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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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