In a recent response to questions about the role of the war and the attacks on foreign health workers, I wrote:

…. if war has changed anything, the incredible influx of humanitarian interventions and aid workers during the war and its immediate aftermath — where outsiders and their local cronies seemed to benefit openly from others’ suffering — has also engendered suspicion that has helped fuel the backlash against local and international health workers.

Here, I am expanding on this claim, which is intended to complement Susan Shepler’s piece about mistrust of the ‘vampire state’.

When I first traveled to Sierra Leone in 2003, I was a research consultant working with an international NGO. While it was not my first time consulting to NGOs in Africa, it was my first time working in a certified post-conflict zone. Peacekeeping forces were still very visible and present. Expatriate security was often a topic of official conversation. The free movements of outsiders, particularly whites and Westerners, but also expatriates from ‘developing’ countries, shed light on the kinds of hierarchies that lie at the core of humanitarian enterprise. Their unfettered mobility in the form of NGO sports utility vehicles, easily secured travel visas, and financial resources did not go unnoticed.

Disparities in mobility between aid workers and locals were brought to the fore whenever someone asked me about getting visa sponsorship, or asylum in Europe or the US, or when anyone commented about the short duration of my several months’ (initial) stay in Sierra Leone. Humanitarian mobility and the ease, scale and direction of humanitarian movement reflected a hierarchy of risk and protection, in which local populations’ protection — presumably the reason for humanitarian aid in the first place — is secondary to the protection of humanitarian aid workers. This is not a new concern for anthropologists of humanitarianism.

So when I wrote about mistrust of the humanitarian aid industry, I was focusing primarily on the mistrust of the institutions and individuals who represent them — not the sorely needed aid they provide. Far too many mainstream journalists have come to conflate suspicion of foreign health workers with mistrust of Western medicine. While Ebola may impact how and whether people seek care at government health facilities, people are willing to seek biomedical treatment, especially if qualified health personnel provide them in well-stocked facilities and at a cost they can afford. Many communities eagerly accept highly skilled and specialized international service providers, like MSF; such organizations usually deliver health care in a way that people appreciate.

Yet it is important to note that the coordinated international response that one should expect in an outbreak of Ebola, much like that during the wars in the region, came late and was poorly organized. The national health systems tasked with containing the outbreak are under-resourced and ill-prepared for an epidemic of this magnitude. The characteristics of the disease, communities’ lack of experience with it, and limited health workforce, clearly shape their reactions to institutional responses to the outbreak.

It does not help, either, that in this particular crisis, the differential valuing of local versus foreign lives is brought into sharp relief. When a previously unseen disease like Ebola makes its appearance and foreign health workers and all their brethren in the development and international aid community are immediately evacuated for their protection, questions of their motivations, commitments and sincerity about providing relief inevitably surface: where are the “helpers” when the going gets tough? While US media have primarily focused on international health workers’ efforts to combat the disease, national health workers and volunteers have been putting their lives on the line to contain the virus and to care for sick patients. Others abandon have abandoned their posts when faced with the possibility of death.

Through the efforts of powerful local advocates and members of the diaspora, medical supplies are now coming in from all over. When it comes to foreign workers, however, a double standard persists in which protection for health workers is not created equal: a Congolese nurse dies in Liberia, but a Spanish one working for the same mission must not be allowed to languish in the same way; a prominent Sierra Leonean physician and virologist dies — is even denied the opportunity for an experimental therapy– but Americans are flown to Atlanta and given that same experimental therapy.

The humanitarian and development industries, despite operating under different temporal orders (emergency and long-term social change, respectively), are still largely characterized by a kind of ephemerality and mobility. Development-oriented organizations may maintain a long-term presence, but health and development priorities change as political will changes. Expatriate staff move in and out of place, because remaining in place too long often hinders their upward mobility.

Humanitarian emergency relief is just that; in times of crisis, it provides some respite but no cures. In protracted crises like those in the region now affected by Ebola, expatriate staff with long-term contracts receives ample recuperation breaks to decompress from the stress 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. Evacuations of Westerners are seen as necessary, while those who abandon their posts in the absence of protection are seen as pariahs.

As I have written elsewhere, when we hear about mistrust, suspicion and fear amongst the communities affected, it is about the curious appearance of the disease and its severity; it is embedded in a wider history of suspicion of certain institutions — humanitarian and governmental ones among them– and what motivates the work that they do; and it is rooted in a wider history in which charity and aid appear to enrich some while leaving others high and dry.

Adia Benton, Assistant Professor, Department of Anthropology, Brown University, USA. Public health scholar, anthropologist and author of HIV Exceptionalism: Development through Disease in Sierra Leone (University of Minnesota Press 2015).