‘Ebola is a business’: an analysis of the atmosphere of mistrust in the tenth Ebola epidemic in the DRC

ABSTRACT

This paper examines the atmosphere of mistrust that permeated the response to the tenth Ebola epidemic in Eastern DRC (2018–2020). The concept of an ‘atmosphere of mistrust’ that we develop in this article directs attention to the elusive-yet-pervasive presence of mistrust in interactions between responders and communities during the Ebola epidemic. This analysis focuses on the popular notion that ‘Ebola is a business’. Our interviewees frequently used this saying during our research on the Ebola response to explain why mistrust had emerged, how it materialized, and against whom it was directed. Based on these interviews, we examine ‘Ebola is a business’ as a slogan that enabled people to voice mistrust. This slogan, as we aim to show, resonated with a wider atmosphere of mistrust that governed the emergency situation in Eastern DRC. In using it, people responded to their perceptions of mistrust whilst simultaneously perpetuating and extending this atmosphere of mistrust. Our analysis of the atmosphere of mistrust highlights the power of atmospheres in governing situations, mobilizing people, and disrupting structures of discrimination. It aims to contribute to a better understanding of the barriers inhibiting the collaborations between affected communities and responders, which are required to deliver effective epidemic responses. Moreover, we argue that voice and the atmosphere are important analytics for exploring the histories of mistrust that Ebola epidemics ask for.

KEYWORDS:

• Ebola epidemics
• mistrust
• atmospheres
• Democratic Republic of the Congo

Introduction

The tenth Ebola epidemic in Eastern Democratic Republic of the Congo (DRC) in 2018–2020 was the second largest in history, with 3481 reported cases out of which 2299 people lost their lives. The scale of this epidemic was in many ways unexpected. Especially after the Ebola epidemic in West Africa, the largest in history, there was a global sense that multiple lessons had been learnt and the world would never again let tragedy unfold at such a scale. Moreover, the public health emergency response in Eastern DRC employed a range of innovations such as vaccines, improved therapies, and most notably patient-friendly Ebola treatment centres, which improved the standard of care and treatment considerably. According to official reports, fatalities at treatment centres in the Eastern DRC decreased from an average 60–70% in past epidemics to 35% (WHO, 2019a). However, despite the availability of these new technologies for Ebola care and treatment, the disparate combination of entities known as ‘the response’ (la riposte) – comprising government and UN agencies, humanitarian relief organisations, and national and international NGOs – failed to win the active support of communities. Instead, suspicion and resentment grew and escalated. There was civic unrest and community resistance, including violent attacks on treatment centres and frontline health workers (Nguyen, 2019; Richardson, 2019). According to various scholarly analyses, major incidents of violent events correlated strongly with a surge of new Ebola cases, which in effect prolonged the epidemic (Kalenga et al., 2019; Wannier et al., 2019).

This paper explores community mistrust of the response to the tenth Ebola epidemic in the DRC. During our collaborative field research on the public health emergency response at the height of the epidemic, between July and November 2019, our informants explained that we had to recognise that ‘Ebola is a business’ if we want to understand the emergence of mistrust and resistance toward the response. In this paper we will explore this phrase as a slogan¹ through which actors voiced mistrust. The voicing of mistrust, as we aim to show below, resonated with what we came to view as a wider atmosphere of mistrust that governed the interactions between local communities and responders in the Ebola epidemic in Eastern DRC.

The analysis of the atmosphere of mistrust that we develop in this paper brings scholarly works on trust into conversation with recent anthropological works on atmosphere (Eisenlohr, 2018; Riedel, 2019). Hermann Schmitz (2014) introduced the concept of the atmosphere to suggest that feelings do not only reside in individual bodies or minds but are ‘poured’ into a space where they sensate people. Atmosphere describes how the voicing of mistrust fills a situation with feelings of mistrust. More specifically, the concept of atmosphere invites an exploration of how mistrust comes to govern a situation in which bodies find themselves (Riedel, 2019). These reflections on atmosphere can enrich anthropological contributions to the study of mistrust of epidemics. Anthropologists have been arguing that an understanding of mistrust requires asking ‘how people think and feel’ about the Ebola epidemic response (Hewlett & Hewlett, 2008, p. 14). While such an approach is useful, it risks reducing trust and mistrust to subjective feelings shaped by values that members of a community share, for example by virtue of their ‘culture’ (Hewlett & Hewlett, 2008). By contrast, an analysis of the atmospheres of mistrust directs our attention to how mistrust comes to shape practices of noticing, assessing, and defining each other.

Most importantly, an atmosphere of mistrust allows critical reflection on the commonly held assumption – found in popular discourse and academic literature – that mistrust and resistance during the Ebola epidemic in the DRC and other epidemics in other countries are to be attributed primarily to ignorance or misinformation and are exacerbated by rumours or conspiracy theories. This perspective reduces utterances like ‘Ebola is a business’ to a conspiracy theory, prompting the conclusion that such views must be ‘corrected’ (Chandler et al., 2014). This perspective conflates trust with the acceptance of scientific knowledge about epidemics, which in turn reduces mistrust to the rejection of scientific knowledge (Calain & Poncin, 2015). The slogan ‘Ebola is a business’, however, suggests that mistrust in the tenth Ebola epidemic was less a rejection of scientific truths about Ebola epidemics than it was a rejection of the modalities of the response. As we explore in more detail below, the slogan ‘Ebola is a business’ outlines how donor funding renders the disease into what Jean-François Bayart calls a ‘resource of extraversion’ to which the majority has no access (Bayart, 1993, p. 74).

This mistrust reflects a form of common sense what donor-funded interventions are about. As Adia Benton and Kim Yi Dionne argue, an understanding of this common sense requires attention to the colonial and postcolonial histories of exploitation and abuse (Benton & Dionne, 2015, p. 226; see also Shepler, 2017). The influx of huge amounts of donor aid money during the Ebola epidemic in Eastern DRC enforced the latent suspicion that powerful actors – be it local elites, international organizations, or foreign countries – are even in a crisis ruthlessly profiteering from that crisis, as people have painfully learned from the history of war and exploitation of natural resources in this region (Richardson, 2019; see also Vlassenroot et al., 2012).

In this article we contribute to anthropological work on trust and mistrust by analysing the atmosphere of mistrust to study how people made sense of the response through slogans such as ‘Ebola is a business’. The concept of the atmosphere does not suggest that mistrust is baseless, but rather points to the fact that trust and mistrust can involve generalised assumptions about others’ behaviour without having complete information about their intentions, as Georg Simmel (2009) argued in his classic work on trust. As he wrote, ‘someone who knows all need not trust, someone who knows nothing cannot reasonably trust at all’ (Simmel 2009, p. 315). This definition of trust has been explored in important ways by scholars like Anthony Giddens (1990) and Niklas Luhmann (2017), who suggest that trust and mistrust allow actors to manage contingency or to reduce social complexity emanating from contingent social interactions. According to these explorations, trust and mistrust enable collective action under conditions of insufficient information, or when the monitoring of actions is neither feasible nor possible (Mühlfried, 2017; Sztompka, 1999).

An interesting thread that runs through these scholarly works is the observation that trust and mistrust have the tendency to reinforce themselves in moments when complexity or contingency is confronted (Luhmann, 2017, p. 74). Trust and mistrust work like filters. They draw attention to ‘proofs’ showing that trust or mistrust were justified (Luhmann, 2017, p. 74). Experiences that challenge mistrust (or trust) tend to be neglected. Once trust shifts to mistrust, there is often little space left for interactions that allow trust to be recuperated. This self-reinforcing dynamic of mistrust also makes it difficult to determine precisely when a seemingly ordinary situation shifts towards one filled with anger, suspicion, and mistrust. These insights echo our own findings. One of our interlocutors from the Ebola response captured this experience of mistrust by underlining how a ‘small’ mistake, for instance during a safe and dignified burial, could turn an entire situation around. This perspective suggests that a key challenge for public health emergency responses is not only the lack of trust per se but how mistrust pervades a situation and can extrapolate itself.

In the sections that follow, we first describe the background and the methods of our field research conducted in Eastern DRC. Secondly, we examine how mistrust was voiced by the pronouncement that ‘Ebola is a business’. We show that this slogan attached the interpretation of the public health emergency response to specific observations, such as the WHO using expensive vehicles, which interviewees quoted frequently to explain mistrust.

Thirdly, our discussion explores the mobilisation of mistrust. Claiming ‘Ebola is a business’ speaks back to the structures of discrimination produced by the response. Furthermore, it shows how an atmosphere of mistrust creates a shared perception of boundaries demarcating the ‘response’ from the ‘community’. The concluding remarks summarise the important clarifications offered by our analysis of the atmosphere of mistrust in DRC’s tenth Ebola epidemic, a particularly useful frame for moving beyond assumptions that mistrust is tied to factors such as traditional beliefs, insecurity, and poverty. Such explanations ignore the reproduction of these factors by the actions of the response itself. The slogan ‘Ebola is a business’ constitutes a useful point of departure to focus on voices that are typically missing in public health representations of insecurity, mistrust, and the history of this Ebola epidemic.

Background of the study

The tenth Ebola epidemic was officially declared on 1 August 2018, only a few days after the ninth Ebola epidemic in Equateur province in Western DRC had been declared over. National and international health organisations quickly redeployed personnel, equipment, and infrastructure to Eastern DRC. When we started our research project ‘Humanisation of the Design of the Ebola response in Eastern DRC’ a year later, the response comprised more than 70 organisations, including government and UN agencies, humanitarian relief organisations, and national and international NGOs (WHO, 2019b, p. 35). At this point, multilateral and bilateral aid for the response stood at 160 million USD. It is estimated that in total between 500 million and 1 billion USD went into the response to the tenth Ebola epidemic (Crawford et al., 2021).

Unlike the previous outbreak in the West of the country, the tenth Ebola epidemic in Eastern DRC emerged in a region affected by protracted conflict. Responders stressed that an Ebola response was for the first time operating in a context of insecurity (WHO, 2019b). This account of insecurity corresponded with the employment of security forces to protect responders against the threats of armed conflict, but equally against communities who were perceived to resist the response. The official account of insecurity dominating the response blatantly ignored that communities and responders were differently positioned in the history of conflict in the region. Security forces protected the response on the one hand, while on the other failing to protect the communities against brutal rebel attacks, as informants repeatedly complained. According to Vinh-Kim Nguyen (2019, p. 1299; see also Crawford et al., 2021), the overt use of force, justified by official accounts of insecurity, thus raised suspicion, and trust could not be gained. These official representations of insecurity underline that the voices of Congolese people are missing in humanitarian discourses about diseases and violence (Hunt, 2008). Thus, our research aimed to give voice to local community members and fill in what was missing from official representations of mistrust that responders provided.

Methods

This paper is based on in-depth interviews, focus group discussions, and observational methods (passive and participant observation) conducted between July and November 2019 by four Congolese field researchers from Beni, Butembo, and Goma (DRC) and the two principal investigators of the project (DRC, Germany). Our main research site was the city of Beni in North Kivu, which was one of the epicentres of the epidemic at the time of our research. We also conducted field research in Kayna and Mangina in North Kivu province and in Mandima in Ituri province to include sites with lower transmission rates.

We conducted 68 open and semi-structured interviews. In addition, 28 focus group discussions with 181 participants were carried out. In total, we included 249 people into our research of which 161 were men and 88 were women (see Table 1). The age of our interview partner ranged from eighteen to eighty. Interviews were conducted in French or Swahili. In each interview field researchers asked for oral consent, which was then recorded. Predefined topic guides were used for semi-structured interviews and focus group discussions, but researchers iteratively probed into the answers and asked additional questions when new topics of interest emerged. The researchers in the field observed elementary precaution measures to protect their interview partners and themselves (vaccination, physical distancing, hand hygiene, and avoiding unprotected contact). The interviews were transcribed and translated into French in the process of transcription.

Table 1. Overview of interviews and focus group discussions.

Actors	Number of interview partners
	Interview	Focus Group Discussion
Survivors	2	9
Relatives of victims	0	20
Community members	10	26
Member of youth groups	0	25
Health workers	17	32
Community sensitizers (relais communautaire)	0	15
Members of the response	14	24
Traditional healers	2	0
Religious leaders	9	0
Journalists	0	10
Dignitaries	3	0
Local authorities	10	20
Members of armed groups	1	0
	68	181
Total		249

Our project employed a grounded theory approach to connect systematic data collection with an openness for engaging a broad range of actors, problems, and discourses. Following a grounded theory approach, we employed theoretical sampling (Clarke, 2015; Glaser & Strauss, 1967). In contrast to other forms of sampling (purposive or random), theoretical sampling determines interview partners iteratively according to the theoretical relevance of their contribution for the studied research questions. To determine the theoretical relevance, we continuously analysed the accounts provided by our informants. Based on this analysis we identified the next group of actors to be interviewed and the next group of questions to be asked. We began with a series of open-ended interviews with survivors and community members to explore the challenges of the Ebola response. As our first interviews gravitated around the explanation that Ebola is a business, we continued our research by identifying actors who could provide additional clarifications of this concept or provide alternative perspectives on the challenges of the Ebola response. We interviewed volunteers, community leaders, members of civil society organisations, local politicians, government officials, and responders employed by the Congolese government, NGOs, and UN agencies (see Table 1).

We used the software Nvivo 11 to code the data for our analysis of the slogan ‘Ebola is a business’. We used the codes like ‘strangers’, ‘business’, ‘lack of respect’, ‘mistrust’, ‘resistance’ to analyze the slogan. Data collection and data analysis with Nvivo 11 was refined during a midterm data analysis workshop in Goma, in which field researchers and three international research partners collaboratively reviewed and discussed the analysis of data. Based on this midterm data analysis workshop we identified additional actors and refined our research questions for a second data collection phase to saturate the analysis. The entire research team, including the field researchers, met for a final data analysis workshop in Berlin. The project received ethical clearance from Oxford University and authorisation from the Ministry of Health of the DRC.

Atmospheres and mistrust: an analytical approach for studying mistrust

In our research, our interview partners frequently explained the resistance toward the Ebola response in Eastern DRC with the slogan that ‘Ebola is a business’. As a local leader in Beni, asked about the meaning of ‘Ebola is a business’, remonstrated:

It’s not the population, there are some actors in the response who are misbehaving. We have the impression that they don’t want the disease to be eradicated, because they make a lot of money.

Similar claims were made during previous Ebola outbreaks. During the West African Ebola epidemic (2016–18), Abdoulaye Somparé and Ester Somparé (Somparé & Somparé, 2017, p. 134) noted that villagers in Guinea accused the response teams of profiting from donor aid money and described the ‘cold, tense atmosphere’ they encountered in the field (Somparé & Somparé, 2017, p. 130). Somparé and Somparé’s elaborations of the atmosphere of mistrust show that it cannot be reduced to a single cause but resonates with a general feeling towards the political elite and the state. As Shepler (2017) stresses, mistrust of the state in the Ebola response in Sierra Leone was premised upon expectations of how donor aid works normally in the country (Shepler, 2017). Mistrust is present in everyday conversation about the informality of the state as much as the state is absent when people ask for it. To borrow from Shepler (2017, p. 460), the meaning of ‘Ebola is a business’ is both obvious and vague, just as the state is both a ‘shadow’ and real.

In this regard, ‘atmosphere’ usefully captures the omnipresence and ambiguity of mistrust in the phrase ‘Ebola is a business’. The terms ‘climate’ (Luhmann, 2017, p. 46) and ‘atmosphere’ (Misztal, 2013, p. 115) have been used before to capture the diffuse origins of mistrust. Focusing on the citing and reciting of slogans such as ‘Ebola is a business’ illuminates how atmospheres ‘move people beyond the metaphorical’ (Eisenlohr, 2018, p. 38). Slogans like ‘Ebola is a business’ are ambiguous such that ‘everyone who intones it can endow it with its own meaning’, as Hirschman put it (Hirschman, 1993, p. 199).

For example, when asked to elaborate on why Ebola should be seen as a business, a pastor explained to us:

Someone who used to be a teacher in the parish, who is now making $200 a day [by working for the response], can they wish that the disease could be eradicated?

Responders were of course not necessarily intentionally prolonging the epidemic, and our interview partners did not explicitly accuse specific actors of dragging it out (the teacher is an example, suggesting that it could be anyone). The conclusion that the prolonged epidemic enabled responders to keep on profiting from donor aid is implicit in the rhetorical question ‘can they wish that the disease could be eradicated?’

To borrow from Susan Reynolds Whyte, slogans reflect a ‘way of talking’ that is ‘ironic and catchy – revealing’ (Whyte, 2008, p. 97, our emphasis). The catchy phrases we picked up reveal the sentiment that donor aid corrupted the Ebola response. Mistrust powerfully draws observations – for example, of payment exchanging hands or a number of donor-sponsored vehicles – that work together towards the conclusion that Ebola is a business.

The phrase was also used to explain seemingly exaggerated interventions. ‘It was enough for a single case to be announced […] for them to go with 15 Jeeps at the same time’, a respondent claimed. Such accounts were embellished with ironic utterances, such as ‘Merci Ebola!’ (thank you, Ebola!) when WHO vehicles appeared. ‘Ebola as a business’ would also apply to cases where grieving family members were allegedly bribed to declare Ebola-related deaths, as the appearance of the epidemic not being under control would ensure the continued inflow of donor aid. Our informants deplored the inflation of deaths as well as the real increase of deaths by saying it was as if donor agencies were rewarding poor performance. They opposed this strategy in terms reminiscent of Bayart’s (1993) notion of ‘extraversion’, pointing that it should be exactly the opposite: ‘the more deaths, the less funds!’

Such stories drum up the attention of the international media. A series of journalistic investigations published by the New Humanitarian revealed for example how the WHO rented vehicles at an inflated price from its own employees (Freudenthal, 2020).² These reports confirm the extraordinary scale of corruption in the Ebola response, which led, in part, to mistrust and resistance. To fully understand the mistrust our interview partners expressed, we need to ask more specifically what caused a general mistrust towards the state to turn into resistance against the Ebola response. In other words, instead of attributing mistrust exclusively to corruption, we need to ask how extraversion and other experiences of the state accumulated over time and an atmosphere of ‘business as usual’ turned into one of mistrust epitomised by the words ‘Ebola is a business’.

A word on money

From the interviews and our observations, it emerged that the response was not mistrusted from the beginning. The slogan ‘Ebola is a business’ arose as international and Congolese health workers arrived in scores in Eastern DRC to work for the Ministry of Health, the WHO, and other international organisations stemming the response. The inhabitants of North Kivu and Ituri wondered why the response was not hiring people locally. According to our interlocutors, the recruitment of people from elsewhere could not be justified by the lack of expertise in Eastern DRC. Not only were experts hired for the response but also drivers, some of them sent from Kinshasa apparently. Anyone could work as a driver, our respondents answered sarcastically. When people from Kinshasa were appointed, a cook could become a hygienist, a plumber a community mobiliser, the daughter of the Minister of Health could work as a communication officer. These observations fortified the conviction that ‘Ebola is a business’:

When we understood that all the experts who came from Kinshasa [were] recruited by the minister’s entourage, [and] wanted to make a fortune behind our backs. […] So, everyone understood that it is a business because to bring in a national workforce (from Kinshasa) requires a large budget (community health worker, Beni).

Other interview partners vehemently expressed their indignation over the exclusion of local communities: ‘We have nurses and doctors whom we know well here at home and who treat well. Where are they? They send us young girls who are friends of these people without any medical training’.

In addition, our interlocutors complained about the discrepancies in payment between non-local and local staff. For example, a doctor explained:

Local doctors are paid $20 per day (nurses $15, and cleaners $10), doing a relatively high-risk job, while nurses from Kinshasa, working in vaccination, doing a less risky job, receive $90 per day. Equally qualified doctors from Kinshasa receive $150 per day. Even when we were sent to Mangina [outside Beni], the doctor from Kinshasa received $150 per day, and we had only $4 per day, yet our jobs involve the same risks (medical doctor, Beni).

Discrepancies in salaries and per diems reflected the politics of recruitment in the eyes of our interlocutors. Salaries lacked any basis in merit or any relationship to the work that people did, they complained. There was enough local expertise, and there was no way the discrepancies in payment could be justified:

[S]o-called experts who do not know their work, who do not know how to communicate with patients … In the field it is still us who have to show them how to do this or that. The recruitment was bad. You integrate someone in a team only because it is the child of an uncle or an aunt who has no experience in the matter, just that he can benefit from the salary. […] We are recruiting agronomists, veterinarians who know nothing about the work of doctors or nurses. (medical doctor, Beni)

The conclusion drawn was twofold: that the recruitment process was far from objective, and that the inequality resulted in humiliation of the local people involved in the response. This humiliation, as our interview partners explained, was quite graphically depicted by sayings such as, ‘for you the work, for us the money’.

Strangers

The previous section suggested that the slogan ‘Ebola is a business’ emerged around the state excluding local communities from the response. According to Michèle Lamont (2017, p. 421), structures of exclusion and discrimination intertwine to produce material inequalities and reproduce ‘disparities of worth’. Lamont et al. (2016) stress the importance of attending to the ways discrimination is experienced and articulated as humiliation and denigration (see also Park, 2017; Shepler, 2017). In contrast to material inequalities, humiliation constitutes a form of ‘micro-aggression’, which is difficult to measure (Lamont et al., 2016, p. 7).

An interlocutor explained:

Ebola is a business here in Beni, and not a disease; the people attached to it came to make money; it is a disease that they invented to enrich themselves. They will never want to see it end, which is why even the unaffected cases are always declared positive. They seek to inflate the number of patients to raise more money to spend excessively in front of our eyes (local authority).

The conspicuous consumption implied with the statement that money was spent ‘excessively in front of our eyes’ seems to hint at humiliation experienced by the local authority. Perhaps because humiliation manifests as ‘intrapsychic [as] the result of neglect’ (Lamont et al., 2016, p. 7), it is a challenge to observe. Another informant described how:

They had a lot of phones, they wore badges, bought a lot of beers, and therefore used a lot of money in the drinking establishments; they spoke in a strange language, shouted loudly, and made a lot of noise. They automatically stood out. (local authority, Beni)

This description of the ostentatious brandishing of phones and other symbols of bureaucratic power might appear exaggerated, but in light of other experiences of the response, including discriminatory recruitment practices and payment inequalities, the atmosphere of anger and humiliation is palpable, substantiating the conviction that the response cannot be trusted. As an interview partner asked, ‘how can you believe the response teams?’

What these disparities of worth do is that they draw a boundary between ‘us’ and ‘them’ (Lamont, 2017), which in fact ran through most of the accounts explaining the meaning of the slogan that ‘Ebola is a business’. Our interlocutors described those sent from elsewhere to work in the response as ‘strangers’ (étrangers). What struck our informants was that many came from other parts of the DRC yet did not speak the local languages such as Swahili or Kinande. As one interlocutor remarked, ‘It is inconceivable to bring a chief from Kasai [central DRC] who knows neither Swahili, nor French, to come and sensitise the population of Beni’.

It was not only the language spoken that provoked mistrust and resistance. What equally mattered was how they addressed the local population:

The first sensitisers were people from Kinshasa, arrogant people who spoke only Lingala (female vendor, Beni).

The distinction between strangers and locals echoes the growth of discourses of belonging in African countries and elsewhere (Geschiere, 2009). A recent phenomenon in Eastern DRC, the distinction between locals and strangers is ultimately a vague one, expressed in ‘rumors, political tracts, and speeches and draws its energy from imprecise overlaps with other powerful, preexisting identity polarities at particular scales of identity and difference: local, provincial, national, regional’ (Jackson, 2006, p. 99). In fact, as one of our interview partners explained:

Strangers have come here to take jobs, and this is what is at the root of the resistance. But this aspect may depict the local population in a wrong way. […] The population is in general not tribalistic. The population was welcoming the response at the beginning. What is annoying is when they arrive here and the first thing they do is to dismiss the local community (journalist, Beni).

To borrow from Stephen Jackson (2006, p. 100), it is precisely the ‘slipperiness between different scales of meaning’ that gives meaning to the concept of ‘strangers’ by creating new boundaries between ‘us’ and ‘them’. For example, an interview partner explained:

They were so proud and said that they were the only ones who knew how to treat the Ebola virus disease. They spoke strong words in front of the patients, which traumatised them (health worker, Kanzuli).

As with an atmosphere of mistrust, the category of ‘strangers’ lacks a clear historical or cultural origin. Like the slogan that ‘Ebola is a business’, the idea of the stranger was built around selective observations and experiences that ‘proved’ that the response, which relied so heavily on strangers, should be mistrusted.

The atmosphere of mistrust might at face value be considered as an element of what public health research conventionally describe as the ‘context’ of an epidemic. By contrast, the above-mentioned accounts suggest that an atmosphere of mistrust exceeds contextual factors because it also involves ongoing processes, interactions and experiences and comes to shape how a range of contextual factors, such as material inequalities, are interpreted as a humiliating assault on worth. Furthermore, the commodification of Ebola reflects that mistrust also constitutes rhetorical questions and ironic, sarcastic, and hyperbolic utterances. Our analysis reveals that the mistrust was not based on incorrect and inadequate information but on actions of the response that confirmed and reinforced negative expectations of donor aid.

The voice of having no voice

In this paper we explored the atmosphere of mistrust in the tenth Ebola epidemic in Eastern DRC. Our aim is to contribute to the scholarship on Ebola epidemics seeking to understand how mistrust divides responders and the communities they ought to protect. Our analysis of the commodification of Ebola provides crucial insights for building trust in responses to Ebola. The slogan ‘Ebola is a business’ illuminates how donor aid turned the disease into a resource of extraversion and prevented the development of trust relationship between responders and communities. Strengthening community engagement, participation, and communication, frequently suggested in public health discourses on trust, remains ineffective when public health emergency responses lack accountability or even inflict harm. An immediate implication of our analysis is that trust requires a transformation of the architecture of public health emergency responses.

In addition, our study of mistrust aims not only to recommend ways to prevent mistrust from emerging but also aims to offer a theoretical perspective to study how experiences of epidemics and pandemics can be shaped by suspicion, anger, and mistrust. The mistrust of the response to the Covid-19 pandemic, in particular, highlights the importance of revisiting the conceptual aims of studying mistrust. In this way, we can build trust in responses to future epidemics or pandemics.

Our paper uses the atmosphere of mistrust to go beyond reducing mistrust to ignorance or the rejection of scientific facts. As our analysis suggests, mistrust was a reaction to the politics of extraversion more than to science. Moreover, our exploration of the citing and reciting of the slogan ‘Ebola is a business’ to voice mistrust highlights the blatant absence of Congolese voices from official accounts of the response to the disease. In this respect, claims about the commodification of Ebola can be seen as speaking back against historically produced structures of extraversion (Richardson, 2019; see also Weidman, 2014).

In examining the decline of organisations and states, Hirschman (1993, p. 175; Hirschman, 1970). proposes ‘voice’ and ‘exit’ as two opposed answers to perceived ‘deterioration in the quality of services and benefits [people] receive’. For Hirschman, exit is the act of simply leaving an organisation or a country. By contrast, voice means to raise an alert and protest. The important point is that voice aims to achieve an improvement, a correction. Hirschman’s analysis of political slogans concludes that voice is more costly than exit strategies as voice requires group action. Vague and ambiguous slogans such as ‘Ebola is a business’ are particularly effective for mobilisation, as ‘everyone who intones it can endow it with her or his own meaning’ (Hirschman, 1993, p. 199). Moreover, slogans allow those who are voiceless because of their exclusion to claim a voice.

Through our exploration of the atmosphere of mistrust, we examined how the slogan ‘Ebola is a business’ governed the collectively recognised interpretation of the response, leading to and moreover continuously confirming the conclusion that the response cannot be trusted. Responders discriminated against, degraded, and even abused the people of the Eastern DRC – revealing a dramatic lack of accountability and responsibility on the part of government and UN agencies, as well as international health organisations.

The concept of an atmosphere of mistrust invited a consideration of this Ebola outbreak, and the public health responses, as a distinct and unique historical event. Usually, when public health emergency responses fail, we ask what can be learnt from past epidemics, including the intervention. This approach obscures the question ‘What histories does the Ebola epidemic ask for?’ (Lachenal, 2015, as in Benton & Dionne, 2015, p. 231). An exploration of the atmosphere of mistrust seeks to understand how mistrust came to govern the epidemic in unique and distinct ways. Such a history of Ebola holds crucial lessons. It reminds us that people in North Kivu will not remember the Ebola response as described by international health organisations. They will not remember it as ‘true collaboration’ or ‘one of the fastest and best equipped’ in the history of Ebola (WHO, 2019b p. 4, 8). Rather, they will recall the slogans they cited and recited to articulate mistrust and mobilise resistance against a response that turned a fatal disease into a resource of extraversion.

The atmosphere associated with the tenth Ebola epidemic powerfully shapes the expectations of public health emergency responses to future epidemics and pandemics. The Covid-19 pandemic, which started as the tenth Ebola outbreak in the DRC ended, has also been branded as ‘a business’. However, in order to explore the continuities of mistrust we need to understand how people relate their experiences of the Covid-19 response to distinct experiences of the structures of extraversion in the tenth Ebola epidemic. This perspective underlines that we need to employ registers of reflexivity – historical and critical reflexivity – in analysing what went wrong in past epidemics and moreover encourage the production of histories of Ebola epidemics that can engender effective collaborations between responders and communities.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was funded by Elhra’s Research for Health in Humanitarian Crisis (R2HC) under Grant number 43679; R2HC is funded by DFID, Wellcome, NIHR.

Notes

1. We understand ‘Ebola is a business’ as a political slogan. Throughout this paper we refer to authors, most notably Albert Hirschman, to refine our analysis of slogans as a vocal practice through which speakers produce and reproduce collectively recognised meanings.

2. A subsequent journalistic article unveiled sexual violence inflicted on a large scale and both women and men by employees of international health organisations such as the WHO. We did not follow these allegations during our field research because of ethical considerations. At the point of writing this article, the WHO had launched an official investigation, which resulted in a report that confirmed allegations of sexual abuse (WHO, 2022).