Imagining disease outbreak responses
As Lakoff sets out in his book, the concept of preparedness has its origins in the early days of the Cold War when the US civil defence establishment started planning for the consequences of an eventual nuclear attack by the Soviet Union. Ever since, the concept has been applied to the management of different types of crises, including earthquakes, floods, hurricanes and fires, and since the 1990s, infectious diseases. In the United States, preparedness exercises were developed to simulate a biological attack with weaponised anthrax or smallpox, as well as large-scale epidemics of emerging infectious diseases. Lakoff suggests that these initiatives largely convinced US policymakers that pathogens could pose a serious threat to national security. Today, the concept of preparedness continues to be central to health security efforts at both national and international levels, including the International Health Regulations – the international legal instrument revised in 2005 by WHO Member States to prevent and control the cross-border spread of infectious disease.
A health worker, wearing Personal Protective Equipment (PPE), stands inside the high-risk area at Elwa hospital in Monrovia, which is run by the French organization Doctors without Borders. Photo: Dominique Faget/NTB scanpix.
Preparedness, Lakoff argues, constitutes a major shift in the way we respond to disease emergence. Whereas contemporary public health approaches often rely on statistics of the burden of disease to establish priorities and design interventions, preparedness focuses on the
potential impact of disease not only on population health, but perhaps more importantly, on the ‘vital systems’ that are critical to the functioning of the economy and society. The emphasis is on ensuring that, in the event of a major crisis such as a nuclear attack or indeed pandemic flu, the political, economic, and social systems that underpin the state will continue to function.
Thus, in preparing for a catastrophic eventuality, emphasis is placed not on trying to
avoid the event, but rather on generating knowledge on how to mitigate the event’s adverse consequences through scenario planning and simulation exercises. These exercises are ‘carefully scripted activities in which decision-makers [are] presented with the details of a crisis situation, [take] action in response, and then stud[y] the results of their decisions’ (p. 24). Preparedness simulations help to maintain a ‘continuous state of readiness’ (p. 24), feeding a feeling of emergency that is necessary to sustain attention, investment and training to cope with risk. The lessons drawn from them help to develop guidelines to respond to crises, such as allocating responsibilities to different levels of authority or developing crisis procedures, and to identify response capacities worth investing in.
Like many global health efforts today, such imagined scenarios are often based on sophisticated mathematical and statistical models, but they ultimately rely on
assumptions that have little grounding in empirical measurement, such as assumed infection rate, scale of the outbreak, lethality, and likely effectiveness of the response. For instance, in the endnote of a widely cited article, ‘Modelling the Worldwide Spread of Pandemic Influenza’, the authors outline important limitations of the study: ‘Like all mathematical models, this model […] contains many assumptions (for example, about viral behavior) that might affect the accuracy of its predictions. The model also does not consider variations in travel frequency between individuals or viral spread in rural areas.’ (4)
Drawing from this logic of preparedness, Lakoff argues that the scale of the 2014–15 Ebola epidemic in West Africa was partly due to a
failure of imagination: ‘at a crucial stage, health authorities did not conceptualise Ebola as the potential source of a catastrophic epidemic’ because previous epidemics of the Ebola strain were contained relatively easily (p. 141).
Preparedness, then, operates at the limits of our imagination; it demands that we anticipate all potential future scenarios, yet we can only prepare for those situations that we envision as possible. Preparedness, moreover, puts responsibility for future potentially catastrophic outcomes in the actions taken in the present. It demands that we continuously invest in our preparedness, yet we can never be 100 per cent prepared.