The Politics of Fear, edited by Michiel Hofman and Sokhieng Au, draws on internal documents from Médecins Sans Frontières (MSF; Doctors Without Borders) to provide an in-depth and often critical review of the organization’s response to the Ebola outbreak in the spring and summer of 2014. Contributors to the book include MSF employees who were on the ground in West Africa treating patients with Ebola, health policy experts, and other academics whose fieldwork is directly relevant to the Ebola outbreak. The analysis is necessarily qualitative in nature, drawing heavily from anecdotes and physicians’ notes taken during the crisis as well as providing more extensive analysis that puts the outbreak in historical context. While the book obviously centers on health policy, there are broader implications for the study of organizational culture, bureaucratic responsiveness, and accountability between public and private partnerships. The contributions represent both a self-assessment by MSF staff of its response to the outbreak and a proscriptive analysis of how to deal with future outbreaks, including organizational challenges that must be addressed prior to such events.

The book is organized around the themes of “The Response,” “The System,” “Patients,” and “Containment,” but an overarching theme could be “How fear derails good policy intentions” or simply “Fear leads to irrational policy.” The notion that fear affects our attitudes and behavior is not new. Indeed, research from Paul Nail and colleagues has shown that the invocation of fear or (imagining one’s own death) can lead otherwise “liberal” people to hold more conservative views (Nail et al., Reference Nail, McGregor, Drinkwater, Steele and Thompson2009). Similarly, in a new book, How America Lost Its Mind, Tom Patterson writes of our well-documented inability to reason objectively in high-anxiety situations (Patterson, Reference Patterson2019, pp. 8–9). In the case of the response to the Ebola outbreak, the fear of an uncontrollable pandemic led to often short-sighted responses. Standard operating procedures were either ignored, modified, abbreviated, or, when conflict or uncertainty arose, too slow to adapt to circumstances on the ground. The documents and observations presented throughout this volume suggest the inefficiency and irrationality of the response by MSF was immediate, widespread, and lasted throughout the epidemic.

The book begins with two chapters by João Nunes and Adia Benton on the “securitization” of the response to the Ebola outbreak. Early on, MSF, the World Health Organization (WHO), and the international community struggled to adapt and understand the severity of the unfolding crisis. In the face of fear, rationality is often abandoned, and with the response to the Ebola outbreak, this manifested in what Nunes and Benton suggest was a hurried and not well-articulated military presence. As Nunes writes, “The dread of disease is never just about a specific disease; it is also about the political fate of a society” (p. 7). The military presence, because it invoked long-held fears and negative memories of conflict, often with government, led to several unintended consequences. Most notable, and most damaging from the perspective of maintaining and stopping the epidemic, was the widespread perception among citizens of infected countries that external entities such as MSF and the WHO were there to do more harm than good. As Jean-Francois Caremel, Sylvain Faye, and Ramatou Ouedraogo discuss in Chapter 3, citizens were reluctant to seek treatment from “outsiders,” allowing the disease to spread more quickly and further than was necessary. Tellingly, these authors, and others throughout the book, recount instances of citizens thinking MSF and the WHO were secretly infecting people for nefarious purposes and, as such, were reluctant to change their behavior surrounding certain rituals, such as those relating to funerals. Because the MSF failed (as is suggested) to adequately explain their presence, citizens were reluctant to listen.

On a more general level, the role of MSF in the Ebola outbreak speaks to the long-running debate in public administration about how best to preserve accountability when dealing with a mix of governmental and nongovernmental actors, all of whom share the same goal. In the introduction, the editors speak to this directly, writing, “Global health governance needs to be more inclusive but also more transparent” (p. xx). Jonathan Koppell’s work on “global governance,” notably his book, World Rule: Accountability, Legitimacy, and the Design of Global Governance (2010), provides some guidance here. MSF operates outside of government regulation but that does not remove it, or the WHO, from questions concerning issues of accountability. Particularly in the case of the Ebola epidemic, to what extent should MSF be held accountable for the extent of the outbreak, the timeliness of their response, intrusion on local norms and cultures, and missteps that may have contributed to the spread of the disease? Commenting on the need to restore and rethink “order” in the world, Richard Haass, in his book A World in Disarray, writes that, when it comes to responding health crises,

Such collaborations, while necessary, also inevitably lead to more complex questions about who is accountable for what and to whom, and what outcomes should be used to measure accountability.

As documented throughout this edited volume, the conversations between governments, between governments and the WHO, and between MSF and these other actors were often inconsistent, lacking in direction, and played out on a timeline that was unable to keep pace with the spread of the disease. Case in point here are the three poignant vignettes in the book detailing individual stories of suffering and death from Ebola as well as Tim O’Dempsey’s chapter on the death of Dr. Sheik Humarr Khan, one of the most prominent physicians in Sierra Leone at the time. As O’Dempsey’s chapter makes clear, the response from the international community, including MSF but also most notably the WHO, was disjointed at best. Questions over whether Dr. Khan should be given an “experimental intervention” or be evacuated from the country (given his status) paralyzed the WHO such that neither option was implemented. Indeed, on the question of evacuation policies, O’Dempsey’s chapter and Duncan McLean’s final chapter offer important lessons on the limits of public and private partnerships when unanticipated and threatening circumstances arise.

In sum, this is a book that is suitable for a variety of audiences and subdisciplines. The methodological approach is suitable for upper-division undergraduate courses in public policy (certainly health policy) and public administration, and the content is such that graduate students in these fields would also benefit. We expect health professionals to respond professionally and rationally to health crises, but as the chapters in this volume demonstrate, in the case of the most recent and serious epidemic, that was not always the case, and not always the fault of these actors. Miscommunication and unclear procedures hampered the response and ability of governmental and nongovernmental actors to coordinate their response to the most serious threat facing a citizenry. Perhaps what is most important to remember is that those on the front lines were putting their lives at risk on a minute-by-minute basis and acting within the constraints imposed by themselves and others (both governmental and nongovernmental). For current and future policy practitioners, this book ultimately provides good food for thought concerning issues of accountability, transparency, and the importance of relationships between nongovernmental and governmental actors in times of crises.