World Zoonoses Day, on July 6 every year, is a reminder of the continuing problem of emerging diseases, particularly those originating in animals. Zoonoses have dominated policy debates in the past years – from SARS to avian influenza to Ebola. There have been calls to control ‘at source’ and stamp out such diseases through a range of draconian measures, lest they create havoc for the global economy and spread, particularly to richer settings in the global North.
To challenge this simplistic narrative, we need to raise questions around social justice, asking who is affected by such diseases and where.
Although zoonoses can spread far and wide, they are often diseases of poverty, the result of neglect and marginalisation: for example, Rift Valley fever and trypanosomiasis (sleeping sickness), which are the consequence of exposure to vectors that only occur in certain landscapes. The way these diseases emerge is influenced by ecology, economic conditions, patterns of inequality, land use and settlement, as well as social, cultural and political factors.
Responding to disease and building sustainable health systems is about tackling such complexities head on. The One Health approach – which links ecosystem, veterinary and human health – is a key and growing response.
In our book series, Pathways to Sustainability, and the STEPS Centre’s work in general, three themes are central to understanding how pathways to sustainability emerge in response to health and disease challenges:
- Social justice (who wins or loses from disease and how health policy is focused).
- Politics (how health and disease responses are framed, both locally and internationally).
- Governance (how health policies are defined, and how health technologies are regulated and controlled).
Social justice and epidemics
In the book Epidemics: Science, Governance and Social Justice, Sarah Dry and Melissa Leach point out that there are many silences in dominant narratives around disease and health policy.
People living with disease often do not get a look-in when policies are being constructed. Such policies are driven by often elite scientific, commercial or government interests, and too often ignore questions of inequality and social justice.
And dominant narratives, which often identify particular diseases as ‘exceptional’, mobilise huge amounts of money and energy. In doing so, they shape the institutional and political landscape, creating certain pathways in disease response and excluding others.
Such dominant narratives include a number of features. One is a focus on disease eradication: a strong, powerful, top-down response, using all the benefits of science. Another is a focus on short-term, emergency responses, which can be mobilised around an outbreak.
Located in global circuits of power, and presented as modern and scientific, such policy frames have enormous influence, propagated as they are through international institutions, multinational business and science-policy networks.
Such framings, of course, miss other perspectives. One is ‘co-infection’, where people, especially those who are poor, are infected by multiple diseases that interact. Another is context: diseases and people interact in context, and in relation to different occupations and livelihoods, and so not all people will get infected. These issues are marked by inequality and social injustice.
Politics & avian flu
Politics are central to health policy, despite the appearance that simple, objective scientific criteria dominate. The book Avian Influenza: Science, Policy, Politics explores the international response to avian influenza outbreaks in the mid-2000s, asking whether the existing global institutional architecture is fit for purpose.
A series of ‘outbreak narratives’ defined the response to avian flu – emerging:
- from veterinarians, arguing that addressing the cause (chickens and ducks) was central;
- from public health professionals, arguing that the major risks were to humans, and stopping spread was essential; and
- from disaster and emergency planners, arguing that pandemic preparedness, including ensuring on-going surveillance and installing robust response systems, was the most important factor.
When you map the diversity of actors involved in the response, a confusing picture emerges. Some dominant interests are important – not least northern governments desperate to ensure that a major pandemic did not occur, along with industry players eager to supply the drugs and vaccines as part of a technocratic solution to the challenge – and able to sway the debate.
All of these narratives and interests once again ignore alternatives, articulated by local people.
Politics: Lassa fever and trypanosomiasis
How global interests affect the politics of disease responses is illustrated in the chapter ‘Beyond Biosecurity: The Politics of Lassa Fever in Sierra Leone’ by Annie Wilkinson, from the book One Health: Science, Politics and Zoonotic Disease in Africa. Lassa fever virus is defined as Category A by the Centers for Disease Control. This means it is a potential weapon of terror, and so a biosecurity hazard.
This ‘securitisation’ of the disease has major implications. Funding has flowed in large amounts to what was previously seen as a neglected disease of poor people living in West Africa.
Once it was considered a priority pathogen, Lassa garnered global attention, and so huge investments in drugs and vaccines to stop its spread. But relying solely on biomedical solutions “overlooks the realities and perspectives of the people at risk of the disease”, and such interventions notionally focused on such settings are likely to have limited effect.
Science, technology and policy processes are also bound up with efforts in southern Africa to control trypanosomiasis and the tsetse fly that carries the disease. A range of interventions have been applied: ‘scorched earth’ wildlife extermination, massive chemical spraying campaigns, the release of sterile males, baits and traps, and attempts to find appropriate drugs and vaccines to stop the vector or control the disease. None has worked completely, and all have been advocated by particular groups, each with their favoured control methods.
How should health be governed?
In the context of rapid marketisation, with high degrees of informality and with a pluralised health system with diverse providers, both public and private, what institutional and governance systems ensure that health services reach the poor, and assure sustainability?
Conventional responses, based on richer, northern experiences and models, often do not work where the divide between public and private provision is blurred, where there are large informal and highly segmented markets providing health goods and services, where regulatory control is limited and where policy implementation is patchy.
This, though, describes most of the world, and nearly all the world where poor people live (including in richer, northern countries).
Building trust and legitimacy
If we accept this reality, what then are the institutional and governance responses required? At the core is the need to build trust in institutions, such that regulatory regimes gain legitimacy in the eyes of ordinary people, who then see such institutions as responding to their needs.
So what is the future for One Health approaches? In the book One Health: Science, Politics and Zoonotic Disease in Africa, Kevin Bardosh explains how the “dynamics of power and politics shape the origin, distribution and consequences of zoonotic infections, as well as the assemblages of research and policy processes that accompany them”.
More effective governance will emerge, he argues, only with a shifting of conceptual boundaries in health policy from a focus on pathogens to politics. Dominated by medical doctors or veterinarians, health policy is often distorted by a single disease focus, without seeing the bigger picture.
Linking science, technology and participation
Realising better health and wellbeing on the ground, especially in poorer countries, requires linking science, technology and participation in new ways. Rather than the standard technology transfer approach (the techno-economic fix to problems) a more systemic approach is needed. This requires insights from local people living with and responding to disease on a day-to-day basis.
Rather than ‘big data’ and ‘big systems’, ‘small data’ and ‘localised systems’ may be needed. This should not rely on a romantic notion of ‘community’, but instead on a reconfiguration of state and citizen relationships as part of a shift in governance responses.
Plural forms of knowledge and expertise must be accepted as central to any governance system: many knowledges count, not only biomedical knowledge and techno-scientific expertise.
But donor-driven agendas, powerful elite science, fragmented national policy systems, weak capacities for implementation and influential commercial interests all run against a more horizontal, integrated One Health agenda.
Building new pathways to health and sustainability requires some major shifts in thinking and practice. These must take inequality and social justice seriously, and must make politics and political economy at the heart of any response that reshapes governance.
Such perspectives on health and wellbeing – and preventing the emergence and spread of disease, whether of zoonotic origin or not – should be at the centre of any sustainable development agenda, and are a vital step to realising the Sustainable Development Goals.
This blog post is an edited version of the introduction to Pathways to Health and Sustainability, the second in a series of ‘FreeBooks’ from the STEPS Centre. The FreeBook provides open access to chapters from STEPS books on health & disease from the last decade, drawing on the Pathways to Sustainability series published by Routledge.