the NHS by extending Foucault's concept of governmentality to revise the concept of the state. The paper then describes how the government structured health care markets, using managed competition as an instrument of governmentality. It summarises institutional responses by health authorities, hospital trusts, and GP fundholders. The terms "master institution", "dictated competition" and "coercive partnering" are introduced as new concepts for economic sociology and as strategies of governmentality. Implementation, however, led to resistance, opposition and eventual abandonment of managed competition as too disruptive and costly. Yet , this analysis contends, managed competition has left an enduring legacy of accountability to purchasers in economic terms such as efficiency, transaction costs, and cost effectiveness. The policies of the new government are based on coercive partnering and doctor-based "commissioning". This and the Internet imply revolutionary changes for the health professions and the delivery of health care services through networks of moebius-strip organisations interacting in flexible sequences and subject to communication Pressures.
Tuberculosis (TB) is an infectious disease that declined significantly throughout the 20th century. Large-scale TB screening of entire populations in France and Germany has thus been replaced by active screening of risk-groups, particularly migrants. The article engages with its problems and practices on three levels: by looking at the way information on migrants as an at-risk group is produced through disease surveillance data; by analysing how such at-risk group data influence local screening practices; and by showing which political and medical problems arise in the field. I overturn the discussion about screening and surveillance of migrants as a risk-group by showing that it is not the stigmatisation of migrants through disease risk that is most at stake, but the invisibility of the most vulnerable among them in disease surveillance data and the way restrictive national immigration policies interfere with and subvert local screening and treatment practices targeting them. The aim of my article is to promote a pragmatic sociology of screening, while paying attention to the practical complexities, political conditions and medical ambivalences of screening and follow-up care, especially when the migrant groups concerned are socially, politically and medically vulnerable.
During preparations for the Second Gulf War, Israel considered universal smallpox vaccination. In doing so, it faced a problem: how to legitimise carrying out a security action against an uncertain future danger (smallpox pandemic), when this action carried specific, known risks (vaccine complications). To solve this problem, the Israeli preparedness system created a new domain through which the security action could reach its goal with minimum risk: first responders (a group of medical personnel and security forces). First-responder vaccination represents a shift in the form of 'securing health' and in the governmental technology applied to this goal, in which past, present, and future occurrences are governed to enable the execution of a security action. Through this practice, risks are not located in the present or in the future but in a 'shared' temporal space and thus can be seen as existing simultaneously. Preparedness for emerging future biological events, then, involves more than questioning how the future is contingent on the present and how the present is contingent on the future's perception; it also recognises the need for a new time positioning that allows operating on both present and future risks simultaneously. Governing these risks, then, means governing through time.
This conference paper was presented at ‘The Biopolitics of Value(s)': an ESRC Seminar Series. For further details of this conference please visit: http://www.keele.ac.uk/research/lpj/bos/events/Biopolitics%20of%20Values%20docs/ValuesWorkshop.html The outbreak and subsequent worldwide spread of pandemic influenza H1N1, popularly known as ‘swine flu’, from the spring of 2009 has illustrated our continued microbial vulnerability in a highly interconnected aeromobile world. The UK has been particularly affected by the first ‘wave’ of infection, with some commentators suggesting this was an inevitable consequence of the country’s status as a hub of global air communications. Given that the virus was almost certainly brought to the UK by holidaymakers returning from Mexico, the role of the UK airport as the ‘first line’ of defence against the importation of infectious disease has been subject to particular scrutiny. An important debate has subsequently emerged surrounding the ‘rights’ of airline passengers to move unimpeded through the world’s airports (without being subjected to medical screening) against the ‘rights’ of individual nations to be protected from the spread of infection through the employment of ‘strict’ screening practices. Focusing on concepts of ‘value’ and ‘cost’, as applied to individual ‘forms of life’, we consider how the governance of H1N1 risk at UK airports has generated a set of complex and interlocking biopolitical and ethical concerns associated with the safeguarding of the national border. We conclude by indicating how this tension, between securing and ethically valuing life, may inform future UK policy responses to infectious disease control at its international airports. One means is through a process of policy transfer. Not specified
Ebola outbreak: Britain must start screening for the virus, says home office minister
- N Morris
- T Walker
Ebola airport screening: Will it work? BBC News
- S Mundasad