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Pandemic
preparednessfortherealworld
Whywemustinvestinequitable,ethicalandeffectiveapproachestohelpprepareforthenextpandemic
March2023
ids.ac.uk
Pandemicpreparednessfortherealworld2
ThisreportwascommissionedthroughtheCovidCollectivebasedattheInstituteofDevelopmentStudies(IDS)andisfundedbytheUKForeign,Commonwealth&DevelopmentOffice(FCDO).TheCollectivebringstogethertheexpertiseofUKandSouthern-basedresearchpartnerorganisationsandoffersarapidsocialscienceresearchresponsetoinformdecision-makingonsomeofthemostpressingCovid-19-relateddevelopmentchallenges.TheviewsandopinionsexpresseddonotnecessarilyreflectthoseofFCDO,theUKgovernment,oranyothercontributingorganisation.Forfurtherinformation,pleasecontact
.
IDSdeliversworld-classresearch,learningandteachingthattransformstheknowledge,actionandleadershipneededformoreequitableandsustainabledevelopmentglobally.
Frontcoverimage:PeopleinneedfromtheDharaviinformalsettlementinMumbai,Indiaqueuetocollectgovernment-suppliedfreemealsduringthesecondCovid-19lockdown.
PHOTO:©ATULLOKE/PANOSPICTURES
Editing:NaomiMarks
Design:LanceBellers
Suggestedcitation:Wilkinson,A.etal.(2023)PandemicPreparednessfortheReal
World:WhyWeMustInvestinEquitable,EthicalandEffectiveApproachestoHelpPreparefortheNextPandemic,Brighton:InstituteofDevelopmentStudies,
DOI:
10.19088/CC.2023.002
PublishedMarch2023Exceptwhereotherwisestated,thisreportislicensedfornon-commercialpurposesunderthetermsofthe
OpenGovernmentLicencev3.0
.TheCovidCollectivecannotbeheldresponsibleforerrors,omissionsoranyconsequencesarisingfromtheuseofinformationcontained.AnyviewsandopinionsexpresseddonotnecessarilyreflectthoseofFCDO,theCovidCollectiveoranyothercontributingorganisation.©Crowncopyright2023.
DOI:
10.19088/CC.2023.002
InstituteofDevelopmentStudies
LibraryRoad,Brighton,BN19RE,UK
www.ids.ac.uk
IDSisacharitablecompanylimitedbyguaranteeandregisteredinEnglandCharityRegistrationNumber306371
CharitableCompanyNumber877338
ids.ac.uk
3
Abouttheauthors
AnnieWilkinsonisananthropologistandhealthsystemsresearcherandco-leadofthe
HealthandNutritioncluster
attheInstituteofDevelopmentStudies(IDS).Annieconductsinterdisciplinary,participatoryandappliedresearchonhealthandhasexpertisein:zoonoticdisease;epidemic
preparednessandcontrol;drugresistance;andurbanhealth.ShehasworkedextensivelyinWestAfrica,especiallySierraLeone,andwithinemergencyhumanitarianandepidemicresponse.
HayleyMacGregortrainedasamedicaldoctorinSouthAfricabeforecompletingaPhDinsocialanthropology.Hercurrentresearchinterestsincludeemerginginfectiousdiseaseandpandemicpreparedness;theanthropologyofantimicrobialresistance;andconceptsofcareandchronicity
inresponsestolifelongillness,principallyHIV.Sheco-leadsthe
Social
ScienceinHumanitarianActionPlatform(SSHAP)
hostedatIDS,andaWellcome-fundedcollaborativeprojectonpandemicpreparedness.
IanScooneswasco-directorofthe
ESRCSTEPSCentre
attheUniversityofSussexandisPrincipalInvestigatoroftheEuropeanResearchCouncil(ERC)AdvancedGrantproject
PASTRES
(Pastoralism,UncertaintyandResilience:GlobalLessonsFromtheMargins).
MeganSchmidt-Saneisamedicalanthropologistwithinterdisciplinarytrainingandexperienceinpublichealth,workingwiththeHealthandNutritionclusteratIDS.Herworkfocusesonpoliticaleconomyofhealth,urbanhealth,andoverlappingthemesofgender,generation,andinequalities.
Sheusesparticipatory,community-led,andpolicy-engagedapproachesinherresearch.
MelissaLeachistheDirectorofIDS.Sheisananthropologistbytrainingandhaslednumerousinterdisciplinary,policy-engagedresearchprogrammesinAfricaandbeyond,whileengagingwithscientific,policyandpublicdebatesaroundglobalhealth,sustainabilityanddevelopment.Sheco-leads
SSHAPhostedatIDS,andaWellcome-fundedcollaborativeprojectonpandemicpreparedness.
ids.ac.uk
4
PeterTaylorisDirectorofResearchatIDS.Healsoleadsthe
CovidCollectiveResearchPlatform
,whichhassupportedthispublication.PreviouslyhewasDirector,StrategicDevelopment,attheInternationalDevelopmentResearchCentre(IDRC),Ottawa,CanadawherehewasresponsibleforleadingIDRC’s
strategicplanningprocesses,aswellasleadingthe
ThinkTankInitiative
whichsupportedorganisationalstrengtheningofpolicyresearchinstitutionsinAfrica,AsiaandLatinAmerica.Hehasresearchinterestsinparticipatorymethods,organisationallearninganddevelopment,andagriculturaleducationandruraldevelopment.
SantiagoRipollisasocialanthropologistwithskillsandexperienceinsocialscienceanalysis,participatoryandanthropologicalmethods,inthefieldsofpublichealthemergenciesandfoodsystems.Hisacademicresearchfocusesontheclashes(oralignments)thatoccurbetweenframingsbydifferentsocial
actors(includingpolicymakers)andtherealitiesofpeople’severydaylives,highlightingthemeitherthroughparticipatoryorethnographicresearch.Hehasspecialisedin‘translating’differentformsofsocialscienceevidence(especiallythatwhichemergesfromanthropologicalinsights)todifferentaudiencestomakeitmoreapplicableandoperational.
ShandanaKhanMohmandleadsthe
Governancecluster
andthe
PakistanHub
atIDS.Sheisasocialscientistwhosemainareaofresearchisinequality,inclusivepolitics,andthepoliticaleconomyofpublicpolicyandservicedelivery,especiallyinfragileandcrises-affectedcontexts.Herresearchinterestsalso
includelocalgovernance,women’spoliticalparticipation,institutionaltrust,andinformalinstitutions.ShehascontributedtobothpolicyandsocialscienceresearchinSouthAsia,theWesternBalkans,andsub-SaharanAfrica.
SyedAbbasisapublichealthresearcherwhosemainareaofexpertiseisthepoliticsofmultisector‘OneHealth’collaborationsaroundzoonoticdiseases.Heiscurrentlyengagedinconductingresearchondecreasinghealthrisksfrompoultryfarminginthe
OneHealthPoultryHub
andinadvising
theWorldHealthOrganizationonstrengtheningimplementationofmultisectorpartnershipsaroundzoonoticinfluenza.
TabithaHrynickisamultidisciplinarysocialscienceresearcherbasedatIDSwhereshecurrentlyworkswithSSHAPtoproviderapidsocialscienceinsightforhealthshocksandotheremergencies.Sheisparticularlyinterestedinbridgingcrisis
responsewithlonger-termchangetoaddressstructuralinequalities,andachievesocialjustice.
ids.ac.uk
Pandemicpreparednessfortherealworld5
Contents
Executivesummary
6
Introduction
9
Actionareas
1Pandemicprofessionals–anewfocusonreliability
12
2K
nowledge,evidenceanddata–
embracinguncertaintyanddiversity
17
3M
eaningfulresilience–movingbeyondthecrisislens
23
4I
nstitutions–anoverhaulforinclusiveness
26
5E
thicsandjustice–cross-cuttingimperatives
30
Conclusion
34
References
37
ids.ac.uk
Pandemicpreparednessfortherealworld6
Executivesummary
AcityworkerspraysthestreetsinthedesertedcityofIstanbul,Turkey
duringtheCovid-19lockdown.
PHOTO:©BRADLEYSECKER/PANOSPICTURES
ids.ac.uk
Pandemicpreparednessfortherealworld7
ThecostoftheCovid-19pandemicremainsunknown.Livesdirectlylosttothediseasecontinuetomount,whilerelatedhealth,livelihoodandwellbeingimpactsarestillbeingfelt,andthewiderramificationsacrosssociety,politicsandtheeconomyareyettofullymaterialise.
Whatisknownaboutthesecoststhough,isthattheyhavebeenunequallydistributedbothwithinandbetweencountries.Preparednessplansprovedinadequateinmanysettings–especiallywhenitcametoprotectingthosemostvulnerable,includingthosemarginalisedbygeography,poverty,orexclusionalongthelinesofreligion,ethnicityorgender.
Thetop-down,surge-style,biomedicallydominatedandtechnologicallydrivenpreparednessapproachthathasdominatedglobalhealththinkingandwhichwaspropelledintoactionwithCovid-19wasfoundwantingnotonlyonthegroundsofeffectiveness,butalsoofsocialjustice.Thispresentsbothachallengeandanopportunityforaconvergenceofthepreparednessanddevelopmentagendas.
Drawingonagrowingbodyofsocialscienceevidence,thisreportcontendsthatsecuringhealthinthefaceoftoday’suncertaindiseasethreatsinoftenunpredictablesettingsmeansmakingsocial,economicandpoliticalprioritiesascoretothepreparednessagendaasbiologicalandtechnologicalones.
Wepresenthereaframeworkforavisionofpandemicpreparednessfortherealworld–onethatacceptsthatcontextisparamount,embracesinclusivityandjustice,shiftspowercentresandrejectssimplistic,one-size-fits-allsolutions.
Weargueforfreshapproachesacrossfivepriorityactionareasforpandemicpreparedness:
ProfessionalsIdentifying,supportingandrewardingkeypeopleincriticalinfrastructuresintroducesmuch-neededreliabilityintouncertainandcomplexcontexts.Afocusonnurturingreliabilityprioritisesbuildingthecapacitiesandconnectionsofindividualswhoseknowledgeandunderstandingofthesystemswithinwhichtheyworkarecriticalinahealthemergency.Itseespandemicprogrammingbecominganongoingprocessandasmuchabouthorizonscanning,relationshipbuildingandempoweringpeopleasitisaboutwaysandmeanstodealwithcrises.
KnowledgeCreatingopportunitiesandbuildingmechanismstoaccountfordiverseknowledge,expertiseandevidencefacilitatespreparednesswhichisbetteradaptedandmoreresponsivetolocalcontextsandacceptabletocommunities.Suchaninclusiveapproachwelcomesfreshinsightsintowhere,howandwithwhatimplicationsdiseaseoutbreaksmightemergeandunfoldtocomplementbioscientificunderstanding.Itenablestheemotionalandaffectivedimensionsofpandemicimpactstotaketheirplacealongside
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8
thebiomedicalinpreparednessconsiderations.Itmeansembracingnewdisciplinaryevidence,fromsocialandenvironmentalsciencesandhumanities;aswellasunderstandings,perspectivesandknowledgefromarangeofstakeholders,includingthosewithvitalinformalandindigenousknowledge.
ResilienceRedressingtheinequitableunderlyingconditionsthatleavepeopleandcommunitiesvulnerabletocrisesinthefirstplaceisthe
bestroutetoensuringtheycanwithstandshocks.Effectivepandemicpreparednessbuildsresiliencebylookingbeyondtheimpactofsinglehealtheventstoconsiderlong-termstructuralchangestothesystemsthatleavepeopleimpoverished,disenfranchised,marginalisedorotherwisesusceptible.Itsupportsequitableaccesstoqualityhealthcare,education,housing,safety,andeconomicandlivelihoodopportunitieswhichbenefitcommunitiesbothwithinandoutsidepandemicsituations.Suchresiliencecanonlybefullyenabledandpromotedwhenledbylocalpeoplewhoknowtheircommunities’strengths,prioritiesandchallengesbest.
InstitutionsAddressingthecrisisofconfidenceinstateinstitutionsispartandparcelofpandemicpreparedness.Politicsplaysoutinpandemicsituationsinavarietyofways,fromreinforcingblamenarrativestolegitimisingmisinformationtoexcludingmarginalisedgroupsfromhealthinterventions.Workingtorenewtrustinpoliticsandstateinstitutionsandrebuildstate–citizenrelationshipsisthereforeanessentialcomponentofpreparedness.Decentralisingdecision-makingandensuringitisbothaccountableandinclusiveatalocallevelisonewaytodothis,withbenefitsforpandemicpreparednessaswellaslong-terminstitutionalequityandsocialjustice.
EthicsPolicymakinganddecision-takingforpandemicsnecessarilyembraceawidersetofissuesthanaccountedforbyconventionalbioethicsanditsfocusonindividualrights.Forsocialjusticeandequity,anew‘epidemicethics’mustaccountforawiderangeofcontext-specificsocietalissues,inparticularinequitiesinpowerandresourceallocationatlocal,nationalandgloballevels.Decolonisingpandemicpreparednessdemandsthatquestionsbeaskedaboutwhereinvestmentsaremadeandwhy.Ethicalissuesariseineveryaspectandateverylevelofpandemicpreparedness.Investmentintoresearchandbroaderdebateaboutepidemicethicscanfurtherasociallyjustandequitablepreparednesstobenefitallpeople.
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Pandemicpreparednessfortherealworld9
Introduction
AresidentofKlongToeicommunityinBangkok,ThailandreceivesaSinovacvaccineatagovernment-runvaccinecentre.
PHOTO:©ADAMDEAN/PANOSPICTURES
ids.ac.uk
Pandemicpreparednessfortherealworld10
TheworldwasunpreparedforCovid-19.CountriessuchastheUSandUK,top-scorersingloballyrecognisedrankingsforpreparedness,faredamongtheworstoninfectionanddeathratesfortheircitizens(Bollykyetal.2022).TheunevendistributionofCovid-19vaccineswasglaring.Thepandemicwreakedhavocnotonlywithpeople’shealth,butalsowithlivelihoods,socialcohesionandpoliticalstabilityinwaysthatwillplayoutforyearstocome.
Factorscontributingtothisfailureinpandemicpreparednesshavebeenidentifiedasalackofprioritisationandinvestment,failuretoimplementpreviousrecommendationsfully,weaknessesinglobalhealthgovernanceandpoorpoliticalleadership,allexacerbatedbyill-equippedhealthsystems(IPPPR2021).Consequently,post-Covid-19recommendationsandinitiativesarenowfocusingonafamiliarsetofissues:improvedthreatdetectionandsurveillance,datasharing,healthsystemstrengthening,researchanddevelopmentfordiagnostics,vaccinesandtherapeutics,globalgovernanceandcoordination,politicalleadershipandfinancing(WHO2021).
However,theseexplanationsandproposedsolutionsareonlypartofthestory.
Epidemics,theevidenceincreasinglyreveals,areasmuchsocialastheyarebiological.Complexpoliticaldynamicsplayoutinoutbreaksituationsandfactorssuchaslevelsofpublictrustcanbecriticalindeterminingpandemicoutcomes(Bollykyetal.2022).
Complexpoliticaldynamicsplayoutinoutbreaksituationsandfactorssuchaslevelsofpublictrustcanbecriticalindeterminingpandemicoutcomes.
Tosomeextentthishasalreadybeenrecognised.Majoractors,suchastheGlobalPreparednessMonitoringBoard,theWorldHealthOrganization(WHO)andtheIndependentPanelforPandemicPreparednessandResponse(IPPPR)nowincludeissuesofequityandtrustintheirrecommendations.Butthedevilisinthedetailandthedetailislacking;vaguenotionsofimprovedriskcommunicationandcommunityengagementfailtoaddressmorefundamentalrelationshipsbetweenstatesandtheircitizensandthefactorsunderpinningpeople’svulnerabilitytocrises.
Withhindsightwecanseethatthecontoursofthecrisisweremanyyearsinthemaking:theCovid-19virusthrivedinlong-deprivedcommunities;onentrenchedinequalitiesanddeepeningpoliticalpolarisation;onprecariousworkandwelfaresystems;andinunhealthypopulations.Suchissuesarestructuralandrelatedtolong-termdevelopmenttrends.However,theserealitiesarenotimmutable.
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11
Weofferevidenceshowinghowprevailingbiomedicallydominatedapproachestopreparednessfailtodealadequatelywiththeincreasingrisksofdiseaseemergenceandspread,andtherelatedvulnerabilitiesandcrisesinsocial,political,environmentalandeconomicsystems.Wecontendthatthekeytosecuringhealthinthefaceofuncertaindiseasethreatsistoshiftthinkingandofferafreshframeworkforpreparednessdrawingonthefullrangeofreal-worldevidence–biomedicalofcourse,butalsosocial,economicandpolitical.IfthemistakesoftheCovid-19pandemicarenottoberepeated,social,economicandpoliticalissuesmustbeascoretothepandemicpreparednessagendaasbiologicalones.
Accountingforunpredictability
So,whatdoesshiftingthethinkingonpreparednessmeaninpractice?
Fundamentally,itmeanstakingaccountoftheunpredictableworldinwhichwelive–andasking:Preparednessofwhat?Forwhatandforwhom?Andbywhom?Outbreaksareoftenframedasinvolvingasequenceofdistinct,evendiscrete,events:emergence,detection,response,recovery–withprogrammesandfundingforpreparednesstargetingtheseinsupposedlyseparatephasesofanemergencycyclethatincludespreparednessastheprecursortoreadinessandresponse.Yetintherealworld,preparednessandresponsearenon-linear.Epidemics,andpandemicsinparticular,aremessy.Linearthinkingcandeepenartificialandunhelpfulseparationsbetween‘peacetime’,‘crisis’and‘recovery’,andbetween‘development’and‘humanitarian’activities.
Preparednessinitiativesneedtoreorientateandbebroaderinscope.Theyneedtorecogniseandleverageconnectionsbetweendevelopmentpatterns,epidemicemergenceandimpacts,andapproachestofosterresilienceinthefaceofradicaluncertainty.Todosotheymustbelocalisedandcontextdependent,andinclusiveofdiversepeople,perspectivesandexpertise.Anexpandedrangeofactorsatmultiplelevelsneedtointeractandaligntheirgoalsandactivities.
Inthisreport,wepresentaframeworkforpandemicpreparednessandshowhowthisnewvisioncanbeachieved.Itfocusesonfiveareasforactioninshiftingapproachestopreparednessinrespectof:professionals;knowledge,evidenceanddata;resilience;institutions;andethicsandjustice.Westartbyexamininghowreliabilityinhealthsystemscanbebuiltunderconditionsofuncertaintythroughnewformsofprofessionalism.Wearguethatmultipleknowledgesfromdiversesourcesareessentialforpandemicpreparedness.Buildingresilienceinadvanceoffuturepandemicsrequiresinturndecentralisedinstitutions,centredonstrengthenedrelationshipsandtrust.Acentralcommitmenttoethicsandjusticeisessentialandprovidesastrongcross-cuttingthemeapplicableacrosstheframework.
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Pandemicpreparednessfortherealworld12
Actionarea1
Pandemicprofessionals–anewfocusonreliability
AcommunityhealthworkerrestsonarockinRobin,Haitiasshewalksthroughthemountainsmakinghomevisitsandvisitingpatients.PHOTO:©DAVIDROCHKIND,USAID,
CCBY-NC2.0
ids.ac.uk
13
Preparednessplanninginescapablytakesplaceinacontextdominatedbyuncertainty.Noone–noteventhebestmodellers–hasacrystalballwhenitcomestodiseaseoutbreaks.
Conventionalbureaucraticandtechnologicalapproachestopreparedness,suchasthoseadoptedbyWHO(seeBox1)andmanynationalgovernments,offerneatandappealingsolutions.Theyaimforimmediateandeffectiveresponsetopotentialhealthemergencies,suchasthecoordinateddrawingdownofstockpiledvaccinesorantiviraldrugsandtheactivationoffinancemechanisms,suchas‘pandemicbonds’,toallowforrapidreleaseoffunds(Jonas2019).Theprospectofpowerfulvaccineplatformsthatcanberapidlycustomisedtoemergentpathogens,ora‘silverbullet’solution,isfrequentlyagoal.
Box1:WHOStrategicFrameworkforEmergencyPreparedness
The
WHOStrategicFrameworkforEmergencyPreparedness
setsoutanambitiousdemandfora‘wholeofgovernmentandwholeofsocietyapproach’,investingingovernancearrangements,capacitybuilding,andfinancialandlogisticalresourcesforefficientandeffectivedelivery.Apreparednesscycleisenvisagedthat‘startsfromassessingrisksandcapacity,andmovesthroughestablishingcoordinatingmechanisms,planning,financingandimplementing,toevaluatingandtakingcorrectiveaction’(WHO2017:ix).
Suchanapproachassumesknowledgeaboutrisks(inwhichlikelihoodsofparticularoutcomescanbeassessed)andasetofcapacitiesacrossawiderangeofstatefunctionsthatworktomanagerisks,withsufficientfinance.Theframeworkemphasisesintegratingsystemsacrossgovernmentandbetweendifferenthazards,andadvocatesa‘OneHealth’approach.
Butwillsuchsurge-stylesolutionsworkincontextsrifewithuncertainty–includingbutalsobeyondtheuncertaintyofthediseaseoutbreakitself?Insuchcontexts,healthservicesareweak,livelihoodsvulnerableandstatesdistrusted.Ambiguitiesoftenflourish,differentgroupsprioritisedifferentaspectsofanoutbreakanditsimpacts,andthereisaproliferationof‘unknownunknowns’abouthowanoutbreakwillunfold.Integrationacrosssectorsislimited,capacitiesareweakandadvancefinanceforemergenciesalmostnon-existent.
Suchturbulentsocial,politicalandecologicalcontextsare,ofcourse,thesituationinmostoftherealworld.
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14
Over-confidenceandlackofattentiontocontextcanbedangerous.Abandoningthemirageofcontrolmaybeunsettling,butitisnecessaryifreliabilityinthefaceofuncertainty,complexityandlimitedresourcesistobeachieved.
Abandoningthemirageofcontrolisnecessaryifreliabilityinthefaceofuncertainty,complexityandlimitedresourcesistobeachieved.
Phasedprogramming
Initsplace,anewfocusonreliabilitywouldacknowledgethathealthsystemsarecomplexandsimplesolutionsrarelywork(Holmesetal.2017;
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