Lassa fever: The politics of an emerging disease and the scope for One Health

One of a series of seven working papers considering the political economy of One Health.This paper explores the politics of knowledge and disease control for Lassa fever, a zoonotic viral haemorrhagic fever which is endemic in parts of West Africa. The Lassa virus has been classified as a Category A pathogen, meaning it is considered to be one of the world’s most dangerous organisms and a potential bioweapon. Unusually for a Category A pathogen it also causes endemic human disease with public health implications. As a rodent-borne virus, Lassa fever is of interest to One Health. The interplay between security, public health and One Health perspectives are explored in Kenema, Sierra Leone, a long-term treatment and research hub. Running through policy processes are institutionalised responses to uncertainty which have privileged certain types of evidence leading to significant gains in laboratory and technology-based interventions. In securitisation debates public health priorities are often judged to be undermined. However this case shows that animal, human and environment interactions, and their socio-economic dynamics, have been marginalised on both national and international levels by political economies of knowledge and policy which tend to overlook the needs and perspectives of poor and rural populations.Ecosystem Services for Poverty Alleviation (ESPA

The process and practice of diagnosis: innovations in diagnostics for Lassa fever in Sierra Leone

This thesis is about the process and practice of diagnosis and the implications of new diagnostic technologies in low resource settings. As a setting and a disease which has seen significant investment in diagnostics, Lassa fever in Sierra Leone has been selected as a case study to examine these themes. In this thesis, 'new diagnostic technologies’ refers to laboratory-based diagnostics which are fast, reliable, accurate and can be used in low income settings. The starting point of this thesis is a narrative surrounding such technologies which suggests that they will revolutionise low income healthcare settings by allowing accurate scientific diagnosis in places where it was not possible before. Various perspectives on diagnosis are examined and some limitations are identified in relation to their accounts of diagnostic process, context, practice and technology. To explore the case, aspects of science and technology studies, the sociology of scientific knowledge and medical anthropology are combined. A multi-sited ethnography of Lassa fever diagnosis was conducted in three settings: a rural village, a laboratory and the wards of a hospital. Documents were reviewed and interviews conducted with key actors and ex-Lassa fever patients. Analysis focused on framings (partial and subjective interpretations), narratives (persuasive storylines which make use of particular framings) and practice in relation to Lassa fever and the development of technology for its diagnosis. Assumptions about the disease, diagnostics and the process of diagnosis are identified and the conclusion considers how they compare with practice in each setting. This thesis argues that diagnosis is a complex negotiated process and that new diagnostics represent only one aspect of that process. Thus, they are not a ‘silver bullet’ to transform low resource healthcare contexts. In particular, ‘improved’ diagnostics do not always have the expected impacts, sometimes even introducing complexity and uncertainty. In challenging narratives about diagnostics, this thesis provides an alternative, practice-based, approach to thinking about diagnostics and innovations in health systems; this approach acknowledges the importance, and complexity, of the diverse contexts which shape innovations and technology use

Local Engagement in Ebola Outbreaks and Beyond in Sierra Leone

Containment strategies for Ebola rupture fundamental features of social, political and religious life. Control efforts that involve local people and appreciate their perspectives, social structures and institutions are therefore vital. Unfortunately such approaches have not been widespread in West Africa where response strategies have been predominantly top-down. Authoritarian tactics have had questionable effect, potentially worsening the epidemic and contributing to social and economic burdens. Failure to involve local people and their concerns is often justified by budgetary and practical restraints such as lack of time and resources. However, some of the current Ebola responses reflect problematic assumptions about local ignorance and capability. These sentiments are deeply rooted, having evolved with unequal power dynamics over long periods of time. The emerging evidence on successful local responses suggests that local populations can learn rapidly to adjust high-risk traditional practices and reduce transmission in conjunction with solid public health measures. Recognising and supporting local resilience will be essential in successfully and sustainably engaging populations in effective Ebola responses.UK Department for International Developmen

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies

Key Considerations: COVID-19 in the Context of Conflict and Displacement - Myanmar

This brief focuses on COVID-19 in Myanmar and how the interplay between conflict, displacement and inter-communal tensions may influence disease control. All health emergencies have social and political challenges, but sensitive consideration and effective management of these is especially important where there is past or ongoing conflict, and where trust in authorities imposing disease control may be low. Myanmar faces COVID-19 alongside serious humanitarian and health system vulnerabilities. The country has a range of conflicts and non-state actors who must be factored into a public health response. This brief highlights key considerations for COVID-19 against this complex governance backdrop. It can be read in conjunction with the SSHAP briefing on COVID-19 in South East Asia which outlines emerging evidence on COVID-19 control measures in the region, with a particular focus on marginal populations including transnational migrants, stateless populations, those working in the informal economy and the urban poor.DFIDWellcome Trus

Towards the Just and Sustainable Use of Antibiotics

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