A pandemic of metrics.

The COVID-19 pandemic prompted critical attention to the performative power of metrics. We suggest that the existential capacities of metrics as a means of pandemic living warrant further consideration. We describe how the COVID-19 pandemic that came into existence as a public health and political event could only have occurred because of the anticipatory metrical practices that were used to transform SARS-COV-2 into a matter of global health concern. By exploring the affective potencies of COVID-19 metrics we show their abilities to engage the public in ways that cannot be contained; in detailing the narrative arcs created through metrics we show their opportunities, misdirections, and erasures. A pandemic way of life persists: a pandemic of metrics.

Designing a leadership and management training curriculum for undergraduate health professions students: Lessons from the University of Sierra Leone.

Leadership by health professionals is key in any health system, but health leadership training programmes are varied in their conceptualisation, learning objectives, and design. This paper describes an undergraduate leadership and management module for health students at the University of Sierra Leone and provides lessons from the design process. Our methods included an initial scoping review and qualitative study, followed by a co-design process of 10 workshops and 17 consultation meetings. The result was a curriculum with learning outcomes emphasising leadership identity, proactiveness, management of people and of change, and the formation of peer relationships. Learning methods included group teaching, team quality improvement projects, mentoring, and reflective practice. Lessons from the design process included the importance of support from university leadership and extensive consultation. Virtual workshops enabled broader participation but limited relationship building. Integrating doctoral research into the process facilitated inclusion of evidence and theory but risked reducing ownership by faculty. The importance of interprofessionalism and management skills in leadership training emerged during the process, illustrating the effectiveness of a co-design approach. Our programme is broadly aligned with other health leadership frameworks and is distinctive due to its undergraduate focus, offering insights for leadership training design in other settings.

The needs and opportunities for housing improvement for malaria control in southern Tanzania.

BACKGROUND: Malaria disproportionately affects low-income households in rural communities where poor housing is common. Despite evidence that well-constructed and mosquito-proofed houses can reduce malaria risk, housing improvement is rarely included in malaria control toolboxes. This study assessed the need, magnitude, and opportunities for housing improvement to control malaria in rural Tanzania. METHODS: A mixed-methods study was conducted in 19 villages across four district councils in southern Tanzania. A structured survey was administered to 1292 community members to assess need, perceptions, and opportunities for housing improvement for malaria control. Direct observations of 802 houses and surrounding environments were done to identify the actual needs and opportunities, and to validate the survey findings. A market survey was done to assess availability and cost of resources and services necessary for mosquito-proofing homes. Focus group discussions were conducted with key stakeholders to explore insights on the potential and challenges of housing improvement as a malaria intervention. RESULTS: Compared to other methods for malaria control, housing improvement was among the best understood and most preferred by community members. Of the 735 survey respondents who needed housing improvements, a majority needed window screening (91.1%), repairs of holes in walls (79.4%), door covers (41.6%), closing of eave spaces (31.2%) and better roofs (19.0%). Community members invested significant efforts to improve their own homes against malaria and other dangers, but these efforts were often slow and delayed due to high costs and limited household incomes. Study participants suggested several mechanisms of support to improve their homes, including government loans and subsidies. CONCLUSION: Addressing the need for housing improvement is a critical component of malaria control efforts in southern Tanzania. In this study, a majority of the community members surveyed needed modest modifications and had plans to work on those modifications. Without additional support, their efforts were however generally slow; households would take years to sufficiently mosquito-proof their houses. It is, therefore, crucial to bring together the key players across sectors to reduce barriers in malaria-proofing housing in endemic settings. These may include government subsidies or partnerships with businesses to make housing improvement more accessible and affordable to residents.

Exit, voice or neglect: Understanding the choices faced by doctors experiencing barriers to leading health system change through the case of Sierra Leone.

This paper presents a study from Sierra Leone that explored the experiences of doctors as they endeavored to improve the health care systems in which they worked. Twenty-eight interviews were conducted with doctors in Sierra Leone, complemented by long-standing experience of national health provision and research by the authors. Drawing on Hirschman's theory of 'exit, voice and loyalty', the paper's framework analysis elaborates the doctor's career decisions and choices under systematic political and economic constraints, and in particular, the specter of retribution, including posting to undesirable jobs and withholding of salaries. This retribution was considered a driver of exit by doctors from the system, and few examples were given of doctors successfully advocating for change through advocacy ('voice'). We suggest that the relevance of Hirschman's theory to this setting is in drawing attention to the critical themes of retribution, opportunity, loyalties, and partial exits, ones often neglected in efforts to reduce emigration of doctors and strengthen their leadership. Ultimately, this paper critiques the overemphasis of mechanistic 'capacity building' in global health and recommends that health system strengthening must be viewed as a jointly political as well as technical exercise.

Human preparedness: Relational infrastructures and medical countermeasures in Sierra Leone.

This paper examines health worker experiences in two areas of post-epidemic preparedness in Sierra Leone - vaccine trials and laboratory strengthening - to reflect on the place of people in current models of epidemic response. Drawing on ethnographic research and interviews with health workers in the aftermath of Ebola, it explores the hopes and expectations that interventions foster for frontline workers in under-resourced health systems, and describes the unseen work involved in sustaining robust response infrastructures. Our analysis focuses on what it means for the people who sustain health systems in an emergency to be 'prepared' for an epidemic. Human preparedness entails more than the presence of a labour force; it involves building and maintaining 'relational infrastructures', often fragile social and moral relationships between health workers, publics, governments, and international organisations. The COVID-19 pandemic has underscored the value of rethinking human resources from an anthropological perspective, and investing in the safety and support of people at the forefront of response. In describing the labour, personal losses, and social risks undertaken by frontline workers for protocols and practicality to meet in an emergency context, we describe the social process of preparedness; that is, the contextual engineering and investment that make response systems work.

Pills and prayers: a comparative qualitative study of community conceptualisations of pre-eclampsia and pluralistic care in Ethiopia, Haiti and Zimbabwe.

BACKGROUND: Pre-eclampsia is a leading cause of preventable maternal and perinatal deaths globally. While health inequities remain stark, removing financial or structural barriers to care does not necessarily improve uptake of life-saving treatment. Building on existing literature elaborating the sociocultural contexts that shape behaviours around pregnancy and childbirth can identify nuanced influences relating to pre-eclampsia care. METHODS: We conducted a cross-cultural comparative study exploring lived experiences and understanding of pre-eclampsia in Ethiopia, Haiti and Zimbabwe. Our primary objective was to examine what local understandings of pre-eclampsia might be shared between these three under-resourced settings despite their considerable sociocultural differences. Between August 2018 and January 2020, we conducted 89 in-depth interviews with individuals and 17 focus group discussions (n = 106). We purposively sampled perinatal women, survivors of pre-eclampsia, families of deceased women, partners, older male and female decision-makers, traditional birth attendants, religious and traditional healers, community health workers and facility-based health professionals. Template analysis was conducted to facilitate cross-country comparison drawing on Social Learning Theory and the Health Belief Model. RESULTS: Survivors of pre-eclampsia spoke of their uncertainty regarding symptoms and diagnosis. A lack of shared language challenged coherence in interpretations of illness related to pre-eclampsia. Across settings, raised blood pressure in pregnancy was often attributed to psychosocial distress and dietary factors, and eclampsia linked to spiritual manifestations. Pluralistic care was driven by attribution of causes, social norms and expectations relating to alternative care and trust in biomedicine across all three settings. Divergence across the contexts centred around nuances in religious or traditional practices relating to maternal health and pregnancy. CONCLUSIONS: Engaging faith and traditional caregivers and the wider community offers opportunities to move towards coherent conceptualisations of pre-eclampsia, and hence greater access to potentially life-saving care.

Imperfect diagnosis: The truncated legacies of Zika testing.

When the Zika virus burst onto the international scene in the second half of 2015, the development of diagnostic tools was seen as an urgent global health priority. Diagnostic capacity was restricted to a small number of reference laboratories, and none of the few available molecular or serological tests had been validated for extensive use in an outbreak setting. In the early weeks of the crisis, key funders stepped in to accelerate research and development efforts, and the WHO took responsibility for steering diagnostic standardization, a role it had successfully played during the West Africa Ebola virus outbreak. Yet when the WHO declared the end of the Zika Public Health Emergency of International Concern in November 2016, diagnostic capacity remained patchy, and few tools were available at the scale required in the countries that bore the brunt of the epidemic, particularly Brazil. This article analyses the limited impact of global R&D efforts on the availability of Zika diagnostic options where they were most needed and for those most vulnerable: women who might have been exposed to the virus during their pregnancy and children born with suspected congenital Zika syndrome. The truncated legacies of testing during the Zika crisis reveal some of the fault lines in the global health enterprise, particularly the limits of 'emergency R&D' to operate in geopolitical contexts that do not conform to the ideal type of a humanitarian crisis, or to tackle technical issues that are inextricably linked to domestic struggles over the scope and distribution of biological citizenship. Diagnostic shortcomings, we argue, lie at the heart of the stunning transformation, in less than two years, in the status of Zika: from international public health emergency to neglected disease.

To bend without breaking: a qualitative study on leadership by doctors in Sierra Leone.

Strong leadership capabilities are essential for effective health services, yet definitions of leadership remain contested. Despite the acknowledged contextual specificity of leadership styles, most leadership theories draw heavily from Western conceptualizations. This cultural bias may attenuate the effectiveness of programmes intended to transform healthcare practice in Sub-Saharan Africa, where few empirical studies on health leadership have been conducted. This paper examines how effective leadership by doctors was perceived by stakeholders in one particular context, Sierra Leone. Drawing together extensive experience of in-country healthcare provision with a series of in-depth interviews with 27 Sierra Leonean doctors, we extended a grounded-theory approach to come to grips with the reach and relevance of contemporary leadership models in capturing the local experiences and relevance of leadership. We found that participants conceptualized leadership according to established leadership models, such as transformational and relational theories. However, participants also pointed to distinctive challenges attendant to healthcare provision in Sierra Leone that required specific leadership capabilities. Context-specific factors included health system breakdown, politicization in the health sector and lack of accountability, placing importance on skills such as persistence, role modelling and taking initiative. Participants also described pressure to behave in ways they deemed antithetical to their personal and professional values and also necessary in order to continue a career in the public sector. The challenge of navigating such ethical dilemmas was a defining feature of leadership in Sierra Leone. Our research demonstrates that while international leadership models were relevant in this context, there is strong emphasis on contingent or situational leadership theories. We further contribute to policy and practice by informing design of leadership development programmes and the establishment of a more enabling environment for medical leadership by governments and international donors.

Addressing key gaps in implementation of mosquito larviciding to accelerate malaria vector control in southern Tanzania: results of a stakeholder engagement process in local district councils.

BACKGROUND: Larval source management was historically one of the most effective malaria control methods but is now widely deprioritized in Africa, where insecticide-treated nets (ITNs) and indoor residual spraying (IRS) are preferred. However, in Tanzania, following initial successes in urban Dar-es-Salaam starting early-2000s, the government now encourages larviciding in both rural and urban councils nationwide to complement other efforts; and a biolarvicide production-plant has been established outside the commercial capital. This study investigated key obstacles and opportunities relevant to effective rollout of larviciding for malaria control, with a focus on the meso-endemic region of Morogoro, southern Tanzania. METHODS: Key-informants were interviewed to assess awareness and perceptions regarding larviciding among designated health officials (malaria focal persons, vector surveillance officers and ward health officers) in nine administrative councils (n = 27). Interviewer-administered questionnaires were used to assess awareness and perceptions of community members in selected areas regarding larviciding (n = 490). Thematic content analysis was done and descriptive statistics used to summarize the findings. RESULTS: A majority of malaria control officials had participated in larviciding at least once over the previous three years. A majority of community members had neutral perceptions towards positive aspects of larviciding, but overall support for larviciding was high, although several challenges were expressed, notably: (i) insufficient knowledge for identifying relevant aquatic habitats of malaria vectors and applying larvicides, (ii) inadequate monitoring of programme effectiveness, (iii) limited financing, and (iv) lack of personal protective equipment. Although the key-informants reported sensitizing local communities, most community members were still unaware of larviciding and its potential. CONCLUSIONS: The larviciding programme was widely supported by both communities and malaria control officials, but there were gaps in technical knowledge, implementation and public engagement. To improve overall impact, it is important to: (i) intensify training efforts, particularly for identifying habitats of important vectors, (ii) adopt standard technical principles for applying larvicides or larval source management, (iii) improve financing for local implementation and (iv) improve public engagement to boost community awareness and participation. These lessons could also be valuable for other malaria endemic areas wishing to deploy larviciding for malaria control or elimination.

Hybrid mosquitoes? Evidence from rural Tanzania on how local communities conceptualize and respond to modified mosquitoes as a tool for malaria control.

BACKGROUND: Different forms of mosquito modifications are being considered as potential high-impact and low-cost tools for future malaria control in Africa. Although still under evaluation, the eventual success of these technologies will require high-level public acceptance. Understanding prevailing community perceptions of mosquito modification is, therefore, crucial for effective design and implementation of these interventions. This study investigated community perceptions regarding genetically-modified mosquitoes (GMMs) and their potential for malaria control in Tanzanian villages where no research or campaign for such technologies has yet been undertaken. METHODS: A mixed-methods design was used, involving: (i) focus group discussions (FGD) with community leaders to get insights on how they frame and would respond to GMMs, and (ii) structured questionnaires administered to 490 community members to assess awareness, perceptions and support for GMMs for malaria control. Descriptive statistics were used to summarize the findings and thematic content analysis was used to identify key concepts and interpret the findings. RESULTS: Nearly all survey respondents were unaware of mosquito modification technologies for malaria control (94.3%), and reported no knowledge of their specific characteristics (97.3%). However, community leaders participating in FGDs offered a set of distinctive interpretive frames to conceptualize interventions relying on GMMs for malaria control. The participants commonly referenced their experiences of cross-breeding for selecting preferred traits in domestic plants and animals. Preferred GMMs attributes included the expected reductions in insecticide use and human labour. Population suppression approaches, requiring as few releases as possible, were favoured. Common concerns included whether the GMMs would look or behave differently than wild mosquitoes, and how the technology would be integrated into current malaria control policies. The participants emphasised the importance and the challenge of educating and engaging communities during the technology development. CONCLUSIONS: Understanding how communities perceive and interpret novel technologies is crucial to the design and effective implementation of new vector control programmes. This study offers vital clues on how communities with no prior experience of modified mosquitoes might conceptualize or respond to such technologies when deployed in the context of malaria control programmes. Drawing upon existing interpretive frames and locally-resonant analogies when deploying such technologies may provide a basis for more durable public support in the future.

Acceptability and perceived utility of different diagnostic tests and sample types for trachoma surveillance in the Bijagos Islands, Guinea Bissau.

BACKGROUND: Trachoma is the leading infectious cause of blindness worldwide and is nearing elimination as a public health problem in Guinea Bissau. It is imperative that elimination is followed by a successful postvalidation surveillance programme. The aim of this study was to determine the acceptability and perceived utility of different diagnostic tests and sample types that could be used for postvalidation trachoma surveillance in the Bijagos Islands, Guinea Bissau. METHODS: Semistructured interviews with community members and stakeholders involved in trachoma elimination were followed by focus group discussions with community members, covering experiences with trachoma and views on trachoma diagnostic methods and sample types. RESULTS: In this setting, all diagnostic tests and sample types used for trachoma surveillance were generally considered acceptable by communities. A preference for laboratory-based testing and finger-prick blood samples was expressed as these results were considered more accurate and applicable to a range of diseases beyond trachoma. CONCLUSIONS: Appropriate community and stakeholder engagement and communication regarding the purpose and processes around diagnostic practice prior to trachoma programme implementation are crucial for long-term successful disease-elimination efforts.

Interventions to strengthen the leadership capabilities of health professionals in Sub-Saharan Africa: a scoping review.

Leadership is a critical component of a health system and may be particularly important in Sub-Saharan Africa, where clinicians take on significant management responsibilities. However, there has been little investment in strengthening leadership in this context, and evidence is limited on what leadership capabilities are most important or how effective different leadership development models are. This scoping review design used Arksey and O'Malley's approach of identifying the question and relevant studies, selection, charting of data, summarizing of results and consultation. A comprehensive search strategy was used that included published and unpublished primary studies and reviews. Seven databases were searched, and papers written in English and French between 1979 and 2019 were included. Potential sources were screened against inclusion and exclusion criteria. Data were grouped into common categories and summarized in tables; categories included conceptual approach to leadership; design of intervention; evaluation method; evidence of effectiveness; and implementation lessons. The findings were then analysed in the context of the review question and objectives. Twenty-eight studies were included in the review out of a total of 495 that were initially identified. The studies covered 23 of the 46 countries in Sub-Saharan Africa. The leadership development programmes (LDPs) described were diverse in their design. No consistency was found in the conceptual approaches they adopted. The evaluation methods were also heterogeneous and often of poor quality. The review showed how rapidly leadership has emerged as a topic of interest in health care in Sub-Saharan Africa. Further research on this subject is needed, in particular in strengthening the conceptual and competency frameworks for leadership in this context, which would also inform better evaluation. Our findings support the need for LDPs to be accredited, better integrated into existing systems and to put greater emphasis on institutionalization and financial sustainability from their early development.

Knowledge and understanding of cardiovascular disease risk factors in Sierra Leone: a qualitative study of patients' and community leaders' perceptions.

OBJECTIVES: Prevalence of cardiovascular disease risk factors (CVDRF) is increasing, especially in low-income countries. In Sierra Leone, there are no previous studies on the knowledge and the awareness of these conditions in the community. This study aimed to explore the knowledge and understanding of CVDRF, as well as the perceptions of the barriers and facilitators to accessing care for these conditions, among patients and community leaders in Sierra Leone. DESIGN: Qualitative study employing semistructured interviews and focus group discussions. SETTING: Urban and rural Bo District, Sierra Leone. PARTICIPANTS: Interviews with a purposive sample of 37 patients and two focus groups with six to nine community leaders. RESULTS: While participants possessed general knowledge of their conditions, the level and complexity of this knowledge varied widely. There were clear gaps in knowledge regarding the coexistence of CVDRF and their consequences, as well as the link between behavioural factors and CVDRF. An overarching theme from the data was the need to create an understanding and awareness of CVDRF in the community in order to prevent and improve management of these conditions. Cost was also seen as a major barrier to accessing care for CVDRFs. CONCLUSIONS: The knowledge gaps identified in this study highlight the need to design strategies and interventions that improve knowledge and recognition of CVDRF in the community. Interventions should specifically consider how to develop and enhance awareness about CVDRF and their consequences. They should also consider how patients seek help and where they access it.

Opinions of key stakeholders on alternative interventions for malaria control and elimination in Tanzania.

BACKGROUND: Malaria control in Tanzania currently relies primarily on long-lasting insecticidal nets and indoor residual spraying, alongside effective case management and behaviour change communication. This study explored opinions of key stakeholders on the national progress towards malaria elimination, the potential of currently available vector control interventions in helping achieve elimination by 2030, and the need for alternative interventions that could be used to supplement malaria elimination efforts in Tanzania. METHODS: In this exploratory qualitative study, Focus group discussions were held with policy-makers, regulators, research scientists and community members. Malaria control interventions discussed were: (a) improved housing, (b) larval source management, (c) mass drug administration (MDA) with ivermectin to reduce vector densities, (d) release of modified mosquitoes, including genetically modified or irradiated mosquitoes, (e) targeted spraying of mosquito swarms, and (f) spatial repellents. RESULTS: Larval source management and spatial repellents were widely supported across all stakeholder groups, while insecticide-spraying of mosquito swarms was the least preferred. Support for MDA with ivermectin was high among policy makers, regulators and research scientists, but encountered opposition among community members, who instead expressed strong support for programmes to improve housing for poor people in high transmission areas. Policy makers, however, challenged the idea of government-supported housing improvement due to its perceived high costs. Techniques of mosquito modification, specifically those involving gene drives, were viewed positively by community members, policy makers and regulators, but encountered a high degree of scepticism among scientists. Overall, policy-makers, regulators and community members trusted scientists to provide appropriate advice for decision-making. CONCLUSION: Stakeholder opinions regarding alternative malaria interventions were divergent except for larval source management and spatial repellents, for which there was universal support. MDA with ivermectin, housing improvement and modified mosquitoes were also widely supported, though each faced concerns from at least one stakeholder group. While policy-makers, regulators and community members all noted their reliance on scientists to make informed decisions, their reasoning on the benefits and disadvantages of specific interventions included factors beyond technical efficiency. This study suggests the need to encourage and strengthen dialogue between research scientists, policy makers, regulators and communities regarding new interventions.

Understanding the Role of the Diagnostic 'Reflex' in the Elimination of Human African Trypanosomiasis.

To successfully eliminate human African trypanosomiasis (HAT), healthcare workers (HCWs) must maintain their diagnostic acuity to identify cases as the disease becomes rarer. HAT experts refer to this concept as a 'reflex' which incorporates the idea that diagnostic expertise, particularly skills involved in recognising which patients should be tested, comes from embodied knowledge, accrued through practice. We investigated diagnostic pathways in the detection of 32 symptomatic HAT patients in South Sudan and found that this 'reflex' was not confined to HCWs. Indeed, lay people suggested patients test for HAT in more than half of cases using similar practices to HCWs, highlighting the importance of the expertise present in disease-affected communities. Three typologies of diagnostic practice characterised patients' detection: 'syndromic suspicion', which closely resembled the idea of an expert diagnostic reflex, as well as 'pragmatic testing' and 'serendipitous detection', which depended on diagnostic expertise embedded in hospital and lay social structures when HAT-specific suspicion was ambivalent or even absent. As we approach elimination, health systems should embrace both expert and non-expert forms of diagnostic practice that can lead to detection. Supporting multidimensional access to HAT tests will be vital for HCWs and lay people to practice diagnosis and develop their expertise.

Uncertainty in times of medical emergency: Knowledge gaps and structural ignorance during the Brazilian Zika crisis.

Uncertainty was a defining feature of the Brazilian Zika crisis of 2015-2016. The cluster of cases of neonatal microcephaly detected in the country's northeast in the second half of 2015, and the possibility that a new virus transmitted by Aedes mosquitoes was responsible for this new syndrome, created a deep sense of shock and confusion in Brazil and around the world. When in February 2016 the WHO declared a Public Health Emergency of International Concern (PHEIC), it noted that it did so on the basis of what was not known about the virus and its pathogenic potential. To better understand the role that non-knowledge played in the unfolding of the Brazilian Zika crisis we differentiate between three different kinds of uncertainty: global health uncertainty, public health uncertainty, and clinical uncertainty. While these three forms of uncertainty were difficult to disentangle in the early weeks of the crisis, very soon each one began to trace a distinct trajectory. Global health uncertainty centered on the question of the causative link between Zika virus infection and congenital malformations, and was declared resolved by the time the PHEIC was lifted in November 2016. Public health and clinical uncertainty, in contrast, persisted over a longer period of time and did, in some important ways, become entrenched. This taxonomy of uncertainties allows us to explore the systematic nonproduction of knowledge in times of medical emergency, and suggests structural limitations in the framework of "emergency research" that global health institutions have developed to deal with unexpected threats.