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Slums and informal settlements have long been a policy concern, particularly in post-independence cities of the global South. Although national and local governments devise public policy seeking to address these habitations, these policy initiatives occur in conversation with the often far less visible global policy discourses of international urban development actors. Positing their ideational influence, this study analyses how global discourses from key multilateral agencies and donors have framed the problem of slums and informal settlements over time, to uncover assumptions and biases that ideationally, if indirectly, contribute to urban inequality, marginalization and socio-spatial othering in the city.

This working paper is the product of the Living Off-Grid Food and Infrastructure Collaboration. It is designed to bring together our thinking on how infrastructure can shape the food and nutritional security of urban marginalised populations. Infrastructure assemblages include the material (physical and technological), as well as the political and systemic factors that ‘govern’ how infrastructure is developed and used. Urban food systems are made up of public and private actors, and market and governance processes that shape the cost and availability of food in different urban contexts. At the intersection of urban food systems and infrastructure assemblages lies the food and nutrition security of urban dwellers. The framing of contemporary debates and policy priorities with respect to both nutrition and infrastructure are heavily conditioned by presumptions – in favour of formality and griddedness, for example, or of the need to raise agricultural productivity – which fail to reflect the reality of marginalised communities in Southern cities. For these communities, their experience is one of hybridity, with formal and informal infrastructures and economies central to their lives and livelihoods. These hybrid arrangements are imbued with power structures and socio-political dynamics that are context specific and further condition communities’ experiences. Together, these are the factors that condition or shape the possibilities for individuals and households pursuing different food strategies. However, there is a failure to reflect this reality in the conceptualisation of infrastructure challenges, leading to unworkable solutions and policies that end up perpetuating problems. There is an urgent need to reframe problematic assumptions, starting first and foremost from the entry point of urban informal settlements in the global South. By taking food as a lens in this process, we illuminate these contexts, and how they relate to hybrid infrastructure arrangements and potential alternatives. This reformulation is vital at this critical juncture, when Southern cities need infrastructure development that meets the needs of rapidly changing demographics without locking cities and nations into unsustainable pathways.

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.

Childhood obesity is a growing global challenge, and no country has yet reversed the upward trend in prevalence. The causes are multifaceted, spanning individual, societal, environmental, and political spheres. This makes finding solutions complex as traditional linear models of treatment and effect have proven only minimally successful or unfeasible at the population level. There is also a paucity of evidence of what works, and few examples of intervention that operate on a ‘whole systems’ level. The city of Brighton in the United Kingdom has experienced a downward trend in child obesity rates compared to national figures. The aim of this study was to explore what has led to successful change in the city. This was done through a review of local data, policy and programs, and thirteen key informant interviews with key stakeholders involved in the local food and healthy weight agenda. Our findings highlight key mechanisms that have plausibly contributed to a supportive environment for obesity reduction in Brighton according to key local policy and civil society actors. These mechanisms include; a commitment to early years intervention such as breastfeeding promotion; a supportive local political context; the ability to tailor interventions to community needs; governance structures and capacity that enable cross-sectoral collaboration; and a citywide framing of obesity solutions in the context of a ‘whole system’ approach. However, substantial inequalities persist in the city. Engaging families in areas of high deprivation and operating in an increasingly difficult context of national austerity are persistent challenges. This case study sheds light on some mechanisms of what a whole systems approach to obesity looks like in practice in a local context. This is of relevance to both policymakers and healthy weight practitioners across a spectrum of sectors who need to be engaged to tackle child obesity.

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.

The Myanmar Pig Partnership piloted two approaches to farmer training in Yangon Region: one participatory, one more advisory. The work offers useful practical advice which can help inform further initiatives. It also highlights the limitations training interventions alone offer.

Pilot research findings from the Myanmar Pig Partnership show increasing antimicrobial resistance (AMR) in pig farming in Yangon Region, Myanmar. They highlight challenges in AMR awareness, antibiotic use and disease prevention relating to farmers, slaughterhouse workers, vets and others in the pig meat supply chain. Decision makers need to consider these challenges at all levels.

Research findings reveal that disease-causing bacteria, including Salmonella, are widespread on pig farms of all sizes in Yangon Region, Myanmar, as well as in pig meat sold to consumers in the city and rural areas. This evidence provides a snapshot of how intensification in pig production can affect food safety – and points to potential responses.

The UN Security Council's response to Ebola in 2014 legitimised militarised responses. It also influenced responses to COVID-19 in some African countries. Yet, little is known about the day-to-day impacts for ordinary citizens of mobilising armies for epidemic control. Drawing on 18 months ethnographic research, this article analyses militarised responses to COVID-19 during, and following, two lockdowns at contrasting sites in Uganda: a small town in Pakwach district and a village in Kasese district. Both field sites lie close to the border of the Democratic Republic of Congo. Although the practice of health security varied between sites, the militarised response had more impact than the disease in these two places. The armed forces scaled back movement from urban conurbations to rural and peri-urban areas; while simultaneously enabling locally based official public authorities to use the proclaimed priorities of President Museveni's government to enhance their position and power. This led to a situation whereby inhabitants created new modes of mutuality to resist or subvert the regulations being enforced, including the establishment of new forms of cross-border movement. These findings problematise the widely held view that Uganda's response to COVID-19 was successful. Overall, it is argued that the on-going securitisation of global health has helped to create the political space to militarise the response. While this has had unknown effects on the prevalence of COVID-19, it has entrenched unaccountable modes of public authority and created a heightened sense of insecurity on the ground. The tendency to condone the violent practice of militarised public health programmes by international and national actors reflects a broader shift in the acceptance of more authoritarian forms of governance.

More than one billion people are affected by neglected tropical diseases (NTDs) and many of these diseases are preventable. While the grouping of these conditions as NTDs has generated vast mapping, mass drug administration and surveillance programmes, there is growing evidence of gaps and weaknesses in purely biomedical approaches, and the need for responses that also recognise the social determinants of health. In order to unpack the social and political determinants of NTDs, it is important to view the problem from a social science perspective. Given this background, the Social Sciences for Severe Stigmatizing Skin Diseases (5S) Foundation has recently been established by the Centre for Global Health Research at Brighton and Sussex Medical School. The broad aim of the 5S Foundation is to incorporate social science perspectives in understanding and addressing the problems around three NTDs, namely, podoconiosis, mycetoma and scabies. This protocol paper sets out the aims and approaches of the 5S Foundation while activities such as research, public engagement, training and capacity building get underway.

The securitization of health is not a new phenomenon. However, global responses to the 2014–2016 Ebola outbreak in West Africa reveal the extent to which epidemic preparedness and response is now s...

International audience; Global debates about vaccines as a key element of pandemic response and future preparedness in the era of Covid-19 currently focus on questions of supply, with attention to global injustice in vaccine distribution and African countries as rightful beneficiaries of international de-regulation and financing initiatives such as COVAX. At the same time, vaccine demand and uptake are seen to be threatened by hesitancy, often attributed to an increasingly globalised anti-vaxx movement and its propagation of misinformation and conspiracy, now reaching African populations through a social media ‘infodemic’. Underplayed in these debates are the socio-political contexts through which vaccine technologies enter and are interpreted within African settings, and the crucial intersections between supply and demand. We explore these through a ‘vaccine anxieties’ framework attending to both desires for and worries about vaccines, as shaped by bodily, societal and wider political understandings and experiences. This provides an analytical lens to organise and interpret ethnographic and narrative accounts in local and national settings in Uganda and Sierra Leone, and their (dis)connections with global debates and geopolitics. In considering the socially-embedded reasons why people want or do not want Covid-19 vaccines, and how this intersects with the dynamics of vaccine supply, access and distribution in rapidly-unfolding epidemic situations, we bring new, expanded insights into debates about vaccine confidence and vaccine preparedness.

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.

Background: Although many healthcare workers (HCWs) are aware of the protective role that mask-wearing has in reducing transmission of tuberculosis (TB) and other airborne diseases, studies on infection prevention and control (IPC) for TB in South Africa indicate that mask-wearing is often poorly implemented. Mask-wearing practices are influenced by aspects of the environment and organisational culture within which HCWs work. Methods: We draw on 23 interviews and four focus group discussions conducted with 44 HCWs in six primary care facilities in the Western Cape Province of South Africa. Three key dimensions of organisational culture were used to guide a thematic analysis of HCWs’ perceptions of masks and mask-wearing practices in the context of TB infection prevention and control. Results: First, HCW accounts address both the physical experience of wearing masks, as well as how mask-wearing is perceived in social interactions, reflecting visual manifestations of organisational culture in clinics. Second, HCWs expressed shared ways of thinking in their normalisation of TB as an inevitable risk that is inherent to their work and their localization of TB risk in specific areas of the clinic. Third, deeper assumptions about mask-wearing as an individual choice rather than a collective responsibility were embedded in power and accountability relationships among HCWs and clinic managers. These features of organisational culture are underpinned by broader systemic shortcomings, including limited availability of masks, poorly enforced protocols, and a general lack of role modelling around mask-wearing. HCW mask-wearing was thus shaped not only by individual knowledge and motivation but also by the embodied social dimensions of mask-wearing, the perceptions that TB risk was normal and localizable, and a shared underlying tendency to assume that mask-wearing, ultimately, was a matter of individual choice and responsibility. Conclusions: Organisational culture has an important, and under-researched, impact on HCW mask-wearing and other PPE and IPC practices. Consistent mask-wearing might become a more routine feature of IPC in health facilities if facility managers more actively promote engagement with TB-IPC guidelines and develop a sense of collective involvement and ownership of TB-IPC in facilities.

Livestock diseases are examples of negative externalities that affect livelihoods and health of poor people across the world. We investigate how the governance and power relationships along a value chain can contribute to reducing the negative effects of livestock diseases. We conducted a case study of Myanmar’s pig value chains and examined the relationship between power and efforts to minimize the risks of pig-borne diseases. We find that power relationships along the value chains are not directly linked to value chain actors’ effort to control negative externalities, unless powerful actors (1) understand the effects of negative externalities on the wider society, (2) monitor others’ practices, and (3) could hold those who generate negative externalities accountable. Satisfying these conditions requires effective coordination between governments, value chain actors and civil societies in order to mobilize value chain actors to help improve public health.

BackgroundTransmission of respiratory pathogens, such as Mycobacterium tuberculosis and severe acute respiratory syndrome coronavirus 2, is more likely during close, prolonged contact and when sharing a poorly ventilated space. In clinics in KwaZulu-Natal (KZN) and Western Cape (WC), South Africa, we estimated clinic visit duration, time spent indoors and outdoors, and occupancy density of waiting rooms.MethodsWe used unique barcodes to track attendees’ movements in 11 clinics in two provinces, multiple imputation to estimate missing arrival and departure times, and mixed-effects linear regression to examine associations with visit duration.Results2,903 attendees were included. Median visit duration was 2 hours 36 minutes (interquartile range [IQR] 01:36–3:43). Longer mean visit times were associated with being female (13.5 minutes longer than males; pOverall, attendees spent more of their time indoors (median 95.6% [IQR 46–100]) than outdoors (2.5% [IQR 0–35]). Attendees at clinics with outdoor waiting areas spent a greater proportion (median 13.7% [IQR 1– 75]) of their time outdoors.In two clinics in KZN (no appointment system), occupancy densities of ∼2.0 persons/m2 were observed in smaller waiting rooms during busy periods. In one clinic in WC (appointment system), occupancy density did not exceed 1.0 persons/m2 despite higher overall attendance.ConclusionsLonger waiting times were associated with early arrival, being female, and attending with a young child. Attendees generally waited where they were asked to. Regular estimation of occupancy density (as patient flow proxy) may help staff assess for risk of infection transmission and guide intervention to reduce time spent in risky spaces.

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.

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.

IntroductionOur project follows community requests for health service incorporation into conservation collaborations in the rainforests of Papua New Guinea (PNG). This protocol is for health needs assessments, our first step in coplanning medical provision in communities with no existing health data.Methods and analysisThe study includes clinical assessments and rapid anthropological assessment procedures (RAP) exploring the health needs and perspectives of partner communities in two areas, conducted over 6 weeks fieldwork. First, in Wanang village (population c.200), which is set in lowland rainforest. Second, in six communities (population c.3000) along an altitudinal transect up the highest mountain in PNG, Mount Wilhelm. Individual primary care assessments incorporate physical examinations and questioning (providing qualitative and quantitative data) while RAP includes focus groups, interviews and field observations (providing qualitative data). Given absence of in-community primary care, treatments are offered alongside research activity but will not form part of the study. Data are collected by a research fellow, primary care clinician and two PNG research technicians. After quantitative and qualitative analyses, we will report: ethnoclassifications of disease, causes, symptoms and perceived appropriate treatment; community rankings of disease importance and service needs; attitudes regarding health service provision; disease burdens and associations with altitudinal-related variables and cultural practices. To aid wider use study tools are in online supplemental file, and paper and ODK versions are available free from the corresponding author.Ethics and disseminationChallenges include supporting informed consent in communities with low literacy and diverse cultures, moral duties to provide treatment alongside research in medically underserved areas while minimising risks of therapeutic misconception and inappropriate inducement, and PNG research capacity building. Brighton and Sussex Medical School (UK), PNG Institute of Medical Research and PNG Medical Research Advisory Committee have approved the study. Dissemination will be via journals, village meetings and plain language summaries.

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

In recent years, fears about infectious diseases with pandemic potential have led to global initiatives to predict, prepare and respond to outbreaks. Practices that are focused on prediction and control centre on turning uncertainties into ‘risk’, through surveillance, modelling and scenario planning. We argue that, alongside scientific uncertainties, a further source of uncertainty has come into view for science-policy communities: the behaviour of affected populations and the social and political dynamics of disease ‘hotspots’. We contend that this has catalysed an increased recognition of social science perspectives, with new practices emerging, detected in approaches that aim to standardise risk communication and community engagement, or to synthesise social knowledge to make ‘context’ more discretely legible. We suggest that such initiatives can also be viewed as part of a broader suite of technologies to transform uncertainties into calculable risks. In this chapter, we seek to open up a richer dialogue about the different understandings of uncertainty, illustrating the potential contestation between the official response efforts of agencies, and alternative ways of knowing and responding to outbreaks in ‘communities’, grounded in local-level practice. In conclusion, we reflect on the limits in comprehending the ontological dimensions of uncertainty: for people living in these settings, it is not ‘context’ that is salient, but the ongoing flow – or text – of social and ecological life, where everyday uncertainties are constantly faced. We ask if alternative processes might be possible for formulating international planning frameworks, more attentive to views ‘from below’ that could reveal alternative priorities and ways of being-in-the-world.

This article problematises the ways in which behavioural change by poor individuals dominates the global discussions on means to tackle issues caused by systemic problems. We do so by focusing on the case of animal diseases, a symptom of many systematic failures. While livestock farming has long been praised as a mitigating factor against poverty, livestock diseases threaten the lives and livelihoods of poor and marginalised people who depend on animals. Aiming at controlling animal diseases, policy makers tend to focus on behavioural change by individual farmers by enhancing their knowledge. We conducted an in-depth qualitative research among pig farmers in Myanmar, a country that is rapidly increasing livestock production, to document contextual and systematic constraints that influence farmers' understandings and perceptions of disease-related risks and household-level decisions to invest in animal disease control. We conducted in-depth interviews, focus group discussions and participant observation in three townships in the Yangon region. Structural constraints such as weak veterinary health system and limited access to low-interest credit prevent farmers from gaining necessary knowledge about disease prevention and make them economically vulnerable. These systematic constraints drive behaviours considered 'risky' for disease emergence and spread. As a result, many small- and medium-scale farmers in low- and middle-income countries remain trapped in a vicious cycle of poverty and ill health for both animals and humans. We conclude that, instead of focusing on individual behavioural change, interventions need to combine enhancing knowledge by individual farmers and tackling economic and structural constraints that limit their agency and ability to address practices that are considered risky.

Infection prevention and control (IPC) measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis (TB) in health facilities are well described but poorly implemented. The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative, environmental, and personal protective measures as discrete entities. We present an on-going project entitled Umoya omuhle (“good air”), conducted in two provinces of South Africa, that adopts an interdisciplinary, ‘whole systems’ approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis (Mtb) through improved IPC. We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines, health facility space, infrastructure, organisation of care, and management culture. Methods drawn from epidemiology, anthropology, and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs, as well as opportunities to address the problem holistically. A ‘whole systems’ approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission.

Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.

Background In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. Results Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches. Conclusions We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.

Cross-species transmission of pathogens is intimately linked to human and environmental health. With limited healthcare and challenging living conditions, people living in poverty may be particularly susceptible to endemic and emerging diseases. Similarly, wildlife is impacted by human influences, including pathogen sharing, especially for species in close contact with people and domesticated animals. Here we investigate human and animal contacts and human health in a community living around the Bwindi Impenetrable National Park (BINP), Uganda. We used contact and health survey data to identify opportunities for cross-species pathogen transmission, focusing mostly on people and the endangered mountain gorilla. We conducted a survey with background questions and self-reported diaries to investigate 100 participants’ health, such as symptoms and behaviours, and contact patterns, including direct contacts and sightings over a week. Contacts were revealed through networks, including humans, domestic, peri-domestic, and wild animals for 1) network of contacts seen in the week of background questionnaire completion, 2) network of contacts seen during the diary week. Participants frequently felt unwell during the study, reporting from one to 10 disease symptoms at different intensity levels (maximum of seven symptoms in one day), with severe symptoms comprising 6.4% of the diary records and tiredness and headaches the most common symptoms. Besides human-human contacts, direct contacts with livestock and peri-domestic animals were the most common. Wildlife contacts were the rarest, including one direct contact with gorilla with a concerning timeline of reported symptoms. The contact networks were moderately connected and revealing a preference in contacts within the same species or taxon and within their groups. Despite sightings of wildlife being much more common than touching, one participant declared direct contact with a mountain gorilla during the week. Gorillas were seen very close to six animal taxa (including themselves) considering all interaction types, mostly seen closer to other gorillas, but also people and domestic animals. Our findings reveal a local human population with recurrent symptoms of illness in a location with intense exposure to factors that can increase pathogen transmission, such as direct contact with domestic and wild animals and proximity among animal species. Despite significant biases and study limitations, the information generated here can guide future studies, such as models for disease spread and One Health interventions.

Rapid development has brought significant economic and health benefits, but it has also exposed populations to new health risks. Public health as a scientific discipline and major government responsibility developed during the nineteenth century to help mitigate these risks. Public health actions need to take into account large inequalities in the benefits and harms associated with development between countries, between social groups, and between generations. This is especially important in the present context of very rapid change. It is important to acknowledge the global nature of the challenges people face and the need to involve countries with different cultures and historical legacies in arriving at consensus on an ethical basis for global cooperation in addressing these challenges. This chapter provides an analysis of these issues, using examples on the management of health risks associated with global development and rapid urbanization and on the emergence of organisms that are resistant to antibiotics.

This chapter focuses on the framing of the “global” nature of noncommunicable diseases (NCDs) with reference to the implications of the growing burden in low- and middle-income countries. It argues that the complex nature of these conditions and of causality require a nuanced and context-specific picture in terms of understanding the social and economic patterning of NCDs and the implications for poor people. Within an overall consideration of health justice, these issues fall under two broad areas: firstly, prioritization and resource allocation; and secondly, questions of responsibility with respect to prevention measures. The chapter focuses on the tension between emphasizing individual-level action and a systems approach that pays attention to broader structural factors, global and national inequalities, health system drivers, and sociopolitical determinants of NCDs.

This paper discusses health policy and systems research in complex and rapidly changing contexts. It focuses on ethical issues at stake for researchers working with government policy makers to provide evidence to inform major health systems change at scale, particularly when the dynamic nature of the context and ongoing challenges to the health system can result in unpredictable outcomes. We focus on situations where ‘country ownership’ of HSR is relatively well established and where there is significant involvement of local researchers and close ties and relationships with policy makers are often present. We frame our discussion around two country case studies with which we are familiar, namely China and South Africa and discuss the implications for conducting ‘embedded’ research. We suggest that reflexivity is an important concept for health system researchers who need to think carefully about positionality and their normative stance and to use such reflection to ensure that they can negotiate to retain autonomy, whilst also contributing evidence for health system change. A research process informed by the notion of reflexive practice and iterative learning will require a longitudinal review at key points in the research timeline. Such review should include the convening of a deliberative process and should involve a range of stakeholders, including those most likely to be affected by the intended and unintended consequences of change.

International audience

At the turn of the millennium, people with mental disturbance often lived in circumstances of economic marginalization in South Africa. The historical material of one low-income urban area reveals the place of kin relations and reciprocity in enabling negotiation of a more fluid set of responses to mental illness. In this sociocultural context, "stigma" was not an inevitable reaction to mental illness, and a more complex set of social dynamics could mitigate marginalization. Research on how changing informal care practices relate to state-based community care continues to be important to inform contemporary health reforms.

During a five-day workshop, former clinical trial participants and local musicians wrote the lyrics and recorded a song about an HIV prevention trial. Born of concerns about misconceptions regarding experimental drug trials, the aim was to engender engagement with medical researchers and open dialogue about the risks and benefits of trial participation. Composing lyrics that highlighted their credibility as communicators of medical scientific knowledge and their selfless sacrifice to stem the transmission of HIV, women performed their social positioning and cultural authority in contrast to men as well as other women not part of the trial. While involvement in HIV prevention initiatives often attracts stigma, scorn and criticism, the song's lyrics highlighted women's new-found identities as heroines searching for a solution to the spread of HIV, challenging these stereotypes. Methodologically, the paper describes a novel approach that uses artistic expression for public engagement with biomedical research.

Many serious emerging zoonotic infections have recently arisen from bats, including Ebola, Marburg, SARS-coronavirus, Hendra, Nipah, and a number of rabies and rabies-related viruses, consistent with the overall observation that wildlife are an important source of emerging zoonoses for the human population. Mechanisms underlying the recognized association between ecosystem health and human health remain poorly understood and responding appropriately to the ecological, social and economic conditions that facilitate disease emergence and transmission represents a substantial societal challenge. In the context of disease emergence from wildlife, wildlife and habitat should be conserved, which in turn will preserve vital ecosystem structure and function, which has broader implications for human wellbeing and environmental sustainability, while simultaneously minimizing the spillover of pathogens from wild animals into human beings. In this review, we propose a novel framework for the holistic and interdisciplinary investigation of zoonotic disease emergence and its drivers, using the spillover of bat pathogens as a case study. This study has been developed to gain a detailed interdisciplinary understanding, and it combines cutting-edge perspectives from both natural and social sciences, linked to policy impacts on public health, land use and conservation.