Problematising the emergence of outbreak science in the governance of global health: making time for slow dis-ease

KEYWORDS:

Outbreak sciencescience and technology studiesevidencetemporalityperpetual care

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‘Outbreak science’ is emerging as an interdisciplinary field in the detection, prediction, and governance of outbreaks in global health (Houlihan & Whitworth, Citation2019; Rivers et al., Citation2019, Citation2020). Proposed to improve emergency response initially in relation to epidemics, the approach has been described as “the functional use of models, clinical knowledge, laboratory results, data science, statistics, and other advanced analytical methods” to support decision-making between and during outbreak threats (Rivers et al., Citation2019, p. 2). These methods work to trace outbreaks as they emerge, but also to pre-empt them through forecasting and projection before they happen (Rivers et al., Citation2020). Outbreak scientists claim to “turn outbreak data into actionable information for decisions about how to anticipate the course of an outbreak, allocate scarce resources and prioritise and implement public health interventions” (Morgan, Citation2019; Rivers et al., Citation2019, p. 2). In the presence of uncertainty, outbreak science offers “evidence-enough” for action (Lancaster et al., Citation2020, p. 477).

In crisis situations, when decision-makers are faced with unexpected outbreaks of disease and harm, it is all the more apparent that evidence is uncertain and emergent. Outbreaks unsettle evidence-based policy (Pearson, Citation2021), forcing a re-evaluation of evidentiary standards and methods (Greenhalgh et al., Citation2022), speeding up and challenging conventional ways of conceiving of the relationship between evidence and policy (Lancaster & Rhodes, Citation2022; Lancaster et al., Citation2020). At stake, however, in the development of new approaches to outbreak science and their promise of fast, actionable information in situations of uncertainty is not only the relationship between evidence and policy but also how evidence-making practices and paradigms govern, and the effects that flow from this. As outbreaks continue to multiply and become more complex (Chatterjee et al., Citation2021), there is a need to consider carefully how ‘outbreak’ is constituted as a particular kind of problem for science and intervention. The evidence-making of ‘outbreak’ shapes what is possible in the governance of crisis, health, and populations, enabling particular kinds of action in an ‘evidence-based’ approach, with profound social and material repercussions.

Contemporary outbreak science is said to invite a “paradigm shift” in how evidence-makers and decision-makers work together to produce timely responses to emerging yet uncertain threats (Morgan, Citation2019; Rivers et al., Citation2019, p. 3). This reflects growing interest, and urgency, in developing methods of early warning, preparedness, and response in relation to outbreaks, especially pandemics (Bedford et al., Citation2019; George et al., Citation2019; Polonsky et al., Citation2019). What is novel about the fast-changing field of outbreak science is not only how existing methods of epidemic intelligence are being adapted but also how the field is assembling new infrastructures of advice and networks of expertise, bringing technologies, data, and experts together in new ways to map, integrate, target, and translate evidence to guide policy at speed. Outbreak science thus extends and remakes the rationalities of rapid assessment approaches which were developed to attempt to speed up the processes of evidence-making and decision-making in situations of complex public health and humanitarian emergencies (Fitch et al., Citation2004; Johnson & Vindrola-Padros, Citation2017; Manderson & Aaby, Citation1992). By combining efforts to prepare, predict, and respond in time, outbreak science enacts “anticipatory governance” (Adams et al., Citation2009; Caduff, Citation2019).

But what are the effects of framing and governing ‘outbreaks’ in this anticipatory mode? What ways of knowing and doing preparedness and response does outbreak science open up and foreclose, especially through its promise of fast, actionable information in situations of uncertainty? How can we think about evidencing outbreaks otherwise? We suggest that there is much to be learned by investigating the rationalities of outbreak science. By critically examining how outbreak science does its work in global health, it becomes possible to illuminate how ‘outbreak’ enacts particular modes of governance as well as how ‘outbreak’ itself is made governable through its evidencing.

Taking ‘outbreak science’ as a form of proposal, we consider how outbreak science does its work, the conceptual logics on which it relies, and crucially, the effects it makes in constituting outbreak as a particular kind of problem and object of governance (Bacchi & Goodwin, Citation2016). Approaching scientific practices as “shaped by” and “simultaneously shaping” the social worlds in which they participate (Law, Citation2004, p. 12) allows us to trace how outbreak science helps to produce realities as well as describe them. Rather than taking ‘outbreak’ as taken for granted and fixed in shape, our attention shifts to the relations and practices involved in its becoming through its evidencing, and the politics involved in its coordination and governance (Mol, Citation2002; Woolgar & Lezaun, Citation2013). In doing so, we draw attention to the ontopolitical effects of contemporary investments in new modes of outbreak science, that is, to the “lived realities” (Bacchi & Goodwin, Citation2016, p. 6) that are produced by these evidence-making practices.
Outbreak made governable

There has been growing global investment in funding and attention to the methods, technologies, and infrastructures of outbreak science, including preparing for threats to come (Houlihan & Whitworth, Citation2019; Oppenheim et al., Citation2019; Polonsky et al., Citation2019; Raftery et al., Citation2021; Rivers et al., Citation2020; Tam & Haas, Citation2016). For example, in 2018, the World Health Organization added to its list of research priorities ‘Disease X’, recognising that a serious international epidemic could be caused by an unknown pathogen and that responses will inevitably be needed with urgency and at scale (Van Kerkhove et al., Citation2021). Investments focus on developing new networks and platforms of knowledge generation and coordination, including through collaboration with global and national policy initiatives, as well as on new technologies in the detection, prediction, projection, and management of outbreaks. For example, there has been increased focus on technological developments in wastewater-based epidemiology, big data, and machine learning, and the incorporation of modelling as elements in early warning surveillance, along with an expanding array of guidelines, methods packages, and directives to standardise approaches (Brooks-Pollock et al., Citation2021; Nelson, Citation2022; Rivers et al., Citation2020). The constitution of an outbreak through its evidencing can generate massive infrastructure as is evident in the recent emergence of multiple new centres, institutes, and laboratories, and the investments made by governments and global agencies in cross-national collaborative efforts, following Covid-19.Footnote1 Such investments relate not only to the detection and anticipation of new and unknown threats but also to evidencing the elimination and control of known and potentially reoccurring pathogens (as with recurrent detections of polio, even in the ‘endgame’ of eradication efforts: Kasturi, Citation2022; Patel & Cochi, Citation2017).

But governing health through the rationalities of ‘outbreak’ is not neutral. Rather, it is political and contingent, with major and lasting effects, distributed unevenly across contexts. This is evident in the multiple effects of declarations made by the World Health Organization of Public Health Emergencies of International Concern (PHEIC) (Ghebreyesus, Citation2022) – as in the case of Zika, COVID-19 and mpox – which work to constitute outbreaks as particular kinds of problems profoundly shaping what gets done and not done. The act of classifying a situation as a PHEIC indicates “both the potential for disaster and the urgency of immediate response” bringing the outbreak of concern into “a technical and administrative relationship with a range of other public health threats” (Lakoff, Citation2019, p. 60). Given the growing investment in infrastructures of outbreak science – especially in the Global North – alongside established institutions of global health, it is sometimes difficult to imagine how outbreaks might be evidenced and governed otherwise. However, it is by constituting an ‘outbreak’ as a particular kind of problem, that is, as a ‘problem of preparedness’, that the development of global infrastructures for detecting and managing future outbreaks is made possible (Lakoff et al., Citation2015). Scholars have argued in the wake of the Ebola epidemic that it was the anticipation of such a severe event that provided motivation for assembling infrastructures of global health security and surveillance, but in constituting the problem as one of preparedness, what was lacking was ‘basic health infrastructure in much of the region, making it difficult to isolate patients and trace contacts; limited capacities of humanitarian NGOs to manage the spread of the disease on their own; and health authorities’ inability to enrol a sceptical public in disease prevention efforts and in case reporting’ (Lakoff et al., Citation2015). How a matter of concern is made visible and manageable as a category of emerging disease, and a problem for science and policy, is therefore not self-evident but an ontopolitical question (Bacchi & Goodwin, Citation2016; Lakoff, Citation2019).

Annemarie Mol proposes “ontological politics” as a composite term combining ‘ontology’ with ‘politics’ to suggest that the conditions of possibility are not given but open and contested (Mol, Citation1999). This thinking has implications for how we attend to what evidence-making practices, like those of outbreak science, do: the conditions of possibility we live with are not immutable; that which we take as the real is not anterior to, but rather made in, practices; and because realities are enacted in a variety of practices, realities are multiple, continually in-the-making, and might also be made otherwise (Law, Citation2004; Law & Urry, Citation2004; Mol, Citation2002). The ontopolitical dimensions of how outbreaks come to be seen as particular kinds of problems are in many ways obscured by the dominant discourse of the ‘problem-solving paradigm’ that underpins evidence-based approaches in public health, grounded on the assumption that problems are pre-existing, waiting to be ‘addressed’ through evidence-informed intervention (Bacchi & Goodwin, Citation2016; Lancaster & Rhodes, Citation2020). However, by taking a different view, we can consider how the material-discursive practices of science, policy, and other interventions work to ontologically constitute ‘problems’, with particular effects. Following Foucault, Bacchi argues that the problematisations produced in proposals “become part of how governing takes place. They are enacted as part of ‘the real’” (Bacchi, Citation2018, p. 6). They are constitutive of realities, including of outbreaks as knowable objects of governance and intervention.

We propose, then, that there is a need to interrogate the practices involved in the shaping of ‘outbreak’ governance, including how the evidence-making of outbreak is done. This is important because how ‘outbreaks’ are constituted as “governable domains” (N. Rose et al., Citation2006, p. 101) affects the management of populations, spaces, nations, and citizens, with profound social and political effects. The declaration of outbreak, for instance, may generate capacity for action and governance of populations in unforeseen harmful ways and in ways which extend beyond ‘health’ given the multiple, and unpredictable, ways in which evidence is put to use (Rhodes & Lancaster, Citation2023). The securitisation, policing, and militarisation of epidemic preparedness and infection control, the shaping of social stigma in affected populations, of citizenship responsibilities, and of virulent geographic and spatial danger zones are examples (Fearnley, Citation2020; Kamradt-Scott & McInnes, Citation2012; Parker et al., Citation2020; Prince, Citation2019). The ‘crisis framing’ of outbreak events also emphasises speed, favouring ‘specific analytic technologies, poised for quick judgement’, helping to “mobilise characteristic analytic techniques with distinct temporal and spatial parameters” (W. Anderson, Citation2021, pp. 169–170; see also Wigen et al., Citation2022). Equally, how situations are constituted not as outbreaks, and therefore not in need of urgent or crisis response, has major resource implications and social-political effects (Rhodes & Lancaster, Citation2023). What happens to investment and infrastructure when outbreaks become declared as controlled or are made absent, is one consideration, as the example of shifts from governing COVID-19 through a mode of ‘outbreak’ to a mode of ‘living with’ illustrates (Limb, Citation2022; Nelson, Citation2022). Here, we can see the dismantling of outbreak science and response infrastructures in the re-assembling of problems from outbreaks of crisis potential to epidemics to endemics. The science of outbreak is not apart from, but rather forms part of, this governance.
Making time for slow dis-ease

Our focus in this commentary is on one problematisation intrinsic to the practices of outbreak science, that is, the need for speed. There are temporalities at play in how outbreaks are enacted across different settings and scales, including in their evidence-making (Nguyen, Citation2017, Citation2019; Roth, Citation2020; Wigen et al., Citation2022). In a global health landscape increasingly characterised by disparities between the Global North and South, a crucial question is: when, where, and for whom is outbreak made as an emergent, and emergency, event? We suggest that Nixon’s concept of ‘slow violence’ is useful here. Through the concept of slow violence, Nixon reassembles customary conceptions of violence, calling for engagement with a different kind of violence that occurs ‘gradually and out of sight […] typically not viewed as violence at all’ (Nixon, Citation2011, p. 2). The violence perpetuated in these situations is one not conceived as an ‘event or action that is immediate in time, explosive and spectacular in space’ but rather a violence that is ’incremental and accretive, its calamitous repercussions playing out across a range of temporal scales’. We draw on this concept to highlight how the logics of speed and immediacy can foreclose visibility, sometimes with deleterious effects. The recent naming of mpox as a PHEIC is one example of how the immediacy of the designation of a disease as ‘re-emerging’ can obscure or marginalise the slow, enduring experiences of communities in parts of the world which have experienced endemic cycles of disease and continued vigilance. First identified in humans in 1970 in the Democratic Republic of the Congo, mpox outbreaks have until recently predominantly affected remote populations in Central and West Africa, with the first outbreak out of Africa in 2003 in the United States of America, and large outbreaks reported in Nigeria and Cameroon in 2017 and 2018 (Beer et al., Citation2019; WHO, Citation2022). Here we can begin to see how ‘slow’ relates not only to the pace of time with which an outbreak progresses but also to a politics of time in how conditions are rendered visible, or not. Similarly, the limits of the political-administrative category of public health ‘emergency’ were challenged in the context of the Zika outbreak in 2016, when it was recognised that developing treatments or preventative measures would require ‘lengthy’ scientific and public health investigation, highlighting the “mismatch between the rationality of preparedness and the experience of disease” (Lakoff, Citation2019, p. 66). As Lakoff noted, “the envisioned period of sustained attention extended well beyond the confined temporal structure of emergency” (p. 65, emphasis added), and this had implications for funding for research and intervention which had been tied to emergency-oriented donors.

We suggest then, slow dis-ease as a lens through which to re-assemble disease outbreak in long and ecological view. The older (Latin) term of dis-ease has given way to disease as an invention coinciding with the emergence of pharmaceutical and biomedical technological solutions to bodily disruptions (Graham, Citation2011). Emphasising ‘dis-ease’ returns disease and ill-health outbreak as more than a biological rupturing event requiring a technological fix, and as a situated and contingent ecological and socio-political concern (Boddice & Hitzer, Citation2022). Dis-ease accentuates a condition of discomfort and disruption giving rise to the potentiality of harms to create the imperative to act (Jovanovic, Citation2014). Problems framed as crisis, emergency, or outbreak can also extend the conditions of dis-ease they seek to govern, creating, for instance, an ‘uncomfortable science’ in which reflexive uncertainty embodies the practices of outbreak science and outbreak responses (Rhodes & Lancaster, Citation2022a, Citation2022b). Dis-ease then, looks beyond a physical body that is disrupted or lacking to encompass conditions of affective unease in the social body (Boddice & Hitzer, Citation2022; Sweetman, Citation2003). Acknowledging illness events as both slow and as matters of social, political, and affectual dis-ease accentuates temporal diversity in local experiences and effects of outbreak, thereby questioning the presumptions of technoscientific rapid response.

Apprehending and attending to different situated temporalities opens up problem-framings that allow for outbreaks to be made otherwise, conceptualised and located differently, to precipitate different kinds of action. This is not merely a conceptual challenge, but a practical and political one. This reorientation can potentially break what Director General of the World Health Organization, Tedros Adhanom Ghebreyesus, has called a cycle of “panic and neglect” crisis response to epidemics, including to no longer ignore pathogens that spread “‘only’ in low-income countries” (Ghebreyesus, Citation2022). Here, we can see how the temporal logics of rapid technoscientific response also have spatialising effects, in terms of where, and for whom, outbreaks are indicated, and problems located, in global health. Attending to slow dis-ease reassembles temporality but in so doing also reconfigures the spatial dimensions of ‘the problem of outbreak’, and by extension, the locations of expertise as well as the forms of response. This is a critical move as epidemics have distal ecological histories and not merely proximal ones (Hinchliffe et al., Citation2021). The very constitution of a problem as one to be managed with immediacy and speed delimits alternative problematisations of ‘outbreak’ shaped by long-enduring temporalities of slow dis-ease in more complex ecological relations, including, for example, “structural inequalities that cause poverty and racial discrimination and determine living conditions, and globalisation and market-based inequities that shape relationships to animals and landscape” (Hinchliffe et al., Citation2021, p. e232; Wigen et al., Citation2022).
Pollutants, viruses, and perpetual care

In re-assembling outbreak as slow dis-ease, we draw inspiration from the fields of environmental science and science and technology studies (STS), which have been grappling with depollution and the implications of the impossibility of elimination and remediation of long-enduring wastes such as ocean plastics, nuclear wastes, and persistent organic pollutants (Gray-Cosgrove et al., Citation2015). With resonances to the control of viruses and other outbreaks of public health concern, Gray-Cosgrove and colleagues accentuate the challenges of temporality, attending to how pollutants endure in time and across space, with the ‘extreme longevity’ of these materials made apparent via spills, leaks, and the reintroduction of harm. Containment of pollutants is temporary; known pollutants might be ‘cleaned up’ in one area, but the emergence of new potential harms is always possible. So too for viruses and other pathogens of outbreak potential in global health. The ongoing monitoring of eradicated disease such as polio is one example, with its potential re-emergence in the United Kingdom and the United States of America a timely reminder of the fragility of such declarations (Kasturi, Citation2022). Moreover, in another parallel between depollution and viral outbreak, harms produced tend to be unevenly distributed, with unequal and enduring effects often experienced by low-income and Indigenous communities (Fox, Citation2022; Hinchliffe et al., Citation2021; Sandset, Citation2021; Speed et al., Citation2022). When we consider how and from where outbreak science emanates – with its emphasis on global networks of knowledge coordination and data analytics, locating infrastructurally and technologically in practices with a long history of responding to global health and disease as ‘problems of the south’ – by re-enacting certain places and populations as in need of correction or intervention, the science of outbreak, as currently construed, risks perpetuating these harms.

Scholars studying the implications of long-enduring environmental wastes have called for approaches that take extreme longevity into account in terms of “perpetual care” (Gray-Cosgrove et al., Citation2015, p. 2), moving beyond ‘point-in-time’ approaches to acute events and acknowledging the need for responses which grapple with the longevity, persistence, and recurrence of harm, and the knowledge and care relations this entails. Through the lenses of ‘slow violence’, ‘slow dis-ease’, and ‘perpetual care’, we can begin to see how ‘outbreak’ might be made otherwise. There are also parallels, in work which emphasises how crisis conditions emerge as ‘slow emergencies’ (B. Anderson et al., Citation2020; Rhodes & Lancaster, Citation2023). Grappling with the temporal and spatial complexities of ‘outbreak’ harm, and its long timescales, opens up questions of how we might best intervene in outbreaks, recognising these not necessarily as a ‘break’ from the norm – as in the rhetoric of outbreak ‘preparedness’ and ‘response’ – but as in need of ongoing attention. The notion of ‘perpetual care’ carries with it political organisation, infrastructures, and ethical frameworks to unite them, bringing to the fore enduring social and ethico-political concerns that might ordinarily sit outside the immediate focus of science (especially scientific practices situated in a cycle of event-based speed and response). In the field of global health, an ethics of perpetual care may entail a notion of stewardship and responsibility for the future of planetary health, beyond that imagined in an implementation toolkit; not delimited by biomedical and technoscientific fixes but also incorporating social technologies, expanding the temporal dimensions of how ‘outbreak’ is constituted in ways that grapple with what it means to do this work “now and in the long future” (Gray-Cosgrove et al., Citation2015, p. 6). Yet, as feminist STS scholars have emphasised, there is a need to consider who benefits and who is burdened by this care, especially when it continues to fall to communities most affected by enduring harm (Gray-Cosgrove et al., Citation2015; Puig de la Bellacasa, Citation2017). The field of global health abounds with examples of the enduring care work done by affected communities (see, for example, the social technologies of negotiated safety and sustained HIV prevention strategies among gay men: Epstein, Citation1996; Kippax & Race, Citation2003; Kippax & Stephenson, Citation2016). In the context of global health and the evidencing of outbreak, we must ask: how do we do the labour of caring for, as opposed to merely containing dis-ease? What sort of outbreak science might contribute evidence which supports such a response?
Another outbreak science is possible

Can outbreaks be evidence-made otherwise (Stengers, Citation2018)? Not only as crises in need of immediate and swift response, but as slow dis-ease? And with what effects? The COVID-19 pandemic is a reminder of the need for understanding how scientists, decision-makers, and other experts might approach viral outbreaks as enduring problems, without recourse to the promissory discourse of elimination efforts (or, we might add, of biomedicine). It is, after all, the complex social and ecological relations between humans, non-humans, and environments which makes the conditions for enduring, slow dis-ease (Hinchliffe et al., Citation2021). The challenges of animal reservoirs and zoonotic pathogens extend the ways that outbreak potential exists not only in acute events shaped by human agency but also in deep time, dispersed across ecosystems and enduring beyond containment efforts. The logics of speed and technoscientific promise embedded in new outbreak science data infrastructures are arguably not well attuned to the overlapping and enduring temporalities and conditions of outbreak. The hegemonic timescape of technoscientific futurity and the promise of biomedical ‘silver-bullets’ to advance global health are arguably put into question as the uncertainty of outbreak crises persist in a pandemic assemblage such as we are currently experiencing. But nonetheless, the ‘inexhaustible pull’ of evermore innovation orients practices in the present, fostering “uncertainty and expectation about an imminent breakthrough that could change it all for the better or the worse” (Puig de la Bellacasa, Citation2017, p. 174), with the emphasis on acting fast.

If time is not given but made through everyday practices and arrangements, then it is imperative to consider how the immediate, innovation-driven technoscientific promise of outbreak science might exist along with and co-constitute other timescales, including those not of fast-response to anomalous events but of slow dis-ease and enduring crisis located in multispecies entanglements in time and space (Puig de la Bellacasa, Citation2017; D. B. Rose et al., Citation2017; van Dooren et al., Citation2016). The example of the COVID-19 pandemic reminds us of this. Here, outbreak science serves to rupture or break COVID-19 from a more ecological knowing and situated response, which might otherwise co-exist, by obscuring alternative understandings of this event as an effect of slow-burning ecological disaster within a planetary health approach (a problematisation which would foreground socioecological relations and the “more complex terrain of a disease”) (Hinchliffe et al., Citation2021, p. e232). The slow-burn of COVID-19 dis-ease, for instance, might enact a terrain shaped by entanglements of ‘habitat destruction, illegal trade in wild animals, climate instabilities’ as well as ‘structural inequalities that cause poverty and racial discrimination and market-based inequities that shape relationships to animals and landscape’ (Hinchliffe et al., Citation2021, p. e232). Although planetary health approaches seek to reconfigure health as an effect of these slow and ecological changes, such problematisations largely go unseen within the speedy technoscientific logics and globalising effects of outbreak science as currently configured.

There is a practical difference made possible by “making time” (Puig de la Bellacasa, Citation2017, p. 177) for slow dis-ease, a time that is currently obscured by the rapid, anticipation and event-based focus of outbreak science. We do not simply need to speed up existing evidence-based approaches but rather develop new ways of thinking and adapting in the unfolding situation (Lancaster et al., Citation2020; Rhodes & Lancaster, Citation2019, Citation2023; Savransky & Rosengarten, Citation2016). Making time for slow dis-ease and reorienting evidence-making practices towards perpetual care can reconnect outbreak science with long-enduring temporalities and socioecological relations and help move toward more positive and ethical outcomes for those whose lives are affected.
Acknowledgements

We are grateful for support from the UNSW SHARP (Tim Rhodes) and Scientia (Kari Lancaster) schemes. Kari Lancaster is supported by the Australian Research Council DECRA Fellowship (DE230100642).
Disclosure statement

No potential conflict of interest was reported by the author(s).
Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.
Additional information
Funding
This work is funded by the Australian Research Council (DE230100642).
Notes

1. Examples of recent investments and initiatives in outbreak science globally include: the Johns Hopkins Center for Public Health Preparedness; the MRC Centre for Global Infectious Disease Analysis; the London School of Hygiene and Tropical Medicine Centre for Epidemic Preparedness and Response; the University of Oxford Pandemic Sciences Institute; the National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response; the Institute of Development Studies Pandemic Preparedness program; Rutgers Center for COVID-19 Response and Pandemic Preparedness; the Duke-NUS Centre for Outbreak Preparedness; the Task force for Global Health; the Global Research Collaboration for Infectious Disease Preparedness; the Global Task Force on Pandemic Response; the Early Warning and Response System of the European Union (European Centre Disease Prevention & Control); Outbreak Response Division of Foodborne, Waterborne, and Environmental Diseases, and the Emergency Preparedness and Response division, Centers for Disease Control and Prevention; the World Bank’s the Regional Disease Surveillance Systems Enhancement Program; the World Health Organization’s Health Emergencies Programme; the Coalition for Epidemic Preparedness Innovations; the UK National COVID-19 Wastewater Epidemiology Surveillance Programme; the UK NHS Environmental Monitoring for Health Protection wastewater surveillance programme; the SCORE-NORMAN SARS-CoV-2 in sewage database.
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