In recent months the news of the financial crisis has sidelined a major global health issue that had been covered quite thoroughly over the past several years, the pandemic flu or H5N1 crisis. I’ve been involved with Michigan State University and CDC in organizing a Salzburg Global Seminar on zoonoses and the convergence of public and animal health in September 2007. As a social scientist the issue is quite rich in that different disciplines, institutions, governments and socio-economic players have very different views and framings of ‘the crisis’. Recently Ian Scoones and Paul Forster, social scientists from the Steps Centre at the Institute for Development Studies and the University of Sussex published a much needed analysis of the politics of avian influenza entitled “The International Response to Highly Pathogenic Avian Influenza: Science, Policy and Politics”.
This much needed unpacking of the intersecting, conflicting, and overlapping stories of virus genetics, ecology, pharmaceuticals, epidemiology, economics and politics, the authors argue, may open up the silenced voices and opportunities to rethink the discourse around the crisis and enable alternative policy framings to emerge. Their work covers the period from 1997-2008 and focuses on the key actors, networks and narratives that have framed the international response to the avian flu threat. The key actors include veterinary concerns framed by agriculture, animal health and livelihood concerns. The public health narrative that frequently dominates mediatic representations and is concerned with drugs, vaccines and behavior change eminating from WHO, UNICEF and some NGOs. And finally a “preparedness” narrative that involves civil contingency planning, business continuity, and containment. I’ll provide a brief overview of each below.
Veterinary Response: The avian flu issue helped to substantially elevate the role of the global veterinary medical institution, the OIE and the FAO (Food and Agriculture Organization). The veterinary narrative emphasizes culling, movement control and vaccination to eliminate the disease. But framing the issues in terms of a global response directed toward poulty and eradication which overlooks how different geographics and social groups may require a different response at odds or not in complete alignment with the global vision put forth by an international organization. There are also important uncertainties when you dig down to causal pathways in wet markets as well as disagreement over what a safe, hygienic poultry sector would look like in different places. These conflicts came to the fore when vets and socio-economists had to take into account framings by producers and consumers in different settings. Endemicity vs pandemic framings also require different solutions and approaches. The situatedness of different actors also means different framings of risk from Indonesia to Vietnam to Rome. Add to the mix the inaccuracies and challenges of reporting cases from the field. This ecology of knowledges created the following tensions:
- Are backyard flocks or commercial flocks to blame or something in between?
- What are the implications for ‘restructuring’ and ‘biosecurity’? Can bans work? Who wins? Who loses?
- Wild birds, ducks, or trade? Roles in spread and persistence in different agro-ecological and economic settings?
- Disease dynamics–seasonality, cyclicity–and patterns of re-infection. Is elimination really feasible with large hot spots of ‘viral soup nearby
- Culling strategies: complete, ring, or not at all? What approaches to compensation? Is this a high cost but low return option in many places?
- How effective is vaccination? Why is there cyclical re-infection despite thorough campaigns?
If one examines the official policy discourse of the institutions involved we rarely see all of these issues come to light, however, these are the issues that come to the forefront “on the ground” and determine the efficacy of interventions. Good social science doesn’t shy away from these issues–it explores these contradictions and re-surfaces them as a tool to rethink how we might address the problem or think about it otherwise.
Public health as embodied in the WHO focused on the ‘outbreak’ discourse. The response has two parts. The technological responses which focuses on drugs and vaccines is the dominant. And this discourse has been hampered by the controversies over vaccines. Who could make a vaccine in time? Who would have access? How to finance vaccine production and distribution? Despite all of the public media on pipelines and global philanthropic contributions the technological fix, the authors argue, is on quite shaky grounds. The non-pharma public health narrative emphasizes public education, communication and ‘social distancing’. UNICEF is one of the key players here and has had to deal with the challenges of the ‘social distancing’ discourse when you’re telling people in some parts of the world to just stay home when there are 10 people in a room. The narrative has largely been top-down and instrumentalist. The third approach is the “health systems” approach that argues for a well-functioning information, prediction and early warning system–something, quite frankly, that does not exist. Agencies are arguing over how to create an organization that could transcend the information silos and address the problem but the debate is plagued with the experience of UNAIDS–for many a lesson of what not to do. The public health discourse also uses the language of ‘rights’, ‘responsibility’, ‘equity’ but these come up against the technological rationality of drug and vaccine production. Behind all of these discourses is the spectre of the HIV epidemic which the field has not handled historically in a very effective manner.
The final discourse the authors cover is the ‘preparedness’ discourse which rose in prominence particularly after September 11. For this reason it receives a great deal of the funding. Security under the Bush administration had its advantages. Finally the authors seek to uncover what is missing and look at the rise of the “one world, one health” discourse that emerged in recent years to address some of these issues. I was present at one of the conferences, the Salzburg Global Seminar, when the “one world, one health” discourse was shaped and disseminated globally. The authors also reflect on the fact that there is little input from social scientists in the institutions responsible for controlling pandemic flu yet most experts acknowledge the fact that social science insights and knowledge are urgently needed. There unpacking of discourses can help shed light on the decision of Indonesia to withhold viral samples from WHO out of lack of trust in the political interests of global institutions. Respect and recognition are not to be taken for granted, but rather earned. Recognizing the voices silenced helps to see why some marginalized stakeholders mobilize the discourse of rights and access. Political pressure from the central can help explain why reporting on cases from the field are inaccurate (due to meeting goals for immunization coverage is the classic case that anthropologist Veena Das has explored in India) and why rights are sometimes violated by health workers.
The conclusion focuses on the central role that risk, uncertainty and expertise play in this space. There are substantial zones of uncertainty and ignorance in an issue this big when we look at causal mechanisms, incidence, transmission, impact and response. This is widely recognized by experts yet public discourses still continue to be framed in terms of probabilities. Policy narratives demand it, much to the own peril. These framings may occlude equally important issues of shifting disease ecologies and the need for more sustained deliberation and nuanced approaches in policy circles. The implications of all of this for the “one world, one health” agenda are summarized as:
1) moving beyond a strict ‘outbreak’ approach to managing endemic situations
2) embracing uncertainty–stop black-boxing uncertainty and ignorance
3) rethinking surveillance to include systemic surveillance of ecosystems, dynamic shifts and new equilibria
4) a focus on ethics, equity and access–‘global’ policies often obscure structural inequalities
5) a new perspective on health security–rethinking the relationship between health and foreign affairs
6) rethinking global governance and accountabilities–attention to how universalized globalism obscures competing interests, local politics, etc.
7) new organizational arrangements–revitalizing core UN agencies in ways that do not entrench existing interests and allows for better cross-agency working
8) expanding the range of disciplines and expertise involved beyond narrow techno-scientific disciplines
9) improving program design and implementation–better targeting while taking in cross-sectoralism
10) vision of success and indicators for assessing impact and success
If you have any thoughts please take a look at the paper and feel free to comment here. I’ll be posting more on this general theme as it plays out in food safety and global health in the future.