Threats, Risks and Sustainability - Answers by Space (Studies in Space Policy, Volume 2)
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This frame emphasizes social vulnerability through a concern over the potentially catastrophic impact of health issues such as pandemics. Whereas previous studies have discussed the changed level of health risks in the era of globalization, 11 we engage with the changed meaning of risk. It draws on the technical understanding of risk prevalent in the public health arena, using advanced epidemiological methodologies and modelling techniques to assess the likelihood of the spread of disease and infection. Within this discourse, risk assessment is seen as a tool rather than a process, as objective rather than contested, and as scientific rather than political.
Nevertheless, the move from global health security to global health risk can help mobilize public attention and political action, because it places global health within the wider contemporary sense of society being at risk. The sense of vulnerability to health risks, especially disease outbreaks, cannot be separated from the broader feeling of social vulnerability, evident not only in public policy but also in cultural products.
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Risks from disease are both a reflection of and a contribution to this feeling. At the heart of our analysis is the argument that risk is not independent but socially constructed, and part of a political process in which values and interests shape outcomes.
We present this argument in two ways. Second, we demonstrate how different organizations construct risk in different ways, thereby privileging different pathways of response.
To demonstrate this, we examine how different organizations framed risk during the —15 outbreak of Ebola in west Africa. The understanding and assessment of risk here are characterized by organizational interests and values. We begin, however, with two important background discussions.
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The first concerns the way in which the rise of global health on the international agenda has been accompanied by a tension between, on one hand, the technical orientation and cosmopolitan ambition of global health, and, on the other hand, the politics of global health, which is especially evident when health intersects with other sectors and interests. This discussion clarifies our position that global health is both inherently political and characterized by superordinate ambitions that often obscure or delegitimize this dimension, thereby rendering the risk frame attractive as appearing to move beyond politics.
Second, we outline ideas of framing and risk, which inform our subsequent analysis. This not only makes explicit our underpinning social constructivist leanings, but gives us the theoretical tools necessary to understand risk in global health. Global health issues, and especially risks from disease outbreaks, have risen ever higher on the international political agenda in the last two decades.
Since then, outbreaks of other infectious diseases, such as severe acute respiratory syndrome, SARS — , Middle East respiratory syndrome, MERS , Ebola —15 and Zika —16 , recurrent alarms about pandemic forms of influenza such as avian flu and swine flu , and concerns over antimicrobial resistance AMR have all appeared prominently on the international agenda.
In —, for example, the SARS outbreak demonstrated how novel viruses could spread across continents within weeks. Not least of its effects was that this discursive shift allowed health risks to be constructed as shared between and across states.
The potential of infectious diseases to spread quickly across the globe also meant that, for the first time in several generations, high-income states appeared vulnerable to outbreaks of infectious disease. At the same time, the increasing prominence of global health has brought with it an increasingly prominent global health politics. These include national and international security, macroeconomic growth, international development, human rights, and global commerce and trade.
Sachs, identified poor health as a risk to macroeconomic growth. Global health, then, is not a policy silo, but has become part of the business of institutions outside the narrowly defined field of international health organizations; and these institutions bring their own interests, ideas and values to debates on global health issues.
While the rise of global health politics is intrinsically linked to the rise of global health more generally, there is a notable tension between these two phenomena.
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Politics sits uneasily with both the emphasis on the global nature of health problems and the tradition of public health as a technical field grounded in positivism and scientific rationality. But the idea that health issues are shared in an age of globalization tends to obscure the facts that some populations are more likely to be affected by health problems than others, that some health issues are more relevant in some countries than in others, and that policy responses tend to benefit some people more than others.
The field of global health and global health governance is also dominated by policy-makers and experts with a background in public health, epidemiology and medicine, long permeated by an ethos of positivism and scientific rationality. The idea is that there is an optimal solution to a given problem, which can be arrived at through the use of a robust empirical methodology. Risks can be scientifically assessed through rigorous observation of events and the application of lessons derived from deductive reasoning.
We take a different approach, arguing that global health requires a broader understanding of the process and consequences of risk assessment. To this end, we apply insights from two sets of ideas located in social constructivism: framing, and the risk society. Framing is understood as the presentation of an issue in such a way as to tie it into a broader set of ideas about the world, and through this to gain influence and policy purchase. We use frames to examine two specific examples of how the concept of risk is used in global health.
Second, we move the discussion of risk on to suggest that there is no single, agreed global health risk frame, but rather that different actors frame risks from health issues differently, leading to competing understandings of the nature of the problem and the means of resolution. The first is that risk does not exist independently of observation but is socially constructed. Consequently every conceivable experience has been transformed into a risk to be managed. Understandings of dread risk vary—for Slovic and Weber, for example, it refers to a combination of lack of control and extreme potential, whereas Gizerenger uses it to refer to low-probability, high-consequence events.
This fear may be prompted by the symptoms involved, the lack of a vaccine or cure, or the stigma associated with the disease. Both are disruptive challenges to everyday life, 36 and both are reflections of the uncertainties and vulnerabilities of reflexive modernity. In so arguing we are also influenced by Giddens's distinction between risk and danger or hazard. For Giddens, danger or hazard exists independent of observation, whereas risk is socially constructed through societies' concern for the future. Its most important use is to calculate the statistical likelihood or probability of an event happening.
Over the past decade, we have seen the emergence of a discourse that portrays certain global health issues, notably infectious disease pandemics and AMR, as global health risks.
This discourse is manifest in a range of policy documents and reports and, indeed, the names of institutions that have recently been created. The perception that the world faces a number of risks with potentially disastrous consequences has also been the focus of scholarly debates, driven most prominently by the works of Ulrich Beck and Anthony Giddens. Beck distinguishes between risks that societies and governments have found ways to cope with, such as accidents in factories or traffic, and those large-scale problems that call into question the capacity of modern societies to deal with them.
Both Beck and Giddens highlight the impact of globalization on the quality of these risks, which have potentially enormous repercussions not only because they are large scale, but also because they are inherently global. Moreover, the global and catastrophic impact appears unavoidable: new pathogens with pandemic potential emerge all the time through natural evolution, and their transmission is facilitated through global systems of travel and trade, which cannot be disrupted, because they are of vital importance for the functioning of modern society.
The perception of infectious disease outbreaks as global risks therefore feeds into a general sense of vulnerability to disaster in modern societies. This sense of social vulnerability is linked mainly to the potential impact of an event, rather than its likelihood , reflecting the shift from a probabilistic to a possibilistic view of risk. If this is the perception of the problem, what does an appropriate response look like?
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Interesting insights into this question come from Andrew Lakoff's and Stephen Collier's work on the emergence of a new set of organizations and strategies in US security policy for the protection of transport and energy infrastructures and economic and financial systems. Because these events are deemed unavoidable, conventional security policies that focus on prevention are seen as inadequate. The US government has therefore adopted a strategy focused on mitigating the impact of such events by becoming more prepared for their occurrence.
Hence, preparedness emerges as the key rationale for how to respond to the incalculable risk of unavoidable and potentially disastrous events. The basis for acting on risks framed as unpredictable, yet unavoidable and potentially catastrophic, is not to calculate what is more or less likely to happen, but to be prepared for whatever happens. This language and rationality of preparedness are evident beyond the United States in the international debate on global risks, including global health risks. Compared with other high-profile threats to human and economic security—such as war, terrorism, nuclear disasters and financial crises—we are underinvested and underprepared.
The rationality of preparedness is manifest not only in the language used around global health risks, but also in the instruments and tools of policy responses. Key to this are surveillance systems designed to pick up signs of an outbreak early and monitor the spread of diseases. Thus, in the last two decades, many states especially OECD countries have strengthened their infectious disease surveillance systems.
WHO member states are now required to implement early-warning systems and establish laboratories that can detect potential threats and report outbreaks to the WHO.
Finally, the rationality of preparedness as a response to global health risks is manifest in the development of procedures, legislation and financing mechanisms that can be activated in an emergency. Procedures have been created to facilitate the accelerated development and use of relevant drugs and vaccines.
The Animal Efficacy Rule responds to the problem posed by the fact that many of the diseases that are considered health security threats occur rarely if at all in nature. Drugs and vaccines against such threats can often not be approved on the basis of human clinical trials, because disease outbreaks may be too short or involve too few people for large-scale clinical testing to be organized, while deliberately exposing humans to pathogens merely for the purpose of pharmaceutical development is considered unethical.
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The safety of any product developed by this route, however, does have to be demonstrated in human studies. Similarly, the EUA, established as part of the Project Bioshield Act and the Pandemic and All-Hazards Preparedness Reauthorization Act , 73 can provide authorization for the use of pharmaceuticals and medical devices that have not yet been fully tested for safety and efficacy.
Although there is no equivalent to the animal rule in other countries or at the international level, some countries and international organizations have nevertheless prepared emergency use authorization procedures as part of pandemic preparedness strategies. In addition, financing facilities have been created to strengthen global pandemic preparedness.