Ebola, Influenza, Zika: in the past decade, outbreaks of diseases with the potential for significant spread and devastating consequences have grabbed headlines and global attention. In between the states of emergency, a fear resurfaces: What Disease X will rise next, and where might that be?
Haunted by a spectre of a rapidly advancing global pandemic, a discourse of disease ‘preparedness’ has gained ground in recent years. It has spawned new institutional configurations, funding streams, material objects and technologies, and ideas and symbols. Core agencies of the United Nations, governments and funders of global health research have all invested in this agenda. High-level meetings are convened at regular intervals to discuss the core elements: how to strengthen preparedness capacities, how to evaluate indicators of progress, and coordinate efforts to build preparedness and mobilise outbreak responses. We ourselves have attended many of these. The envisaged ‘solutions’ chase risk reduction and coalesce in the domain of the technical and biomedical – whether drugs, vaccines, surveillance systems or scenario planning exercises. Along with these, committees, sub-committees and networks are proliferating fast.
Yet despite all this heightened interest and activity, preparedness remains a contested and ambiguous idea and one requiring critical scrutiny. A vibrant scholarship is starting to emerge tracing its history and the powerful imaginaries it inspires. However, a gap remains, both in policy and in academic literature, namely attention to the perspectives of people in places envisaged as ‘hotspots’ for outbreaks.
Villagers in rural Sierra Leone or in Uganda on the border with DRC, for instance, are imaged in global discourses in powerful and particular ways. They are often seen as vulnerable, ignorant with respect to ‘scientific medical knowledge’, and resistant to changing problematic cultural practices. Viewed as sources of global disease, they are also increasingly slated to be a resource for global preparedness and response, through initiatives aimed at ‘risk communication’ and ‘community engagement’. Yet in these, the framing is often narrow and the social is readily reduced to extractive tools and targets. But what are they actually thinking and doing? And how is this shaped by their own histories, practices and experiences – such as those of conflict and inequitable political economy?
With this in mind, we have launched a new project funded by the Wellcome Trust: Pandemic Preparedness: local and global concepts and practices in tackling disease threats in Africa. This provides a fantastic new opportunity to address these gaps and questions. The project aims to track the meanings and concepts of pandemic preparedness at global, regional and local levels, and the ways these interconnect – or fail to. We’re excited to be working as part of a team combining ideally-placed expertise from two locally-embedded universities – Njala University in Sierra Leone and Gulu University in Uganda – and a regional research institution – CRCF in Senegal, part of the Institut de Recherche pour le Développment (IRD) network; as well as other anthropologists from the London School of Hygiene and Tropical Medicine, IRD and IDS.
Exploring ‘preparedness from below’
At this crucial juncture, there is an urgent need to reflect on differences between preparedness as a global health concept, and what we term ‘preparedness from below’ – the understandings and practices of communities through which they anticipate and manage disease and other adversity on an everyday basis. Put slightly differently: who is being prepared, for what, and by whom? These are critical questions – for the ethics of humanitarian engagement, for considerations of global justice, and indeed for the effectiveness of disease control and response.
IDS and partners’ work on Ebola, including through the award-winning Ebola Response Anthropology Platform and the expanded remit pursued by the Social Science in Humanitarian Action Platform shows the importance of local perspectives on disease response. As Paul Richards has argued, ‘people’s science’ has vital roles to play. As earlier work in the Dynamic Drivers of Disease in Africa Consortium showed, local understandings and practices emerge from complex, interconnected ecologies and social processes.
Work on epidemics by the STEPS Centre has also shown that pathways of disease and response are embedded in far wider political and social contexts, in which narrow notions of risk are quite unhelpful. Understandings of preparedness and local responses might emerge from improvisation, flows of new information, or recollection of past experiences of dealing with events perceived as threats to life and health (for instance hunger, lightning strikes, floods, political danger).
Focusing on risk and uncertainty, knowledge and information and agency and authority
Underpinning our approach is the hypothesis that global and local approaches offer quite different ways of addressing risk and uncertainty, knowledge and information, and the allocation of agency and authority. These three themes, highlighted in diverse strands of social science work, are important in characterising and understanding current gulfs between concepts and practices at different levels, and considering how these might be connected and bridged in more effective preparedness approaches.
- Risk and uncertainty
Disease threats and outbreaks can be understood as inherently uncertain, involving events whose character and occurrence cannot be predicted in advance. Yet many preparedness efforts address them as if they were risks focus on turning such uncertainties into manageable risks via surveillance, prediction, early warning, and scenario planning. Yet, experience both in relation to disease and, indeed, a far wider range of fields has shown that such efforts are limited where threats are genuinely uncertain or unknown. Linking with a wider STEPS Centre initiative, we want to explore how approaches geared to recognising and living with uncertainty may be needed; social science literature from diverse sectors identifies flexible institutions, ongoing iterative adaptation and learning, and capacities to anticipate and respond as key dimensions of this.
- Knowledge and information
In building preparedness, what is known, by whom, and how, and how do different states and forms of knowledge interconnect? Global preparedness initiatives prioritise the intensified collection and use of scientific, public health and epidemiological data and modelling of disease occurrence and spread, supported by clinical and laboratory information as well as novel (e.g. digital) means to collect and share it. Yet, these forms of technical knowledge and innovation may bypass social knowledge and everyday experience that could offer vital complementary, or even transformational, perspectives.
- Agency and authority
The project is interested in which people and groups are deemed to have the capacity to act and engage (have agency) in relation to disease preparedness and response, and the different forms of authority called upon in governing disease threats. We want to identify how people and institutions at global, national and local levels allocate agency and authority differently – and how they understand each other’s roles. For instance, within global preparedness assemblages, it is often assumed that capacity and authority to prepare for and deal with disease threats rests with international and regional institutions, albeit working through national governments and decentralised health systems. In these organizational frameworks, local communities are often represented either as blameworthy – the source of outbreaks – or as the target for top-down preparedness and response efforts.
In the last few years, global efforts in the WHO and beyond have embraced a commitment to ‘community engagement’, yet this is often conceived narrowly in terms of imparting information about disease prevention to counteract ‘ignorance’, and represents communities as passive, idealised or homogeneous. Yet long traditions of anthropological work present a different perspective, revealing the significance of actions and practices within communities in dealing with health threats, and their embeddedness in salient social differences and relations (e.g. gender, age, status), historical experiences (such as of war and external intervention), and institutional formations and forms of public authority.
Taking forward engaged approaches
Through grounded ethnographic fieldwork in Uganda and Sierra Leone, and multi-sited research tracking up to the level of global institutions, the new project will investigate the connections and disconnections in the diverse concepts, meanings and practices of preparedness.
By exploring whether there are principles and endeavours salient to ‘preparedness from below’, we will to engage policymakers, practitioners and publics in catalysing discussion of alternative approaches to preparedness that might become part of multi-level, more connected, socially-sensitive and in turn effective efforts to respond to disease threats.
We also believe that this is a timely moment for added impetus to ongoing debate about the involvement of anthropologists and anthropological knowledge in preparedness efforts. We have witnessed how problematic the framing and mobilisation of social science findings can be once these enter the maelstrom of urgent response modes. We also ask if there might be ways to engage in dialogue about evidence for disease preparedness and response, yet maintain critical distance, and remain alive to the politics of knowledge.
We’re looking forward to an exciting four years ahead – and would be delighted to engage with academics, policymakers, practitioners and others interested and involves in these vital and timely debates.