Fear,duty and the moralities of care: The Ebola 2014 threat

Ebola as a biophysical entity

The Ebola viruses are members of the family Filoviridae, and cause outbreaks of viral haemorrhagic fever, with fatality rates of up to 90% ² within 6–16 days of the onset of symptoms in the worst hit regions (Rougeron et al., 2015; WER, 2014). Ebola haemorrhagic fever was first described in 1976 after two outbreaks in the Sudan and the Democratic Republic of Congo. For the first 20 years after the initial identification of Ebola, only three outbreaks were documented, but there has been a substantial increase in reported outbreak frequency over the last two decades with 20 further outbreaks identified (Rougeron et al., 2015). Ebola outbreaks prior to 2014 have mainly occurred in remote areas of central Africa, with the 2014 outbreak the largest in history. There is currently no disease-specific treatment other than supportive care, nor vaccines approved for use at the time of writing (WER, 2014). Relative ease of transmission, elaborate personal protective equipment required and high mortality rates have resulted in Ebola being a particularly fear-inducing prospect for health professionals (cf. Hewlett and Hewlett, 2005).

The 2014 outbreak

The 2014 Ebola outbreak in fact started in December 2013, when a 2-year-old child died in the village of Meliandou (Gatherer, 2014). Ebola then spread throughout Gueckedou (southern Guinea) by March 2014, penetrating the borders of Guinea, Liberia and Sierra Leone, resulting in 24,701 infections and 10,194 deaths (a case fatality rate purported to be around 41%). At the time of writing there remains ongoing transmission in Guinea and Sierra Leone. There has been a substantial impact on healthcare workers in these extremely resource-poor settings (see Chan, 2014), with 881 infections in healthcare workers resulting in 512 deaths (CDC, 2015). Over the course of the pandemic, Ebola spread through international travel to Mali, Nigeria, Senegal, the United States, the United Kingdom and Spain. Secondary spread to healthcare workers occurred in the United States, producing a significant and sustained international response (McCarthy, 2014; WER, 2014).

Globalising risks and a ‘climate of fear’

It is important to consider the sociocultural context within which we embark on this analysis of the Ebola threat. Scholars have argued that, globally we have entered a ‘climate of fear’ (Altheide, 2006), cascading ‘ontological insecurity’ (Giddens, 1991) or preoccupation with ‘global anticipated uncertainties’ (Beck, 1992; see also Figuié, 2013). These scholars argue that the advance of globalisation has had both negative and positive consequences: the unravelling of certainty about one’s place in the world has allowed increased freedom of identity, yet these freedoms are unevenly distributed, and often entail greater sense of risk for the individual (Beck and Beck-Gernsheim, 2002). Alongside this process, the difficulty of defining risk creates tension and lack of trust between individuals and social institutions, perpetuated, arguably, by the plethora of global economic, environmental, security and health crises of recent years (Bauman, 2006). This body of scholarly work has emphasised the proliferation of entrenched relations of risk in the current (globalised) social context.

Such dynamics have led to a recent emphasis on cosmopolitics – the political response to an increasingly cosmopolitan world (Cheah and Robbins, 1998). Cosmopolitics is both embodied and situated, recognising the multiple outcomes of this process and the subjective responses produced. While processes of globalisation may have increased connections across space and time, increased individual risks have arguably perpetuated views of ‘the other’ as both a threat and a spectacle (Chouliaraki, 2013). Such social relations inflect experiences of, and responses to, infectious diseases outbreaks in important but often subtle ways (cf. Furedi, 2005; Giddens, 1991; Ungar, 2001).

An important recognition is that risks like Ebola have constructed elements (Beck, 2009; Figuié, 2013) and are prone to practices of dramatisation, minimisation, transformation and even denial (Beck, 2009: 30). In this sense, the 2014 Ebola threat is a complex assemblage of histories, economies and current forms of (global) social order, and emerges from the existing cultural milieu of uncertainty and mistrust in authority. There are also some important specificities to Ebola, including the instability of scientific knowledge regarding its management, engendering a heightened sense of dread in the context of perceived or actual cascading global insecurity.

Another consideration here is the cosmopolitics of infectious diseases outbreaks (Schillmeier, 2008; see also Cheah and Robbins, 1998), and recognition that Ebola is assembled in line with an evolving mix of local and global risks, as well as political, economic, legal and ethical concerns. For example, Ebola 2014 raised duty of care issues in the context of globalising risks for health professionals. While localised expectations for duty to one’s national ‘community’ are well established, what constitutes an acceptable personal risk within transnational care can be unclear.

Such dynamics raise further anxieties around the risks of globalisation and emerging vulnerability of the nation state (Hoffman, 2013). This, as Schillmeier (2008) notes in relation to SARS, reflects a tendency toward the politicisation of risk and production of forms of anticipation, despite outbreaks not materialising in many contexts. This ‘induce[s] complex ways of acting in the present’ (Schillmeier, 2008: 180). These ways of acting in the present, as Muzzatti (2005) outlines, can draw upon past and present cultural myths of dangerous Others, producing phobic narratives (see Abeysinghe and White, 2011; Morris, 1998), including fear of being exposed to the ‘Other’, often placed alongside a fear of being excluded from the benefits of a steadily globalising world (Abeysinghe and White, 2011; Morris, 1998).

Another by-product of a cultural milieu of risk, fear and anxiety can be dismissiveness of the significance of threats such as Ebola. This may be emergent from mistrust in forms of authority and a subsequent questioning of how proportionate responses are to a particular global threat (Beck, 2009). This links to broader relations of public mistrust in the state or authorities in disaster management and their agendas in risk communication. Fear in the context of global infectious diseases outbreaks can be enmeshed in the enactment of power, including the utility of ‘negative expectations’ for authorities (Davis et al., 2014a; see also Nerlich and Halliday, 2007) – strategies that play to a wider dynamic of fear in society (Nerlich and Halliday, 2007; see also Gislason, 2013). As Davis and colleagues point out, while inducing fear provides some means of garnering consent for action, it may in turn encourage mistrust and cynicism (Davis et al., 2014a). We explore such dynamics with an emphasis on how relations of mistrust may influence health workers’ experiences of the potential for caring for someone with Ebola.

Positioning Australian healthcare workers: Duty within and across borders

Globalising threats such as Ebola present unique moral professional dilemmas, raising considerations around the value of human life, professional responsibilities and forms of duty across borders (Ehrenstein et al., 2006; Ruderman et al., 2006). Such moral dilemmas are neither consistently experienced across individuals nor professional groups. Historically there have also been gendered dimensions to care during outbreaks, where women were placed at much greater personal risk (e.g. Godderis and Rossiter, 2013). Moreover, duty of care is embedded in power relations, with an interplay between notions of citizens/non-citizens and professional duty (Schillmeier, 2008). That is, individual and group responsiveness to outbreaks expresses concern around political jurisdictions – including the global north versus south (Stephenson and Jamieson, 2009; Taylor, 2013). The question thus becomes duty to whom and, moreover, who among us should perform such tasks (Ehrenstein et al., 2006; Ruderman et al., 2006)? Hitherto the only research on frontline health professionals’ experiences of Ebola is that of Hewlett and Hewlett (2005), who interviewed nurses who worked in three earlier Ebola outbreaks. They found that nurses were hindered by a lack of resources and suffered intense stigmatisation in both the workplace and their communities.

For health professionals in Australia, however, the potential for an Ebola outbreak offers very different dilemmas as individuals and professionals. Ebola being ‘other’ – from elsewhere, and from the developing world – challenged existing structures of responsibility and inflected the forms of virtue emerging from the practice of exercising professional duty. In such contexts, as we shall see below, what is considered moral or ethical practice becomes contingent on broader perceptions of global versus local responsibilities. Experiences of outbreaks thus necessarily weave together relations of risk and insecurity, the dynamics of cosmopolitics, and an evolving duty of care.

With Ebola’s high mortality rate, ease of transmission to health workers, and the perceived futility of care, assumptions around acceptable professional risks and obligations related to duty became increasingly precarious during 2014. The question of who a risk should or could be taken for surfaced – an undefined ‘other’ versus duty to one’s own community (Cheah and Robbins, 1998; Elbe, 2009). We posit that health professionals’ experiences of this threat were enmeshed with global dispositions toward risk and security (Furedi, 2005; Gislason, 2013), expressing cultural desires, ambitions and discontents (cf. Stephenson and Jamieson, 2009). These include forms of transnational protectionism (Bhagwati, 1989), notions of relative human value, and negotiations around care of the (professional) self versus care of the Other (Ball and Olmedo, 2013; Rhodes, 1997).

Analysis

The methodology for this project draws on the interpretive traditions within qualitative research. The aim was to achieve a detailed understanding of the varying positions adhered to, and to locate these within a spectrum of broader underlying beliefs, agendas and life experiences. The approach to data collection was developmental in that knowledge generated in early interviews was challenged, compared with, and built upon by later insights and experiences. This method provided an opportunity to establish initial themes and then search for deviant or negative cases, complicating our observations and retaining the complexity of the data. We approached the analysis of the interviews thematically, systematically reading through each transcript several times, writing notes, discussing ideas with colleagues and noting emerging patterns within the data collected. Within this process, we continually sought to retain the richness of the respondents’ experiences, documenting atypical cases, conflicts, and contradictions within the data. Once we had identified a theme we would search through the interviews for other related comments, employing constant comparison to develop or complicate these themes further. This process helped ensure that events initially viewed as unrelated could be grouped together as their interconnectedness became apparent. The final step involved revisiting the literature and seeking out conceptual tools, and/or refining those that had emerged in our prior examination of the scholarly literature, and that could be employed to make sense of the patterns that had emerged from the data.

Distinctiveness: Pain, no gain

As a premise to discussions about risk and professional preparedness, we were interested in what – if anything – distinguished Ebola from other threats (e.g. SARS, H1N1, H5N1). As outlined above, Ebola has specific clinical and epidemiological characteristics, including being highly contagious at certain stages, and high mortality post-transmission. We were interested in how these professionals perceived Ebola vis-à-vis other recent threats. Throughout the interviews Ebola produced highly emotive responses, conjuring up apocalyptic images from its extreme case fatality rate. Such catastrophic imagery was enhanced by popular depictions of Ebola (Hollywood representations), and almost total uncertainty regarding how to manage it. It thus emerged as producing unique levels of fear among frontline healthcare workers – those considered most at risk. This was partnered with what was described by the participants as ‘impractical’, ‘elaborate’, ‘intensive’ and ‘fear-inducing’ Ebola precautionary processes – which further fuelled uncertainty rather than providing a calming influence during the threat:

Ebola poses specific challenges because (a) its case fatality rate was so high and (b) the personal protective equipment [PPE], the donning and doffing, was so much more complex than what we’d ever seen before with any of the other… And that was because the risk of a breach was associated with an infection and then the case fatality rate was much higher…. And that made people think about ‘Well, would I put myself at risk for that? How confident do I feel in my training?’ … Or ‘What if I infect my children?’ There was that emotional aspect to it. Which we don’t have … with measles and meningococcus and H1N1 … (Consultant, management role)

It is important for the following sections to capture the peculiarities of the emotions and perceived risks associated with Ebola. What was evident across the participant accounts was oscillation between fear and risk minimisation, captured in one participant’s statement ‘the risk of this is low but the consequence is extreme’ (Nurse). Ebola’s high fatality rate was significant and fear-inducing, but so was a fear of the unknown and subsequent sense of dread. Regardless of global epidemiological mortality, the participants and the public more broadly were ‘comfortable with influenza’ (Consultant). Ebola, however, produced apocalyptic, dread-invoking imagery, commonly referred to as ‘something you saw on Dustin Hoffman movies’ (Nurse) or some kind of ‘Zombie apocalypse’ (Nurse). The dynamics of dread led to a sense of professional care in the context of Ebola as both futile and dangerous. Ebola care was thus viewed as about personal sacrifice rather than meaningful professional care. Just as Ebola transgressed global jurisdictions, Ebola management challenged the limits of professional duty, blurred personal and professional priorities, and unsettled professional boundaries. Inherent uncertainties in turn compromised the institutional mechanisms perceived as shielding healthcare workers from physical and ontological risk, and articulating the boundaries of professional duty. This disruption produced dread, which was in turn amplified by anxiety around lack of guidelines and professional standards.

Fear, uncertainty and risk

A significant driver of fear during Ebola 2014 was the epidemiological uncertainties around Ebola and its clinical management, and the instability of medical knowledge therein. During the Ebola threat the Centers for Disease Control (CDC) – the peak body for Ebola management guidelines – consistently shifted or ‘updated’ its advice about best practice in Ebola management and the likelihood of transmission to a health worker in well-resourced clinical settings. As Schillmeier (2008) notes in relation to SARS, the longer one is unsure of a threat, the more one exacerbates the risk of it becoming a deadly dangerous global assemblage. This was certainly evident for Ebola, with a distinct lack of stable knowledge of how to maximise protection of (OECD) health workers and prevent transmission, combined with a lack of understanding of whether emerging containment practices would work. In essence, knowledge of Ebola management was in a constant state of flux, increasing levels of anxiety. Within the interviews, clinical guidance on Ebola management was talked about as ‘a moving feast’ (Consultant) with large swaths of information available, often contradictory, and ‘constantly shifting’ (Nurse):

I thought it [Ebola] was a problem. But the more reality has kicked in I’ve gone ‘This is not actually a real threat for us at this point.’ But it might be and then we’re in trouble… I remember being really upset that I might have to deal with a patient and I felt underprepared to do it and I didn’t know if I wanted to. And that [made me] question … from a moral point of view … did I want to go into a resus[citation] room when I thought my odds, and their odds were hopeless? Well, their odds are hopeless, mine may be 50% … (Consultant)

As shown above, and in other participants’ accounts, there was oscillation between fear and awareness within this account, limited by a lack of faith in the communication from authorities (cf. Schillmeier, 2008; Stehr, 2003). Fear was enhanced by the perceived tokenistic, and even disingenuous, attempts by institutions and government agencies to create the illusion of Ebola preparedness. This produced mistrust amongst frontline workers – a relation we expand on below – and increased professional fear, with the participants largely considering themselves completely unprepared for Ebola:

… e are totally out of our depth. We have no protocol, we have no plan … we have medical staff who would not in any way be interested in getting anywhere near such a patient … the joke of looking at the Health Minister wandering around [particular hospital] with people wearing their PPE with all types of areas of skin [exposed] … (Consultant)

I don’t think we’re prepared at all. For someone to be competent at looking after an Ebola patient you’ve got to put the personal protective equipment [PPE] on and off at least 10 to 15 times. You’ve got to do at least two or three dry runs and one with a dummy patient. So no, we’re not prepared at all. (Nurse, management)

Across the nursing and doctor interviews there was a broad recognition of a lack of Ebola preparedness, but also frustration at the broader political agenda to be perceived as being prepared for Ebola to ‘calm the community’ (Nurse). Mistrust was confounded by the realisation that there was no clarity around best practice globally – with high anxiety emerging from the lack of consensus around how to deal with a virus previously ‘an African problem’ (Consultant):

There was a discordance between the solid science of how it’s transmitted versus … what was done… How the guidelines changed for the PPE, going just from glove and masks to full negative pressure and more than we would use for airborne precautions… So there was that discordance…. And then it all got changed [again]. (Consultant)

It’s a scary non-curable disease … there’s always the crisis level… So these things are very top heavy and expect a public response. And a local expectation is then borne in the hospital, and then part of what we do is we have to manage that expectation. (Consultant, management)

While the frontline worker in the first excerpt talked about confusion, uncertainty and even mistrust, the participants in managerial roles talked about being ‘realistic about resources we can commit’ (Consultant, management) and the importance of recognising ‘you’re not really going to please everyone’ (Consultant, management). While there is an inevitability to fear in the context of an outbreak, there was more to this dynamic than merely reasonable unknowns. There was a reported active collusion to convey preparedness, without adequate amelioration of fear and commitment to safety for health workers, introducing important dilemmas regarding their moral status.

Morality and the duty of care

A key dialectical tension evident in the interviews was that of professional duty versus personal safety. Responding to the threat of Ebola involved an articulation of the values of the profession/s, offering as Godderis and Rossiter (2013) suggest, an interchange between moral or ethical obligation (professional imperatives) and physical risk. The 2014 Ebola threat pressed them to thus question their moral stance on care – a moral dilemma driven by an understanding of Ebola care as futile and palliative, but something which ‘someone has to do’ (Nurse). Providing care was articulated as maintaining a moral position they had internalised as professionals (both as doctors and nurses), rather than a logical or rational form of action in risking personal exposure:

… any healthcare worker will have a massive moral and ethical issue to tell to this person ‘No, you’re not coming in, you stay right there, we’re not going to help you.’ … Therefore they [health professionals] are in it, whether they like it or not. (Consultant, management)

… the sick ones where you don’t do something, they’re potentially dead … that leaves us in a very, very difficult moral place as to what to do…. I’m willing to risk my life to the point of accidentally having a needlestick… I’m not willing to go into an environment where I have a significant possibility of catching something that is 50% fatal. I think that’s beyond the calling of any job. (Consultant)

These participants’ moral bases of action, and of risk-taking, were in turn shaped by the dynamics of professional hierarchies and the expectations therein. The following quotes – in relating to Godderis and Rossiter’s (2013) reflections on the disproportionate exposure to risk in pandemics – capture the dynamic of risk and sacrifice across professional groups. There is an interplay between gender – given the make-up of professional groupings – and expectations of duty:

I felt a duty of care, it’s just part of being a nurse. And I can understand people you know with young children or possibly looking after elderly parents, I know that was one thing mentioned, there are different dynamics in people’s family, personal lives, that may stop them from wanting to care because it’s too high a risk for them. But for me I’m young and single. (Nurse)

So doctors can [treat Ebola], and you don’t want to send in the infectious diseases physician because if they end up on 21 days quarantine, there’s only three or four of them. Whereas nurses are a bit more dispensable! (laughs) … you’ve got a greater workforce. (Nurse, manager)

While it is reasonable to rationalise exposure of certain professional groups to Ebola as more problematic within a healthcare delivery system, such logics reflect (often concealed) hierarchies of dispensability and exposure to risk during outbreaks across professions. The fact that nurses were often considered more ‘dispensable’ because they ‘outnumbered doctors’, reflects an underpinning (and often gendered) hierarchy within the hospital, whereby medical expertise transcends, and is prioritised over, other forms of care and expertise (see Davies, 2003, for discussion around doctor/nurse hierarchical and gendered relations).

During Ebola 2014, people’s willingness and commitment to duty became visible as Australian health authorities required lists of hospital workers willing to care for an ‘Ebola case’. This move to formalise ‘Ebola volunteers’ pushed the professional duty/self-preservation dialectic to the surface, encouraging collective expressions of benevolence or lack thereof (i.e. the willing versus the unwilling), and making visible people’s personal moral assessments and professional responsibility:

… because you know more people around you are willing to do it too [care for an Ebola case], that makes you willing to do it … back then they had the [war] posters saying that it was your duty and if you didn’t do it you were … seen as weak … you know how they were … discriminated against for not doing it. I guess up here everyone is willing to do it and you’d feel odd if you didn’t do it because of everyone else. (Nurse)

So initially they wanted a list of names and so on. We didn’t comply with that and that … fell over … at some places [hospitals] they did end up giving names and things, but it’s not just that easy giving a list of names. People need to understand what does it mean if you put your name on a list like that … (Consultant, management)

This particular hospital did not provide a list of ‘Ebola volunteers’ to health authorities. Yet the act of requesting an indication of willingness to care pushed these professionals to consider their personal versus professional positions and explicitly compare their moral position vis-à-vis others around them. Furthermore, expectations around duty and thus moral dilemmas were differentiated and unequal across groups, interplaying with professional hierarchies and the gendered division of labour (Godderis and Rossiter, 2013), with ‘frontline’ workers (often junior doctors and nurses) perceived as facing disproportionate risks of Ebola transmission (Ruderman et al., 2006). What follows, as Ruderman et al. (2006) argue, are important questions around the latent (and often gendered) dynamics of duty and obligation, transforming women (and some men) into caregiving and risk-laden subjects. Risk is thus produced from within a particular interprofessional milieu, where certain professions are of more value (or scarcity). There was an interplay between such dynamics and relations of mistrust across and within professional groups.

Mistrust and Othering Ebola

Mistrust has been covered in the scholarly literature in relation to public responses to health warnings (e.g. Smith, 2006), but less so the dynamics within hospitals. We posit that duty to care is tied to (and disrupted in the absence of) trust and the authenticity of health authorities’ claims. In this particular context, uncertainty regarding how real the Ebola threat really was, combined with the lack of expertise in guiding care, produced an anxious dismissiveness and rationalising the disproportionate character of the national and/or local response:

… if you keep two metres away and you get them into the right spot and you’ve got a mask on, the chances of you getting Ebola is infinitesimally small. You’d have to be vomited on, or go and lick the sweat of their arm or something like that. (Nurse)

… a lot of staff would say to you that [Ebola training is] a complete joke and it’s a complete disaster and they’re completely unprepared… But there’s also the realities of life, the likelihood of every hospital in [Australian state] getting sick Ebola patients isn’t that high. And so all of the massive effort that would be required to get us to the standard where we would all want to be, is going to be counterproductive … (Consultant, management)

One can see above that some participants were tentative about the real risk of Ebola, with deliberation over the seriousness of the threat. As another participant stated ‘I think the [Ebola] threat was always magnified more than it should be’ (Consultant). A sense of the inauthenticity of health authority responses perpetuated mistrust; communications which had little resonance with frontline realities and fears. There was an initial period of panic:

I initially thought [the government] they’re panicking. I got the impression ‘Oh my goodness, how many people have died?’ Like ‘Oh my god!’ … and then there wasn’t [many western fatalities]… There was a panic and I thought I had missed something. (Nurse)

… the Executive [of the hospital] didn’t really get interested until that Cairns [potential Ebola] case. And all of a sudden that picqued their interest and it became important for them to be involved. (Consultant)

These participants recounted a period of panic, followed quickly by a period of ‘tokenism and box ticking’ (Consultant) whereby Ebola preparedness strategies were rushed out in order to create a sense of responsiveness, further isolating frontline health professionals and perpetuating a sense of mistrust:

I do remember the anger that I felt when I heard … they’ve rolled out Ebola training… And I felt … ‘Oh, we can write down for the rest of the world and the public that oh yes we’ve rolled out Ebola training … but you’re not the person in the resus[citation] bay with a risk of transmission.’ … I just felt a bit cheated. It was … ‘Oh yeah, you fill in your little form and your tick box to say you’ve done what you’ve done, but I don’t feel safe.’ (Consultant)

I’m amused by the announcements… [T]here is a desire for people to feel safe… [P]oliticians, whether it’s a load of garbage or not, are going to try and say that they’ve got things sorted… I don’t think anybody is particularly more prepared than they were before… [I]t’s nice to keep the masses happy… [W]e still don’t have any type of a protocol of what we do with a sick person… [W]e don’t have a sense that we have any type of reasonable protection … (Consultant)

The disjunctions between public representation of Ebola preparedness by executives and health authorities, and the realities of preparedness, dramatically increased the sense of everyday risk for the participants, producing both anxiety and defensive dismissiveness. As one participant articulated, there was a ‘complete disconnect between politics and reality’ (Nurse), with a perception that lack of direct exposure of hospital executive or health authority to Ebola led them to being tolerant of risk to staff.

The dynamics of what was a proportionate response was in turn intertwined with a sense of Ebola as out of place – and as hopefully contained to another (troubled) geopolitical realm. While we emphasise that the Ebola risk was considered real, it was framed by the participants in important ways which minimised or Othered the risk it presented. That is, relations of risk, fear, dread or dismissiveness were enmeshed with the idea of Ebola as ‘an African thing’ (Nurse) – as something that had no place in Australia or the First World. This was articulated through a sense of horror at the prospect of it moving west, combined with disbelief that it could breach geopolitical jurisdictions:

I just thought of it as an Africa thing…. Until I think there was some news coverage about someone going home to America … then it was [serious]. (Nurse)

I personally thought ‘It’s in Africa, that sucks but for us we’re ok, that’s the other side of the world.’ Sounds insensitive, but … for me my priority is my family. (Nurse)

Ebola … a weird and wonderful exotic bug from Africa…. And for a disease like Ebola to run rampant through a First World country like Australia, it just won’t happen… they [the Third World] don’t have good practices. Whereas we do … (Nursing, management)

it’s always been a disease of over there [Africa], and it’s something that’s interesting but that we really don’t have to worry about … it’s in Africa and it’s not our problem, we won’t have to look after them…. I think these sorts of issues do tickle the sense of racism … (Consultant)

One could sense within the interviews that Ebola was viewed as geographically contained, as unnatural in its penetration of international borders, and as normal in its presence in West Africa. While this was often acknowledged as ‘insensitive’ (Nurse) or ‘unfair’ (Nurse), there was broad acknowledgement of these realities. The Ebola threat unsettled such logics when it spread, becoming ‘out of place’ and a threat to western countries:

The minute … a white face is affected in a western country, it’s, oh my god, one person in the [United] States, it’s the worst thing in the world. (Nursing, management)

With Ebola [out of Africa] people sat up and listened in our forums a lot more when the nurse was in England. Because that was a real…. And it was a bit more of a wake up … (Nurse)

The quotes above can be seen as both reflection on the practice of Othering, but in turn, how the view of Ebola as out of place is articulated. There was a sense of this globalising risk as unsettling caring responsibilities, and pushing them beyond the expectations of duty and care. The sense of threat was embedded in the notion of the virus unsettling borders, making porous political jurisdictions, and raising questions of care. Captured in the statements ‘Why should we be responsible?’ (Nurse) or ‘It [international travel to Australia] puts us at risk’ (Nurse), the Ebola threat raised questions of latent racism, protectionism or apathy toward a primitive and spatially distant Other, and how such considerations may shape professional sacrifice; that is, care beyond one’s local imagined community.