The recent upsurge in global health emergencies constitutes a public threat that is as potentially catastrophic as it is unpredictable. Beginning with the HIV/AIDS epidemic of the 1980s, the regular emergence of new and mutated pathogens has become increasingly frequent. All evidence suggests the trend will continue. However, as the book’s title suggests, the emergence of each new infectious disease exposes a persistent lack of global institutional preparedness to prevent pandemics. In Unprepared, Andrew Lakoff offers an engaging analysis of the evolving state of emergency response to global health crises. The culmination of a series of comparative analyses leads Lakoff to conclude that the logic underlying the global health security system is both historically contingent and responsible for its own repeated failures. Debates among and between experts in a variety of fields are intertwined with public scrutiny and amplified by the combination of the urgency and uncertainty of the threat. Unprepared is an impressive account of outcomes based on their counterfactuals. Before navigating through a series of outbreak episodes that illustrate serial post hoc adjustments to what has come to be known as global health security, Lakoff introduces the macro-historical context that amplifies the pandemic threat. Contemporary geopolitical relationships, demographic trends, and the international exchange of goods, services, and people create unique challenges to detecting and containing outbreaks of infectious diseases. These challenges are compounded by the involvement of a wide array of participants. Experts in the newly formed field of global health security are joined by infectious disease specialists, nongovernmental organizations, corporations, diplomats, and journalists, among others. To explain global public health experts’ chronic unpreparedness for the threat du jour, Lakoff takes an historical ontological approach. He analyzes the processes by which a global health security apparatus haphazardly consolidated over the course of several decades. He begins with the observation that responses to infectious disease threats are surprisingly detached from the characteristics of the diseases themselves. Instead, they exist within a generalized technocratic regulatory framework that may or may not be appropriate for any given situation. Lakoff’s analytical strategy hinges on stepping back—chronologically and conceptually—questioning each otherwise taken-for-granted premise along the way. He questions preparedness as governance strategy and explains how it came to structure the thoughts and actions of infectious disease experts. Lakoff locates the origins of the preparedness approach in the civil defense techniques developed in the United States during the Cold War. He traces a series of debates over the most effective approach to protecting the public from all urgent and uncertain threats. Ultimately, a “continuous state of readiness” (chapter 1) strategy replaced statistical prediction of risk. The “generic biological threat” (chapter 2) of bioterrorism later brought together the fields of civil defense and public health. Lakoff’s comparison of responses to flu outbreaks in 1976 and 2005 highlights the significance of the transition from prevention to preparedness. He later revisits this still unresolved tension within the “fragile assemblage” (chapter 5) of a heterogeneous set of actors who have a common goal of protecting the public from catastrophic events that may or may not happen. New debates on viral research, its unintended consequences, and intellectual property rights follow. In his analysis of “two regimes of global health” (chapter 3), Lakoff reveals a close link between organizational goals and structure. The comparison of humanitarian biomedical organizations on the one hand, and the World Health Organization on the other, illustrates the ethical, political, and technical dimensions of institutionalizing a global health governance system. The WHO’s formal adoption of the preparedness strategy raises new questions. What constitutes a “public health emergency of international concern”? Who establishes the criteria for intervention and withdrawal? Who benefits? In answering these questions, Lakoff looks to the “real time biopolitics” (chapter 4) centered on tensions between global and national authorities. The consequent imposition of a technocratic global health emergency response system based on preparedness rather than prevention protects states over people. It likewise shapes the public’s expectations and demands. The subsequent process of “diagnosing failure” (chapter 6) to adequately respond to health emergencies results in recurrent post hoc reform within the WHO. Lakoff’s explanation for unpreparedness contradicts the assumption that preparedness is an inevitable goal. Public health experts and the public alike assign responsibility for the successes and failures of the global health security system to conflicts of interest and the poor and/or unethical decision-making of individuals. Formal inquiries and commission reports, for example, focus on features of the existing framework. They recommend revising classificatory schema, flow charts, and other technocratic elements of their system of crisis management. Public health authorities would do well to take note of Lakoff’s argument and revisit their governance strategy accordingly. By implication, regulators in other fields would likely benefit from consideration of Lakoff’s analyses. Beyond its policy implications, Unprepared should be of wide interest to social scientists, especially those interested in explaining macro-historical change. However, the book’s empirical strength is countered by a lack of broad theoretical engagement. Lakoff provides an abundance of evidence that is applicable to a wide range of topics and sub-fields. For example, the overlapping processes of developing a multilateral agreement to share biological materials, a WHO-based surveillance system, and corporate production of vaccines offer fresh cases for scholars of global governance and the relative autonomy of states. Further, Lakoff’s study invokes potential for fruitful social network and cross-national comparative analyses. Most notably, Lakoff’s analyses relate to sociological institutionalist and constructivist perspectives. Ultimately, Unprepared is an analysis of the processes of world cultural norm formation and institutionalization. The preparedness norm’s origination in the domestic institutions of the United States represents initial evidence supporting a theoretically central, yet empirically neglected, assumption. Scholars in these fields should take keen note. Additionally, his analyses suggest the importance of power imbalances within global institutions. This undertheorized topic has potential to contribute to theories of international inequalities in health as well as economic, environmental, and other development outcomes. However, given the book’s scope, omission of the many relevant theoretical perspectives is less a shortcoming than an opportunity for others to expand upon. © The Author(s) 2018. Published by Oxford University Press on behalf of the University of North Carolina at Chapel Hill. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Social Forces – Oxford University Press
Published: Mar 15, 2018
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