This is one of a series of Stories of Change from the ESRC STEPS Centre.
From avian flu and Ebola to the Covid-19 pandemic, STEPS research uncovered the controversies and politics of disease outbreaks and global health.
In 2019, the Covid-19 pandemic starkly highlighted the social and political nature of disease dynamics and response. While Covid-19 is on a different scale with far larger effects than many past outbreaks, similar patterns have been shown for other diseases.
STEPS Centre research over the past 15 years has focused on understanding the political and social dimensions of disease, and the lessons learned have proved highly relevant to the challenges of responding to Covid-19.
The STEPS Centre’s research on epidemics goes back to 2007, with research on avian influenza (H5N1).
Like Covid-19 and Ebola, avian flu is a zoonotic disease — emerging through contact of humans with animals. This means that responses needed to look not just at caring for human patients, but at the changing ways that birds are kept and farmed, and food is produced. It means that vets, doctors, scientists, farmers, politicians, consumers and international agencies were all involved in different ways.
The STEPS project focused on four countries in South-East Asia: Cambodia, Indonesia, Thailand and Vietnam, working with the UN Food and Agriculture Organisation (FAO) under its Pro-Poor Livestock Policy Initiative.
The aim was to understand the policies and politics around avian flu, the assumptions made and how debates are framed by different people. Who would win and lose from different responses to avian flu, and could these be crafted in a way that could cope with uncertainty and surprise?
Even before the project ended, the world was facing a potential pandemic in the form of swine flu.
The lessons learned on avian influenza were compiled in a 2010 book, containing many important implications for the response to COVID-19 a decade on. STEPS work on epidemics looked comparatively at other diseases (include SARS, HIV/AIDS and haemorrhagic fevers, aiming to draw wider lessons on how to confront epidemics, and particularly the social and political dimensions.
lessons from ebola
This work became central to work during the West African Ebola epidemic that broke out in 2014, the first to hit the region and the worst ever recorded. Most of the cases were in Guinea, Liberia and Sierra Leone. By October the disease had killed nearly 5,000 people.
As the outbreak grew, more and more agencies in the region and beyond joined the fight against it. Attention also turned to the dynamics of the outbreak, how best to prevent its spread, and how to treat people safely and effectively in urgent and sometimes chaotic conditions. As well as fighting the disease on the ground, it was important to understand the reasons behind its spread, and the social and cultural responses to it.
Why did the Ebola outbreak get as bad as it did, and what can we learn from the response? The scale and speed of the outbreak was put down to weak health systems, a lack of resources, and fear. But there were other factors too. It became clear that violence in the region had left a deep legacy of mistrust in the population, leading to rumours and suspicion of health workers. Changing patterns of migration may also have led people to be more at risk.
Beyond this, there lay a deeper and less obvious history — largely ignored in the urgency of the response. This was the reality of structural violence — long term exclusions and injustices affecting the countries and communities involved. It wasn’t just that these countries (among the poorest in the world) were more vulnerable because of poverty and a lack of development: it could be said that the histories of inequality actually shaped the rhetoric, institutions and governance at international level that should have moved quickly to help.
Structural violence also influenced how much attention was given to different voices and perspectives in responding to the disease — something that turned out to be highly important for Ebola.
learning from anthropology
In 2014, the STEPS Centre project had to drop its original plans in Sierra Leone when Ebola broke out. Medical facilities and resources were diverted to deal with treatment and prevention. Researchers joined together to apply lessons from their work on epidemics to the current crisis.
One response was to share research on the social, cultural and political aspects of Ebola, in ways that could help to guide medical interventions. With colleagues at other institutions in the UK, USA and Sierra Leone, they set up the Ebola Response Anthropology Platform (ERAP), a website to bring together relevant existing and emerging research (now linked to the wider Social Science in Humanitarian Action Platform — SSHAP).
A related project, part-funded by STEPS, Ebola: lessons for development initiatives, aimed to ask long term and serious questions about how current development models and practices might have contributed to the unfolding crisis — looking beyond the immediate response to the disease.
Cumulatively, the Ebola initiatives influenced and engaged high-level actors including UN Mission for Ebola Emergency Response, as well as across UK and other government departments.
Mark Walport, then the UK government’s Chief Scientific Adviser, reflected that the case of Ebola highlighted “the central contribution of the social sciences and humanities to informed decision-making” — with implications for scientific advice in other fields. The team won an ESRC prize for outstanding international impact.
why are pandemics so controversial?
A common thread in the stories of pandemics was that, although there seemed to be a clear case for preparing for them, governments often took much persuasion to come to the planning table. One reason appeared to be that so many aspects of preparing for pandemics were deeply controversial. Access to medicines and intellectual property for vaccines were hotly debated; there were even arguments about what to call swine flu.
In a workshop at the Institute of Development Studies in 2013, STEPS explored what could be learned from these controversies. The event, co-organised with the Centre for Global Health Policy, brought together academics with those working in international agencies related to public health, including the UN Food and Agriculture Organisation (FAO), the International Livestock Research Institute, the World Bank and the World Health Organisation (WHO).
It seemed that controversies would always arise around preparing for pandemic flu: which interventions should we put in place to protect public health? What effects would they have for different people? Are rich countries given greater priority than poor ones? What do local people in different parts of the world want, and how does this clash with what scientists or politicians think is important?
Beyond medical concerns, there will always be questions of economics, politics and justice involved in responding to disease. This has become very clear during the COVID-19 pandemic.
Reflecting on pandemic influenza — alongside other infectious diseases, our work has highlighted the importance of embracing uncertainty and including different sources of knowledge in planning and preparation.
dynamic drivers of disease
In 2011, the STEPS Centre became a leading partner in another research initiative, the Dynamic Drivers of Disease in Africa Consortium, focusing on four zoonotic diseases (Lassa fever, Henipavirus, Rift Valley fever and trypanosomiasis) in five African countries. As a multidisciplinary project, it included environmental, biological, mathematical, social, political, and animal and human health researchers from 21 partners across three continents.
The mix of disciplines would help in understanding the complex relationships between disease, ecosystems and poverty — in particular how wider global patterns such as climate and land-use change affect how diseases emerge and spread.
When it concluded, Dynamic Drivers published a set of impact stories showing how its research had helped to inform decision making for the future, alongside a major set of articles in the Philosophical Transactions of the Royal Society plus a book highlighting the importance of a ‘One Health’ approach.
A One Health approach means that researchers from different disciplines have to work together and try to integrate their analysis — a challenging task, but one that is increasingly called for in public health research.
Working with field practitioners, policy-makers, medical doctors, veterinarians, disease ecologists and others, STEPS Centre work has aimed to bring a critical social science perspective to the complex challenges of disease preparedness and response.
Working across multiple institutions and disciplines, collaborative work has to overcome differences in language, what assumptions they made about how things work, what methodologies and data they used and how their data could be combined and interpreted.
But collaborative research on major global challenges takes time and requires new ways of working and innovative frameworks and methodologies to make connections that make a difference.
STEPS Centre work continued on questions of disease outbreaks and their response, with a particular focus on zoonoses, including collaborations with the Tanzania-based Livestock, Livelihoods and Health project, and a project on pig-farming and disease in Myanmar.
Interdisciplinary research may be a hot topic, but there are reasons why researchers find it difficult to get involved — from how the research is valued and evaluated, to the need for younger researchers to specialise early, and the way funding is structured. The UK’s Global Challenges Research Fund was established with a call for ‘challenge-led’ research that addresses “complex, protracted and multi-faceted” issues, requiring an holistic, whole-system view.
The STEPS Centre’s experience provides important lessons for the kind of relationships and methods for such research, showing how how researchers, practitioners, governments, health workers and citizens can work together.
These lessons are absolutely critical to the COVID-19 pandemic. As we must prepare for inevitable future pandemics now, learning how to work together across boundaries, and put social and political questions at the centre is vital.
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Stories of Change
From 2006-2021, the ESRC STEPS Centre explored pathways to sustainability – showing the important roles that marginalised ideas, knowledge and forms of action could play in responding to complex social, technological and environmental challenges.
In this process, we were involved in many process of change, from local struggles to high-level international debates. These Stories of Change explore some key themes from STEPS work, to share what we learned.