Authors include: Tabitha Hrynick, Hayley MacGregor, Annie Wilkinson, David Kaawa-Mafigiri, Syed Abbas and Santiago Ripoll
Infectious disease threats, such as outbreaks of epidemic-prone infectious diseases and antimicrobial resistance (AMR), loom ever larger. They are fuelled by a potent, complex and ever-shifting mix of interacting factors from global travel, mass migration, urbanisation and weakened health systems, to economic inequality, changing human-animal interactions, climate change, viral mutations and more. Such complexity tests and transcends the capacities of conventional governance systems and approaches for preventing and managing infectious threats. This report argues that a broader view of governance for infectious disease threats is critically needed. Drawing on social science perspectives – to date undervalued with respect to the governance of infectious threats – we illustrate how ‘bottom-up’ governance is essential to complement more conventional ‘top-down’ governance approaches. Through extensive literature review of the governance of epidemic-prone infectious threats and AMR, as well as through case studies of the governance of AMR in Bangladesh and of Ebola in Uganda, we illustrate the need for governance to transcend organizational, sectoral, disciplinary and methodological boundaries; and to be sensitive to different socio-cultural and political-economic contexts such as conditions of inequality and vulnerability. The COVID-19 pandemic has underscored the importance of reflecting on what constitutes effective preparedness and response in different settings, prompted debate around how complex social, legal, economic, political and ethical trade-offs can be negotiated.
Part 1: The governance of epidemic-prone infectious disease threats – an overarching review
Part 1a: Governing Ebola in Uganda – a case study
Part 2: The governance of AMR – an overarching review
Part 2b: Governing AMR in Bangladesh – a case study
Hayley MacGregor and Annie Wilkinson
The combined impacts of global travel, mass migration, urbanisation, weakened health systems, changing human-animal interactions, and viral mutations, have given rise to significant infectious disease threats including epidemic-prone infectious disease outbreaks and resistance to antimicrobials. These problems transcend the coping strategies of conventional systems of governance. Furthermore, recent emergences of Ebola and COVID-19, have underscored that responding to threats effectively requires overcoming organizational, sectoral, disciplinary and methodological boundaries, as well as sensitivity to different socio-cultural and political-economic contexts. Inequalities and vulnerabilities have been laid bare, both within countries and globally. Reflections on what constitutes effective preparedness and response in different settings will turn to questions of governance, with further debate around how to negotiate complex social, legal, economic, political and ethical trade-offs in the face of these threats.
This introduction to the report on the governance of infectious disease threats lays out the concepts we employ to broaden the view of governance in this context. Specifically, we aim to promote an understanding of ‘bottom-up’ governance as an essential complement to conventional legal and public health understandings of more ‘top-down’ mechanisms and strategies for managing infectious disease threats. In particular, we draw on social scientific perspectives, which have to date been undervalued with respect to conceptualising new requirements for governance of infectious disease threats.
Access other documents which along with the above document, make up the full report ‘Governing Epidemic-prone Infectious Disease and Antimicrobial Resistance: a Review and Case for Governance “from below”’. Each can be read as a standalone piece at the following links:
Tabitha Hrynick, Hayley MacGregor, Annie Wilkinson and Santiago Ripoll
The emergence and spread of disease has long been a concern of the international community. In today’s highly globalised world, and in the wake of several high-profile disease epidemics such as SARS, Zika, Ebola and now COVID-19, such concern continues to animate global health discourse and debate. ‘Governance’, as applied to emerging epidemic- prone infectious diseases, is almost always used in reference to formal relations and arrangements between global health actors, including: evolving, shifting and/or emerging mechanisms or structures (International Health Regulations, World Health Organization, GOARN, NGOs, Private Public Partnerships); normative orientations and their implications (‘sentinel’ vs prevention approaches); and power (state sovereignty; capacity and authority of WHO; ‘enforceability’ of IHRs etc.). Less frequently is ‘governance’ invoked by scholars considering activity at the community level in the context of epidemic preparedness and response, and thus a considerable gap exists in the literature bridging these discussions – formal arrangements on the one hand, and community level on the other hand. This review attempts to map some of the major debates and discourse around the governance of epidemics which have focused on the global level, as well as to highlight work and analysis with more ‘bottom-up’ perspectives which, while not necessarily articulated through a language of ‘governance’, have implications for how governance is conceptualised and operationalised.
Tabitha Hrynick and David Kaawa-Mafigiri
Over several months of 2000 and into 2001, Uganda gained the distinction as the site of the first large scale outbreak of highly fatal Ebola Virus Disease, endemic to central Africa. Smaller Ebola outbreaks have occurred with increasing frequency in and around Uganda, reflecting the region’s continuing and even intensifying vulnerability to the virus, perhaps due to shifts in environmental, social and economic domains, and the ways in which these systems interact. This case study considers these outbreaks, and the outbreak and epidemic preparedness of the country, in the context of this report’s discussion of governance. In general, Uganda’s handling of its outbreaks has been praised for being quick and effective in spite of challenges, and the country has been held up as a positive model of outbreak preparedness and response. Here, we examine the governance of these outbreaks more closely. In the first half of the report, governance of Ebola in Uganda as might be more conventionally understood – entailing formal structures, institutions, resources, norms and protocols as well as how these have changed over time – is presented. The second half of the report pivots to highlight ‘alternative’ perspectives on governance rooted in social science on Ebola generally and in Uganda. The aim is to make suggestions towards enhancing preparation for and handling of future emergences of Ebola in Uganda and in other low-resource contexts in more equitable and effective ways.
Tabitha Hrynick, Hayley MacGregor, Anne Wilkinson and Santiago Ripoll
Antimicrobial resistance is increasingly recognised as a global priority and a major threat to human health and wellbeing, economies and national and global security. Anxieties about the emergence, movement and transmission of drug-resistant microbes (and genes) in the context of globalisation, and the resulting decreasing utility of antimicrobial drugs, are catalysing calls for action. As with epidemics, the emerging discourse about ‘governance’ in the context of AMR is most frequently tied to the realm of the ‘global’. These discussions generally revolve around the roles and responsibilities of, and formal collaboration between, major global governance entities such as the United Nations (UN), World Health Organization (WHO), Food and Agriculture Organization (FAO), World Organisation for Animal Health (OIE) and World Trade Organisation (WTO), and national governments. Researchers and private actors, including industry and civil society, are also seen as necessary for successful response at these levels, but their roles are less fleshed out in these high-level discourses which focus on institutional relationships and accountability at the global level, and which centre biomedical and technical approaches to response. Increasingly, however, anthropological and other social science researchers have considered the emerging discourses around AMR through more critical lenses, as well as analysed AMR and antimicrobial use as they are embedded in complex social, economic and political contexts and thus provide valuable insight and lessons for governance. This review attempts to map the broad contours of ‘governance’ debates around AMR, and bring these together with perspectives from the social sciences which suggest the importance of greater attention to governance ‘from below’.
Syed Abbas and Tabitha Hrynick (with acknowledgement of assistance from Professor Syed Masud Ahmed)
Antimicrobial resistance is increasingly recognised as a global priority and a major threat to human health and wellbeing, economies and national and global security. Despite the need for effective global efforts, the experiences, perspectives and complexities of AMR and AMR policy making at national and sub-national levels, particularly in low- and middle- income countries (LMICs) are largely overlooked. This case study considers AMR and AMR governance in Bangladesh which at high risk for the emergence of AMR. We describe the policy processes, governance mechanisms, and prevailing discourses that have emerged around AMR in the country in recent years. In keeping with the overarching review’s broader aims, this case study also attempts to bridge conventional understandings of governance – formal institutions, structures, regulations and policy – with more ‘bottom up’ and ‘messy’ perspectives from social science. Such views provide crucial nuance to understandings of the drivers of AMR, and highlight the perspectives, incentives, constraints and capacities of actors ‘from below’ (such as formal and informal health workers, pharmacists, salespeople, patients, farmers and others ‘in the community’) which are often otherwise ignored. We aim to contribute to thinking and policy action around how AMR is being addressed in Bangladesh specifically, as well as to illustrate these lessons for broader application to AMR governance debates in other countries (particularly LMICs) and at the global level where AMR agendas have been set and continue to evolve.
The spread of SARS-CoV-2 to pandemic level has accentuated the importance of effective governance of infectious disease threats. This event underscores that these threats transcend the capacities of conventional systems of governance and that a rethinking is required in order to incorporate additional approaches. As some countries turn inwards and focus on their national-level COVID-19 crises, there are renewed calls for greater global solidarity in this endeavour and a more coordinated system of global health governance. The governance challenges that have guided the analysis in this report – of scale, intersectorality, inclusivity and interdisciplinarity – are as critically relevant today as they have been to past and future infectious threats. The conclusion to this report* reflects on these challenges, and on how ‘bottom-up’ approaches to governance can serve as vital complements to governance initiatives ‘from above’. By drawing on social scientific perspectives, we hope to contribute to a rethinking of the governance of infectious threats at this prescient juncture – one which embraces an awareness of power relations and how these shape interests and interventions; attention to citizen state relations and the place of deliberative dialogue; and the value in uncertain times of adaptive and flexible leadership that can respond iteratively to acute as well as slowly unfolding crises. We hope that these perspectives might in the future lead to forms of governance of infectious disease threats that can be more effective and acceptable to the wide range of people affected by these problems.