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In epidemic preparedness and response, it is now commonly accepted that insights from social science disciplines are important in shaping action. Unfortunately, the role of social science is often confined to risk communication and community engagement (RCCE) efforts. In this article, we propose an analytical framework that would allow researchers and practitioners from different disciplines to employ social science insights to enrich their understanding of epidemics and formulate more effective and sustainable responses. The framework goes beyond simply unpacking social, political, economic and cultural dimensions of context; it situates disease itself – as it is shaped by the contexts in which it circulates – and views it in dynamic relation to response. It also explores how different individuals, social groups and institutions shift their knowledge and practices during an epidemic through power-laden processes of dialogue and learning, or even through silencing and side-lining. It is our hope that this framework will enable responders to engage more deeply and systematically with the contexts of emergencies, so as to ensure activities are more adaptive to local dynamics.

The cost of the Covid-19 pandemic remains unknown. Lives directly lost to the disease continue to mount, while related health, livelihood and wellbeing impacts are still being felt, and the wider ramifications across society, politics and the economy are yet to fully materialise. What is known about these costs though, is that they have been unequally distributed both within and between countries. Preparedness plans proved inadequate in many settings – especially when it came to protecting those most vulnerable, including those marginalised by geography, poverty, or exclusion along the lines of religion, ethnicity or gender. The top-down, surge-style, biomedically dominated and technologically driven preparedness approach that has dominated global health thinking and which was propelled into action with Covid-19 was found wanting not only on the grounds of effectiveness, but also of social justice. This presents both a challenge and an opportunity for a convergence of the preparedness and development agendas. Drawing on a growing body of social science evidence, this report contends that securing health in the face of today’s uncertain disease threats in often unpredictable settings means making social, economic and political priorities as core to the preparedness agenda as biological and technological ones. We present here a framework for a vision of pandemic preparedness for the real world – one that accepts that context is paramount, embraces inclusivity and justice, shifts power centres and rejects simplistic, one-size-fits-all solutions.

This paper argues for a rethinking of disease preparedness that puts incertitude and the politics of knowledge at the centre. Through examining the experiences of Ebola, Nipah, cholera and COVID-19 across multiple settings, the limitations of current approaches are highlighted. Conventional approaches assume a controllable, predictable future, which is responded to by a range of standard interventions. Such emergency preparedness planning approaches assume risk - where future outcomes can be predicted - and fail to address uncertainty, ambiguity and ignorance - where outcomes or their probabilities are unknown. Through examining the experiences of outbreak planning and response across the four cases, the paper argues for an approach that highlights the politics of knowledge, the constructions of time and space, the requirements for institutions and administrations and the challenges of ethics and justice. Embracing incertitude in disease preparedness responses therefore means making contextual social, political and cultural dimensions central.

This paper highlights the major challenges and considerations for addressing COVID-19 in informal settlements. It discusses what is known about vulnerabilities and how to support local protective action. There is heightened concern about informal urban settlements because of the combination of population density and inadequate access to water and sanitation, which makes standard advice about social distancing and washing hands implausible. There are further challenges to do with the lack of reliable data and the social, political and economic contexts in each setting that will influence vulnerability and possibilities for action. The potential health impacts of COVID-19 are immense in informal settlements, but if control measures are poorly executed these could also have deep negative impacts. Public health interventions must be balanced with social and economic interventions, especially in relation to the informal economy upon which many poor urban residents depend. Local residents, leaders and community-based groups must be engaged and resourced to develop locally appropriate control strategies, in partnership with local governments and authorities. Historically, informal settlements and their residents have been stigmatized, blamed, and subjected to rules and regulations that are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Priorities for enabling effective control measures include: collaborating with local residents who have unsurpassed knowledge of relevant spatial and social infrastructures, strengthening coordination with local governments, and investing in improved data for monitoring the response in informal settlements.

This article offers an ethnographic and frame analysis of how Mexican anti-gender campaigners have leveraged Mexico’s twin crises of corruption and security to cast “gender ideology” strategically ...

This paper applies an intersectional lens to health in informal urban settlements in Freetown, Sierra Leone. We explored how intersecting social characteristics including gender, age, wealth, occup...

COVID-19 has forced a reckoning about how we live, and in particular how exposure to disease risks are unevenly distributed. This contribution explores connections between the COVID-19pandemic, chr...

International audience; This article shares findings on COVID-19 in Africa across 2020 to examine concepts and practices of epidemic preparedness and response. Amidst uncertainties about the trajectory of COVID-19, the stages of emergency response emerge in practice as interconnected. We illustrate how complex dynamics manifest as diverse actors interpret and modify approaches according to contexts and experiences. We suggest that the concept of "intersecting precarities" best captures the temporalities at stake; that these precarities include the effects of epidemic control measures; and that people do not just accept but actively negotiate these intersections as they seek to sustain their lives and livelihoods.

The Covid-19 pandemic is more than a health crisis. It has worse outcomes among individuals with co-morbidities, has exposed fault lines in our societies, and amplified existing inequalities. This article draws on emerging evidence from low- and middle-income contexts to highlight how Covid-19 becomes syndemic when it interacts with local vulnerabilities. A syndemic approach provides a frame for understanding how Covid-19 is amplified when clustered with other diseases and how this clustering is facilitated by contextual and social factors that create adverse conditions. Public health responses to Covid-19 have also exacerbated these adverse conditions as many face social and economic crises as a result of some policies. These multiple challenges generate major implications for both the public health response and for broader development action: first, one size does not fit all and we must attend to local vulnerabilities; second, short-term public health response and longer-term development approaches must be integrated for improved intersectoral coordination and synergy. A synergised public health and development response will allow us to better prepare for the next pandemic.

Highlights • COVID-19, an unprecedented health and development crisis, has exposed major faultlines and fragilities in current systems. • A novel conceptual framework grounded in a decade of research on epidemics and development emphasises a structural-unruly duality in the conditions and processes of emergence, progression and impact. • Mainstream development thinking and practice are part of the problem; post-pandemic futures require radical transformations in science-policy under uncertainty; economies, and citizen-state relations. • Post-COVID-19 development must fully embrace resilience, diversity, care and solidarity, and egalitarian, inclusive knowledge and politics., COVID-19 is proving to be the long awaited ‘big one’: a pandemic capable of bringing societies and economies to their knees. There is an urgent need to examine how COVID-19 – as a health and development crisis - unfolded the way it did it and to consider possibilities for post-pandemic transformations and for rethinking development more broadly. Drawing on over a decade of research on epidemics, we argue that the origins, unfolding and effects of the COVID-19 pandemic require analysis that addresses both structural political-economic conditions alongside far less ordered, ‘unruly’ processes reflecting complexity, uncertainty, contingency and context-specificity. This structural-unruly duality in the conditions and processes of pandemic emergence, progression and impact provides a lens to view three key challenges areas. The first is how scientific advice and evidence are used in policy, when conditions are rigidly ‘locked in’ to established power relations and yet so uncertain. Second is how economies function, with the COVID-19 crisis having revealed the limits of a conventional model of economic growth. The third concerns how new forms of politics can become the basis of reshaped citizen-state relations in confronting a pandemic, such as those around mutual solidarity and care. COVID-19 demonstrates that we face an uncertain future, where anticipation of and resilience to major shocks must become the core problematic of development studies and practice. Where mainstream approaches to development have been top down, rigid and orientated towards narrowly-defined economic goals, post-COVID-19 development must have a radically transformative, egalitarian and inclusive knowledge and politics at its core.

The heterogeneous epidemiological picture for COVID-19 in Africa continues to generate debate. Modelling projections raise speculation about the phases and trends of SARS-CoV-2 outbreaks across the continent and how these differ from outbreaks elsewhere.[1–4][1] Continental efforts drew praise in

This paper highlights the major challenges and considerations for addressing COVID-19 in informal settlements. It discusses what is known about vulnerabilities and how to support local protective action. There is heightened concern about informal urban settlements because of the combination of population density and inadequate access to water and sanitation, which makes standard advice about social distancing and washing hands implausible. There are further challenges to do with the lack of reliable data and the social, political and economic contexts in each setting that will influence vulnerability and possibilities for action. The potential health impacts of COVID-19 are immense in informal settlements, but if control measures are poorly executed these could also have severe negative impacts. Public health interventions must be balanced with social and economic interventions, especially in relation to the informal economy upon which many poor urban residents depend. Local residents, leaders and community-based groups must be engaged and resourced to develop locally appropriate control strategies, in partnership with local governments and authorities.Historically, informal settlements and their residents have been stigmatized, blamed, and subjected to rules and regulations that are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Priorities for enabling effective control measures include: collaborating with local residents who have unsurpassed knowledge of relevant spatial and social infrastructures, strengthening coordination with local governments, and investing in improved data for monitoring the response in informal settlements.

By September 2014, it was clear that conventional approaches to containing the spread of Ebola in West Africa were failing. Public health teams were often met with fear, and efforts to treat patients and curtail population movement frequently backfired. Both governments and international agencies recognized that anthropological expertise was essential if locally acceptable, community-based interventions to interrupt transmission were to be designed. The Ebola Response Anthropology Platform was established against this background. Drawing together local and internationally based anthropologists, the Platform provided a coordinated and rapid response to the outbreak in real time. This social thought & commentary piece explores how the Platform developed and interacted with other epistemic communities to produce knowledge and policy over the course of the outbreak. Reflecting on the experiences of working with the UK Department for International Development, the World Health Organization, and other agencies, we ask: what do these experiences reveal about the politics of (expert) knowledge and its influence on the design and implementation of policy? Did differing conceptions of the place of anthropology in humanitarian crises by policymakers and practitioners shape the contributions made by the Ebola Response Anthropology Platform? What are the implications of these experiences for future anthropological engagement with, and research on, humanitarian responses to health crises?

Global risks of zoonotic disease are high on policy agendas. Increasingly, Africa is seen as a ‘hotspot’, with likely disease spillovers from animals to humans. This paper explores the social dynamics of disease exposure, demonstrating how risks are not generalised, but are related to occupation, gender, class and other dimensions of social difference. Through case studies of Lassa Fever in Sierra Leone, Henipah virus in Ghana, Rift Valley Fever in Kenya and Trypanosomiasis in Zimbabwe, the paper proposes a social difference space–time framework to assist the understanding of and response to zoonotic diseases within a ‘One Health’ approach.

International audience

This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.

The WHO launched a Global Action Plan on antimicrobial resistance (AMR) in 2015. World leaders in the G7, G20 and the UN General Assembly have declared AMR to be a global crisis. World leaders have also adopted universal health coverage (UHC) as a key target under the sustainable development goals. This paper argues that neither initiative is likely to succeed in isolation from the other and that the policy goals should be to both provide access to appropriate antimicrobial treatment and reduce the risk of the emergence and spread of resistance by taking a systems approach. It focuses on outpatient treatment of human infections and identifies a number of interventions that would be needed to achieve these policy goals. It then shows how a strategy for achieving key attributes of a health system for UHC can take into account the need to address AMR as part of a UHC strategy in any country. It concludes with a list of recommended priority actions for integrating initiatives on AMR and UHC.

This paper argues for an integrative modelling approach for understanding zoonoses disease dynamics, combining process, pattern and participatory models. Each type of modelling provides important insights, but all are limited. Combining these in a ‘3P’ approach offers the opportunity for a productive conversation between modelling efforts, contributing to a ‘One Health’ agenda. The aim is not to come up with a composite model, but seek synergies between perspectives, encouraging cross-disciplinary interactions. We illustrate our argument with cases from Africa, and in particular from our work on Ebola virus and Lassa fever virus. Combining process-based compartmental models with macroecological data offers a spatial perspective on potential disease impacts. However, without insights from the ground, the ‘black box’ of transmission dynamics, so crucial to model assumptions, may not be fully understood. We show how participatory modelling and ethnographic research of Ebola and Lassa fever can reveal social roles, unsafe practices, mobility and movement and temporal changes in livelihoods. Together with longer-term dynamics of change in societies and ecologies, all can be important in explaining disease transmission, and provide important complementary insights to other modelling efforts. An integrative modelling approach therefore can offer help to improve disease control efforts and public health responses. This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

This article explores the implications for human health of local interactions between disease, ecosystems and livelihoods. Five interdisciplinary case studies addressed zoonotic diseases in African settings: Rift Valley fever (RVF) in Kenya, human African trypanosomiasis in Zambia and Zimbabwe, Lassa fever in Sierra Leone and henipaviruses in Ghana. Each explored how ecological changes and human–ecosystem interactions affect pathogen dynamics and hence the likelihood of zoonotic spillover and transmission, and how socially differentiated peoples’ interactions with ecosystems and animals affect their exposure to disease. Cross-case analysis highlights how these dynamics vary by ecosystem type, across a range from humid forest to semi-arid savannah; the significance of interacting temporal and spatial scales; and the importance of mosaic and patch dynamics. Ecosystem interactions and services central to different people's livelihoods and well-being include pastoralism and agro-pastoralism, commercial and subsistence crop farming, hunting, collecting food, fuelwood and medicines, and cultural practices. There are synergies, but also tensions and trade-offs, between ecosystem changes that benefit livelihoods and affect disease. Understanding these can inform ‘One Health’ approaches towards managing ecosystems in ways that reduce disease risks and burdens.This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

TEN MONTHS AFTER THE FIRST INFECTION, Margaret Chan, Director-General of the World Health Organization, described the Ebola epidemic in West Africa as the ‘most severe acute public health emergency in modern times’. The disaster, she said, represents a ‘crisis for international peace and security’ and threatens the ‘very survival of societies and governments in already very poor countries’. As of October 2014, the disease had killed 4,951 and infected 13,567. It has crippled families, health systems, livelihoods, food supplies and economies in its wake. These numbers are likely to be vastly underestimated. How did it get to this? Why has this outbreak been so much larger than previous ones? The scale of the disaster has been attributed to the weak health systems of affected countries, their lack of resources, the mobility of communities and their inexperience in dealing with Ebola. This answer, however, is woefully de-contextualized and de-politicized. This briefing examines responses to the outbreak and offers a different set of explanations, rooted in the history of the region and the political economy of global health and development. To move past technical discussions of “weak” health systems, this briefing highlights how structural violence has contributed to the epidemic. Structural violence refers to the way institutions and practices inflict

Summary Many low and middle-income countries have pluralistic health systems with a variety of providers of health-related goods and services in terms of their level of training, their ownership (public or private) and their relationship with the regulatory system. The development of institutional arrangements to influence their performance has lagged behind the spread of these markets. This paper presents a framework for analysing a pluralistic health system. The relationships between private providers of health services and government, or other organisations that represent the public interest, strongly influence their performance in meeting the needs of the poor. Their impact on the pattern of service delivery depends on how the relationships are managed and the degree to which they respond to the interests of the population. Many governments of low and middle-income countries are under pressure to increase access to safe, effective and affordable health services. In a context of economic growth, it should be possible to improve access by the poor to health services substantially. Innovations in information technologies and in low cost diagnostics are creating important new opportunities for achieving this. It will be important to mobilise both public and private providers of health-related goods and services. This will involve big changes in the roles and responsibilities of all health sector actors. Governments, businesses and civil society organizations will need to learn how to make pluralist health systems work better through experimentation and systematic learning about what works and why.

This paper argues that addressing the underlying structural drivers of disease vulnerability is essential for a ‘One Health’ approach to tackling zoonotic diseases in Africa. Through three case studies—trypanosomiasis in Zimbabwe, Ebola and Lassa fever in Sierra Leone and Rift Valley fever in Kenya—we show how political interests, commercial investments and conflict and securitization all generate patterns of vulnerability, reshaping the political ecology of disease landscapes, influencing traditional coping mechanisms and affecting health service provision and outbreak responses. A historical, political economy approach reveals patterns of ‘structural violence’ that reinforce inequalities and marginalization of certain groups, increasing disease risks. Addressing the politics of One Health requires analysing trade-offs and conflicts between interests and visions of the future. For all zoonotic diseases economic and political dimensions are ultimately critical and One Health approaches must engage with these factors, and not just end with an ‘anti-political’ focus on institutional and disciplinary collaboration.This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

Background The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening. Methods This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams’ experiences along four potential uses of ToCs, namely planning, communication, learning and accountability. Results The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams’ experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams’ initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes. Conclusions The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0272-y) contains supplementary material, which is available to authorized users.

International audience

This chapter examines science-policy processes for Lassa fever, a rodent-borne viral haemorrhagic fever (VHF) in West Africa, and explores some unique practicalities and politics of zoonotic disease control. In 2014, the Ebola outbreak in West Africa once again brought zoonotic diseases to the forefront of the international community's attention. The surprise and horror that the Ebola epidemic provoked, including in Sierra Leone, was a reminder of the value of One Health, but also of considerable unmet challenges in realizing it. In securitization debates, biosecurity priorities are often portrayed as being in opposition to those of public health. Public health efforts and investments in biosecurity have improved the management of Lassa fever but not in ways that have translated into sustained and wide-ranging health systems strengthening, or in improved understandings of the interactions between human and animal health needed for effective disease management.

Ebola is the most severe acute public health emergency seen in modern times. Begun in December 2013 in the Republic of Guinea, the West African Ebola epidemic has attracted unprecedented global attention. The Ebola epidemic provides a unique vantage point to inspect the processes that transform a single zoonotic spillover event into a transnational medical humanitarian disaster in some localities but not others. The concept of structural violence, first proposed by Galtung and refined by Farmer in relation to global health, refers to the ways in which institutions inflict avoidable harm to people by barring access to basic human needs, often in ways that normalize these practices to those most affected. Structural violence is manifest and maintained by a set of interlocking institutions that, across different spatial and temporal planes, act as vectors for interrelated patterns of economic, political, judicial and social exclusions and injustices.

International audience

Sierra Leone and Guinea share broadly similar cultural worlds, straddling the societies of the Upper Guinea Coast with Islamic West Africa. There was, however, a notable difference in their reactions to the Ebola epidemic. As the epidemic spread in Guinea, acts of violent or everyday resistance to outbreak control measures repeatedly followed, undermining public health attempts to contain the crisis. In Sierra Leone, defiant resistance was rarer. Instead of looking to ‘culture’ to explain patterns of social resistance (as was common in the media and in the discourse of responding public health authorities) a comparison between Sierra Leone and Guinea suggests that explanations lie in divergent political practice and lived experiences of the state. In particular the structures of state authority through which the national epidemic response were organised integrated very differently with trusted institutions in each country. Predicting and addressing social responses to epidemic control measures should assess such political-trust configurations when planning interventions.

The high-profile LGBT rights gains of the last decade remain innaccessible or irrelevant for much of Latin America’s LGBT population.

The emergence and spread of antibiotic resistant pathogens poses a big challenge to policy-makers, who need to oversee the transformation of health systems that evolved to provide easy access to these drugs into ones that encourage appropriate use of antimicrobials, whilst reducing the risk of resistance. This is a particular challenge for low and middle-income countries with pluralistic health systems where antibiotics are available in a number of different markets. This review paper considers access and use of antibiotics in these countries from a complex adaptive system perspective. It highlights the main areas of intervention that could provide the key to addressing the sustainable long term use and availability of antibiotics.A focus on the synergies between interventions addressing access strategies, antibiotic quality, diagnostics for low-resource settings, measures to encourage just and sustainable decision making and help seeking optimal therapeutic and dosing strategies are key levers for the sustainable future of antibiotic use. Successful integration of such strategies will be dependent on effective governance mechanisms, effective partnerships and coalition building and accurate evaluation systems at national, regional and global levels.