Trust and uncertainty in public health emergencies: The social life of COVID-19 Testing

Alice Street, 8.10.20

Testing capacity has taken centre stage of the international response to the COVID-19 pandemic. As the epidemic curve has peaked and dipped, so have the meanings and value of testing been dramatically expanded beyond medical and public health uses to include such purposes as restarting economies or regaining intimacy with loved ones. Effective testing strategies have also been revealed to hinge on multiple relationships of trust: including trust in technology, in government, in oneself, and in strangers. In this presentation I will reflect on the social life of COVID-19 testing through research undertaken by a team of social scientists based at the University of Edinburgh and funded by the European Research Council and the Scottish Chief Scientists Office. This research shows that, while promises of certainty are often made for diagnostic tests, the social relationships on which testing depends often generate intense uncertainties in the testing process. Understanding those relationships and the values they embody, I argue, will be crucial if testing is to be effectively harnessed to meet the challenges of the COVID-19 pandemic.

Webinar: Testing and Trust

Dr Alice Street and Dr Shona Lee, 30.09.20

Live Zoom Webinar

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Testing and Trust is a rapid qualitative study investigating public understandings, expectations and experiences of Covid-19 testing in Lothian, Scotland and how testing strategies influence public trust in health services and government response. The study is being led by the DiaDev project team at the University of Edinburgh’s School of Social and Political Science, and is funded by the Chief Scientist Office’s Rapid Research in COVID -19 programme.

In this live webinar, we reported our findings from in-depth, socially contextualised research into people’s understandings of different Covid-19 tests, their expectations of how and when they should be tested, their experiences of testing and how test outcomes influence behaviour. The presentation was followed by a Q&A and discussion chaired by the study’s Principle Investigator Dr Alice Street.

Architectures of preparedness: hope and hidden infrastructures of vaccine development and laboratory strengthening in Sierra Leone

Shona Lee, 28.08.20

Presented at the Association of Social Anthropologists (ASA) online annual conference 'How to live through a pandemic'

This paper examines how the international response to the 2014-2016 Ebola outbreak helped to prepare Sierra Leone’s health system for COVID-19. It draws on anthropological research on post-Ebola vaccine trials and laboratory strengthening programmes to explore health-worker experiences of epidemic response and preparedness efforts. These on-the-ground experiences and perspectives are under-recognised in evaluative exercises, but are critical to understanding which features of emergency response carry forward as sustainable infrastructures of preparedness. Analysis will centre on the hopes and expectations that technology-centred preparedness interventions foster for frontline workers in under-resourced health systems, the hidden efforts of building robust preparedness infrastructures, and the contribution of anthropological approaches to understanding preparedness as a social process. In describing the additional labour, informal networks, personal losses and social risks undertaken by laboratory and vaccine trial workers in order for protocols and practicality to meet, we reveal the social performance of preparedness. That is, the contextual engineering that make systems work through personal connections and sacrifice. The paper expands concepts of preparedness to include its personal and relational aspects, exploring the knowledge and value systems produced in epidemics. From this perspective, the Ebola response and aftermath helped prepare Sierra Leone for COVID-19 by developing capacity at individual and institutional levels, and blueprinting physical and social infrastructures for cultivating laboratory, vaccine development and clinical research systems. Yet failing to build the social experiences of response work into preparedness programmes risks erasing important knowledge of how these temporary assemblages are stabilised and sustained. COVID-19 has confirmed that the rhetoric of resilience is insufficient to capture the extent and expectation of sacrifice placed on staff. Responding to this pandemic requires investing in the long-term safety, security, and support of people undertaking the work prescribed by protocols, as well as that of making protocols work.

The Social Life of COVID-19 testing

Alice Street, 12.05.20

Presented by Dr Alice Street at the 'Edinburgh Responds' webinar series focusing on the response of Edinburgh academics and clinicians to the Covid-19 pandemic.

The coronavirus pandemic has raised public awareness of the important role of diagnostics in public health.

Demands for more tests for COVID-19 continue to be at the centre of political debate and criticism of governments’ handling of the pandemic, particularly in the UK and the US. The political messaging around testing has underplayed the complexity of diagnostics, particularly in relation to the emergency response.

Political leveraging of diagnostics has placed enormous expectations on COVID-19 tests. They are expected to provide certainty on the pandemic situation the country. They are expected to reassure that the measures taken by the government and health authorities are appropriate for controlling the spread of the pandemic. They are expected to provide a guarantee for people to come out of the lockdown and get back their freedom of movement. Perhaps above all, they are expected to set countries on to the path of economic recovery.

Experiences from DiaDev's (Investigating the design and use of diagnostic devices in global health) research in Sierra Leone in the West Africa Ebola response in 2014-2016, and ongoing COVID-19 related research in India and the UK, show that there are multiple kinds of diagnostic technologies with varying usages and benefits. Different kinds of tests are best operated in different places – triaging patients, for making decisions on clinical care of individual patients and for surveillance purposes.

The focus on getting more and better tests has also diverted attention from building capacity of national laboratory systems, particularly in the low and middle income countries.

Reflecting on these experiences, it is evident that even in a country like the UK, there are weaknesses with the supply chain and the manufacturing system for diagnostics. The focus on point of care diagnostics may be distracting concerned authorities from considering the comprehensive ‘diagnostic system’, from production to marketing, distribution, maintenance and waste management.

The Social Life of Diagnostics

Alice Street and Nanda Kishore Kannuri, 9.04.19

Dr A Street and Dr Nanda Kishore Kannuri presented their research at the Indian Institute of Public Health, Hyderbad.

In many rural health facilities in Low and Middle Income Countries, people do not have access to the laboratory facilities or technical expertise that are needed to diagnose disease. With the development and deployment of a new generation of affordable, easy-to-use, and portable diagnostic devices that are designed for places with no laboratory infrastructure, the global landscape of diagnosis is dramatically changing. What do these devices do and what value do they have in the places where they are used? What role can technology innovation play in strengthening health care systems in resource constrained settings? In this talk, we introduce our current research into the changing role of diagnostic devices in global health. We begin by exploring the shift from diagnosis to diagnostics in the framing of diagnostic needs in resource-limited settings. We then introduce preliminary findings from field sites in Telangana, India, where we are at the beginning of an ethnographic investigation into existing laboratory infrastructure. Last, we explore how the concept of the diagnostic system can help us to think beyond the device as a magic bullet solution and develop new models for global health design and innovation.

Getting to Zero: The role of diagnostics in the elimination of infectious diseases'

Michelle Taylor and Alice Street, 14.11.18

Presented at the Infectious Disease Diagnosis Sympsium, Roslin Institute, Edinburgh

Idds Group

The failure of the Malaria Eradication Programme in 1950s led to a spell of disillusionment with the idea of disease eradication, with critics concerned the endeavour was overtly costly, administratively demanding and counter to the WHO’s goal of securing health for all. In the 21st Century however, the idea is enjoying a renaissance with people like Bruce Aylward of the Bill and Melinda Gates Foundation declaring disease eradication the “venture capital of public health.” The intuitive appeal is simple, frontload investment now to save on prevention and control activities once a disease is wiped off the face of the earth. With Gates support, the WHO has backed an ambitious set of targets for disease eradication and elimination, notably in regards to a group of Neglected Tropical Diseases. But these targets are not straightforward and the use of slippery terminology offers opportunities and dangers for a set of diseases which, because they affect the world’s poorest and most marginalised people, typically lack a commercial market and in turn stimuli for innovation.

Diagnostics have come to play a central role in the new elimination era on the basis of some circular thinking which proceeds as thus: the desire to eliminate disease creates a need for new tools; while the promise of new technologies fuels the argument that diseases are eliminable. The ERC-funded DiaDev project at Edinburgh is exploring diagnostics in support of disease elimination as one of its research strands. DiaDev employs social science methods to investigate the design and use of diagnostic devices in global health, and in particular the emergent role that diagnostics are playing in the transformation of health systems in low and middle-income countries. Already, the goal of eliminating disease is breaking with traditional conceptualisations of what and who diagnostics are for, increasing the number of roles diagnostics are designed to play (for disease mapping, post-elimination surveillance, to assess treatment efficacy etc.) and in many instances focusing efforts on the target population rather than the individual. Moreover, in many instances new diagnostics tools are designed to produce data, but again who and what this data is for breaks with past practice when diagnosis was conceptualised as the first step on a pathway to treatment. In this paper, we begin to explore the tensions and opportunities involved in the elimination enterprise and delineate some of the implications for diagnostic development and deployment in global health.

Panel Discussion: Acute and Febrile Illnesses: Needs and Priorities

Shona Jane Lee, 13.06.18

DiaDev Associated Researcher, Shona Lee, presented her research on the role of diagnostics in managing febrile illness at the McGill Summer Institute for Global Health Diagnostics.

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Mobile laboratories: integrating diagnostics with health system infrastructures

Alice Street, 22.06.15

Edinburgh Infectious Diseases Annual Symposium

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