Preparedness for the next epidemic: health and
political issues of an emerging paradigm
Pierre-Marie David & Nicolas Le Dévédec
To cite this article: Pierre-Marie David & Nicolas Le Dévédec (2018): Preparedness for the next epidemic: health and political issues of an emerging paradigm, Critical Public Health, DOI:
10.1080/09581596.2018.1447646
Preparedness for the next epidemic: health and political issues of
an emerging paradigm
Pierre-Marie Davida,b‡ and Nicolas Le Dévédecc‡
aFaculty of Pharmacy, Département Médicaments et Santé des populations, Université de Montréal, Montréal,
Canada; bLaboratoire SPHERE, UMR 7219, Université Paris Diderot, Paris, France; cDepartement de Management, HEC
Montreal, Montréal, Canada
ABSTRACT
‘Preparing for the next epidemic’ has been a recurrent theme in global health in recent years. Starting with SARS, by way of the Avian influenza, and intensifying after the 2013–2016 Ebola outbreak, the urgency of preparing for the next health disaster has been recommended by numerous global health stakeholders. Recommendations and global partnerships are aligned with the many action proposals that have been formulated by international political actors, including the WHO, that have made ‘preparedness for the next epidemic’ a new paradigm, alongside prevention. The intent of this commentary is to argue the need to discuss some aspects of the preparedness paradigm from both health and democratic perspectives. We believe preparedness reveals a new and problematic biopolitical orientation in global health. Our argument is that preparedness enacts a model that: (i) reconfigures knowledge about epidemics by disconnecting them from the social and historical contexts in which they arise and (ii) imposes new modalities of intervention that raise issues for democratic autonomy. After first tracing back the genealogy of the preparedness paradigm, this paper then discusses some of the issues at stake for both health and democracy.
Article:
‘Preparing for the next epidemic’ has been a recurrent theme in global health in recent years. This concern has never been as visible as it was during the last two Davos Summits. The most recent World
Economic Forum (WEF) featured a session specially dedicated to the Coalition for Epidemic Preparedness
Innovations (CEPI), which had been created at the previous year’s summit. CEPI’s mission is ‘to stop
future epidemics by developing new vaccines for a safer world’ by bringing together private and public
investors: the governments of Germany, Norway, Japan and India; the European Commission; the Bill
and Melinda Gates and the Wellcome Trust Foundations; and a consortium made up of large pharmaceutical
companies, such as Pfizer and Johnson & Johnson, research laboratories and biotechnology start-ups (Røttingen et al., 2017). Starting with SARS, by way of the Avian influenza, and intensifying
after the 2013–2016 Ebola outbreak, the urgency of preparing for the next health disaster has been
recommended by numerous global health stakeholders. As Bill Gates pointed out in 2015, the Ebola crisis
had to serve as a wake-up call: ‘The world needs to build a warning and response system for epidemic
outbreaks’ (Gates, 2015). A plan to prepare for the next epidemic was presented in the New England
Journal of Medicine as recommendations mixing improvement of coordination at the global level with
incorporation of preparation exercises, expansion of investments in research and development of new
tools and technologies. These recommendations and the global partnerships like CEPI are aligned with
the many action proposals that have been formulated by international political actors, including the
World Health Organization (WHO), that have made ‘preparation for the next epidemic’ a new paradigm,
alongside prevention (Lakoff, 2007; Zylberman, 2016).
Although preparation practices have been discussed in various fields (terrorism, natural catastrophes,
etc.), the paradigm has received little critical examination in public health, with some significant exceptions (Mwacalimba, 2012; Parmet & Sinha, 2017; Waller, Davis, & Stephenson, 2016). The paradigm
of ‘preparing for the next epidemic’ is now more and more widely taken for granted by many actors
and experts in contemporary ‘global health’. In its March 2017 editorial (The Lancet, 2017), The Lancet
presented the revealing conclusions reached during a meeting on preparedness in Geneva that brought
together major global health actors. ‘Views differed on how to monitor contributions to global, national,
and regional preparedness and mutual accountability, but there was consensus that country-level preparedness, financing, and sharing of information, research, and health technologies are vital’. Thus,
current debates focus mainly on finding ways to prepare as efficiently as possible (e.g. Ross, Crowe, &
Tyndall, 2015). Yet, the preparedness paradigm itself would benefit from further debate. Does it really
prepare us for the next epidemic? And beyond its health impacts, what are the political and especially
democratic presuppositions and implications of this new structuring paradigm?
We argue the need to discuss some aspects of the preparedness paradigm from both a health and a
democratic perspective. To this end, we propose to analyze the preparedness paradigm in the light of
‘biopolitics’ concept proposed by Michel Foucault to account for the specific management and control
of populations from the biological perspective that characterized the modernity era (Foucault,
1979).
The preparedness paradigm manifests a new biopolitical orientation in global health that differs from
prevention (Fearnley, 2007, 2015; Lakoff, 2007, 2015; Sanford, Polzer, & McDonough, 2016). Following in
this vein, we suggest a shift in attention from a technical view of this biopolitical change to a perspective
that more fundamentally and controversially addresses health and democratic issues. Our argument is
that preparedness enacts a model that: (i) reconfigures knowledge about epidemics by disconnecting
them from the social and historical contexts in which they arise and (ii) imposes new modalities of intervention
that raise issues for democracy, defined as the collective capacity to autonomously determine a future and a public health sensitive to those people most directly affected. Starting from a genealogy
of the preparedness paradigm, this paper then highlights its biopolitical specificity to finally bring out
some of the issues it raises for both health and democracy.
Genealogy of the preparedness paradigm
The preparedness paradigm did not begin with the Ebola outbreak in West Africa, or with the Avian
influenza and SARS pandemics of the 2000s, but instead has a longer biopolitical history. It finds its roots
in the 1950s in the Cold-War-era United States (see Lakoff, 2007). The paradigm is more specifically the
product of a different route taken by the US in designing its health system. As Lyle Fearnley points out,
Histories of public health in the United States tend to present a narrative of stalled progress, a failure to enact the universalist insurance systems widespread in Europe. But these narratives conceal the production of an alternative governance of health, focussed on preparing for and managing epidemic emergencies. (Fearnley, 2007, p. 17)
Influenced by NBC (nuclear, bacteriological, chemical) threats, the US did indeed develop a
surveillance-style health system that differs considerably from European welfare-state models that are, despite their differences, insurance-based (Foucault, 2001). The preparedness paradigm grew out of this surveillance
approach, which associates epidemics with biological threats. Alexander Langmuir, a prominent figure at the Centers for Disease Control (CDC) in the 1950s and 1960s, helped this system to materialize
by reforming the knowledge and response system on epidemics, which he saw as biological entities
abstracted from their social context (Fearnley, 2007; Fee & Brown, 2001). Thus, the surveillance model
emerged, along with new institutions such as the Epidemic Intelligence Service, founded by Langmuir
in 1951.
For many years, the preparedness model competed with a more traditional prevention-based insurance
model in the US, but then gradually established itself as the dominant model. The 1990s were watershed years in this regard, coming on the heels of 1980s neoliberal policy reforms that had considerably
undermined the insurance system. The failure of President Clinton’s 1992 healthcare reform plan only strengthened the need to adopt the surveillance model (Fearnley, 2007, p. 17). Preparedness
spread more widely in the late 90s, particularly with the AIDS pandemic, which was perceived as a threat
by the US. As pointed out by Patrick Zylberman, the first signs of the convergence of public health and
national security ‘appeared as early as 1998 but became the official White House line in 1999 at the time
impact
of AIDS on peace and security]’ [our translation] (Zylberman, 2016, p. 73). The attacks of 11 September
2001, put the bioterrorist threat at the centre of concerns, linking health and safety in an increasingly
inextricable way. On 12 June 2002, as President George W. Bush signed the Public Health Security and
Bioterrorism Preparedness and Response Act, he said, ‘Bioterrorism is a real threat to our country. […]
It’s important that we confront these real threats to our country and prepare for future emergencies’
(Bush, 2002). This strongly accelerated the deployment of the preparedness paradigm, as did the official
establishment of the new Homeland Security department in 2002. It made biodefense a national priority and, given the borderless nature of pathogens, a global one.
With the large pandemics of the 2000s, the preparedness paradigm went global. After SARS and then in response to the global influenza epidemics, international health organizations assimilated the
preparedness paradigm as the favoured biosecurity epidemic-response mechanism and restructured
themselves around this approach. Based on an analysis of strategic WHO documents from between 1999
and 2009, Sanford et al. showed how a discourse of preparedness developed within that institution and
then was globalized and became incorporated into everyday practices (Sanford et al., 2016). However,
it was with the 2013–2016 Ebola outbreak in West Africa that preparedness established itself as the
predominant means of intervention in global health. At that time, a consensus about preparedness
appeared, particularly among those policy makers that joined new public-private partnerships like the
CEPI, as did the governments of Norway, India and Japan. Because it associates epidemics with threats,
preparedness, as a world view and an intervention mode, almost naturally seems necessary to all these
policy makers, whose respective ministers penned a column in January 2017 issue of The Lancet: ‘The
outbreak of Ebola virus disease in West Africa in 2013–2016 showed that the world is not sufficiently
prepared to detect and respond to epidemic threats’ (Brende et al., 2017).
A new form of biopolitics
Situated historically, the contemporary adoption of the preparedness paradigm in global health contributes
to implement a unique biopolitical model. This model is characterized first and foremost by a view of disease and epidemics that is unlike that of the prevention model (Waller et al., 2016). Zylberman
indeed makes this point: ‘Prevention – the philosophy of public health in the 20th century – is not purely
and simply excluded from the new 21st-century public health, but it is no longer at its centre’ [our translation] (Zylberman, 2016, p. 72). The prevention model is indeed in keeping with a risk universe,
in which probabilities can be measured and calculated according to social and historical parameters
contrast, by
targeting ‘imagined future outbreaks of disastrous proportions’ (Waller et al., 2016, p. 100), preparedness
replaces the risk universe with a horizon of plausible but unpredictable biological threat that requires
adaptation beyond all probability. This must be done by preparing, as for a natural disaster or terrorist
attack. Likened to de-territorialized global threats, epidemics are seen in the preparedness model as
separate from both their social and historical contexts. Andrew Lakoff compares preparedness to a
‘sentinel’s regimen’, based on the surveillance of threats, as opposed to a ‘actuarial regimen’, based on
the risk prevention: ‘If actuarial devices seek to map disease over time and across populations in order
to gauge and mitigate risk, sentinel devices treat unprecedented diseases that cannot be mapped over
time, but can only be anticipated and prepared for’ (Lakoff, 2015, p. 40).
Preparedness in global health can then be seen through the unique means of interventions that are
different than the ‘classic’ modes of prevention. Preparedness encompasses various operationalization
techniques, including, as Lakoff points out: ‘Scenarios and simulation, early warning systems, stockpiling
for relief supplies, coordinating response among diverse entities, crisis communication systems, metrics
of readiness assessment’ (Lakoff, 2007, p. 254). Designed and tested in times of war (Zylberman,
2016),
scenarios and simulation methods are particularly revealing of the preparedness model. Differentiating
themselves from the statistical models of incidence and prevalence that make prediction possible, these
modelling devices objectify imagined threats and reveal the weak links that must be strengthened in
the health and social system: ‘An apparatus of preparedness comes to know its vulnerabilities through
practices of imaginative enactment: tools such as scenario planning and simulation exercises test the
respond system and reveal gaps in readiness’ (Lakoff, 2007, p. 254). These methods foster a view of
the national health policies less as a means of collectively responding to health issues by confronting
diverging interests democratically, than as a potential obstacle to the necessity of overall readiness,
both in coordination and planning. Characterized as much by a disembedded conception of health as
by operational premises paradoxically aimed at controlling unpredictable threats, preparedness raises
issues for both health and democracy.
Health issues of preparedness
Although preparedness has gained strength since the 2013–2016 Ebola epidemic, this paradigm stirred
lively discussion around its efficacy in controlling the epidemic that began in 2013 and was declared
questioned
the efficacy of the preparedness paradigm, particularly in terms of the length, number of deaths and
propagation of the epidemic. Many surveillance programs were already in operation before the epidemic
erupted, without however truly controlling the epidemic. For some authors, this failure can be attributed to preparedness itself. Vinh-Kim Nguyen points out that preparedness efforts in West Africa
‘not only failed, they produced this Ebola epidemic’ (Nguyen, 2014). Indeed, this author states that ‘huge
sums of money were spent on vaccines for epidemics that never materialized. Yet there were already
clear and unambiguous signs that the key to preparedness would lie in hospitals’. In opposition to this
idea, Lyle Fearnley argues that it is not the preparedness paradigm as such that is to blame, but rather
a lack of coordination:
This failure lies not in the idea of disease surveillance or preparedness itself, but in the disregard for linking disease surveillance with public health and medical infrastructure, and in the neglect of their coordination at the same scales, locales, and jurisdictions.
From this perspective, preparedness and public health should be the focus of greater complementarity:
‘When it is so coordinated, disease surveillance for emerging diseases is a pivotal component of public
health practice’ (Fearnley, 2015).
It remains that the compatibility between the preparedness and the prevention paradigms is questionable
in and of itself. Indeed, it supposes that preparedness is a neutral tool put at the service of public health. However, two types of biopolitical rationality are at work, the means and ends of which
diverge. As we saw, the preparedness paradigm’s conception of epidemics and the world is rooted in
a specific biopolitical history, and one of its main characteristics is turning a blind eye to the social and
political conditions that the prevention model aim on the contrary to manage. This could be clearly
seen in the Ebola crisis, as the preparedness paradigm came at the expense of public health services
in Guinea, Sierra Leone, and Liberia. As Guillaume Lachenal summarizes in the case of Ebola: ‘A major
issue is that these pandemic preparedness exercises siphon off a large part of African health authorities’
energies and resources, even as they are confronted with far more urgent health emergencies’ (Lachenal, 2014). As contrasted by descriptions of local implementations, global preparedness policies
can sometimes reorient public health policies (Waller et al., 2016), or more fundamentally be carried
out at the expense of local preparedness policies, as shown by Mwacalimba in Zambia regarding avian
influenza pandemic preparedness (2012).
Democratic issues of preparedness
Questioning public responsibility for health also leads to an analysis of the democratic issues at stake.
limiting
vulnerabilities to future epidemics, preparedness actually engages, via its means of intervention, a
relationship to the environment, disease, health and collective life. Seen from a biopolitical perspective,
preparedness shapes the social. Therefore, as Lachenal highlights: ‘With pandemic preparedness, the
scenario and role-play have become a full-fledged political technique, a way to “organize the social itself”’
(Lachenal, 2014). The means of implementing preparedness, like scenarios and simulations, contribute,
most especially, to moving undetermined political citizenship towards a determined biological plan. As
much through training exercises as by deploying a worldview of threat, preparedness builds biosubjects
that are led to see themselves more as biological than as political beings. As Bruce Braun shows, biosecurity
devices ‘involve altering the every-day practices of individuals so as to shape the organization of biosocial life more generally. Inculcating the awareness of biological risks, shape individuals who relate
to themselves as biological beings in their everyday activities’ (Braun, 2013). Even if these exercises do
not always lead to the expected results (Adey & Anderson, 2012), they do play a major performative role
on how individuals see themselves and act. As these exercises lead individuals to subjectively consider
biological threat in their daily lives, preparedness disciplines the individual and collective imagination,
and lead to deny the rights of those affected (Parmet & Sinha, 2017).
The political effects of preparedness can also be understood through a particular rapport to time, that potentially limits democratic autonomy. For Lakoff, preparedness builds temporality, the very nature of which is ‘making an uncertain future available to intervention in the present’ (Lakoff,
2007).
The preparedness regime’s feat of strength is, in other words, transforming an unpredictable future into
a present certainty. Presented as inevitable, the future is being imposed from this perspective, at the
expense of present indetermination, which is at the centre of political and democratic space (see Lefort,
1989). With preparation, the present is subjected to expert scenarios of unpredictable and indisputable
futures, without any real possibility of democratic debate. This temporality is discriminatory since the
future of some people and nations is built at the expense of others, often those most directly affected.
Preparedness indeed makes up more the Western world’s preparation, than it fosters the development
of local capacities for response; a system of inequalities intrinsically linked to globalization (O’Keefe,
2000). Joao Biehl and Adriana Petryna aptly situate the issue:
At stake is the development of institutional capacities that go beyond the repetition of history and help to defend, in Hirschman’s words ‘the right to a nonprojected future as one of the truly inalienable rights of every person and nation’. (Biehl & Petryna, 2013, p. 14)
Consensus surrounding the debates on preparedness is revealing and problematic in this respect. Lakoff aptly summarizes this perspective: ‘The need to be prepared is not in question; what can be a
preparedness
as it is implemented by the governments involved in CEPI is a scope of action that cannot be discussed, just as terrorist threat leads to declaring a state of emergency or exception. This dynamic
has an insidious political effect: that of maintaining the existing social and economic order with its inequalities. Kevin Grove points out that preparedness questions put into play undeniable social and
economic interests that should not be avoided in debate: ‘The biopolitical effect of preparedness is to
construct a distinct form of collective life that defends capitalist order against unpredictable threats to
its vital infrastructure’ (Grove, 2013). From this perspective, the consensus surrounding preparedness
paradigm presents the political risk of legitimatizing the current social and economic order, by naturalizing
it. Democratic culture can minimize this risk by creating forums for discussion and opposition where the recognition of antagonism indeed opens up the possibility of questioning the social order
and its inequalities (Mouffe, 2005, 2013).
Conclusion
Although preparedness is an emerging paradigm in global health and its implications in various local
contexts remain to be defined, it contributes to the establishment of a very specific biopolitical order
and therefore should be a more frequent subject of debate, above and beyond its implementation. Our
primary objective was to spur discussion and debate on certain, particularly democratic, aspects of this
preparedness paradigm. Without denying worldwide epidemic threats, other ways of ‘being prepared’
can also be explored and thus feed this debate. It appears in particular essential to appreciate social
forms of relationships with health built in and by the inclusion of locally affected populations. As shown
by Anne-Marie Moulin, the histories of certain major campaign successes, such as the eradication of
smallpox, or failures, such as malaria, demonstrate that solutions should promote a dialogue between
the cultural and the technical, between scientific advances and popular representation (Moulin,
2004).
Several contemporary anthropological and historical perspectives also encourage ascribing an important
role to the fundamental autonomy of individuals and populations:
The agency of local actors is not limited to their blind acceptance of whatever form of knowledge or technology or care provided by extra-local interests. Rather, people’s agency is bound to pre-existing forms of exchange, politics and desire as they find expressions, both new and old, in the changing landscape created by global health initiative. (Biehl & Petryna, 2013, p. 14)
Bringing ‘social science intelligence’ (Abramowitz et al., 2015) into preparedness thus could be a step
forward in stimulating debate.
Acknowledgements
Authors are very grateful to Noemi Tousignant and Tarik Benmarhnia for their insightful comments. Authors also wish to
Guillaume
Lachenal and Laboratoire SPHERE, Université Paris Diderot, were he was hosted and FRQSC (2016-B3-189967) for financial
support. Nicolas Le Dévédec is grateful to HEC Montreal for financial support.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by FRQSC [grant number 2016-B3-189967]; HEC Montreal.
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