22. CRISIS, PUBLIC HEALTH & THE CITY: A conversation with Cristina Temenos

In this episode Beth and Tom are joined by Cristina Temenos from the University of Manchester to discuss a wide range of issues from trust in medicine, responses to COVID-19 and experimentation and evidence in localised healthcare settings. Together, they ask:

• Faced with crisis after crisis, how do municipalities deliver public health care in Athens, Santiago and Greater Manchester?
• What forms of experimentation, innovation and alternative provision emerge during crisis, and what does this mean for the role of state and non-state services in addressing the needs of vulnerable populations?
• What does crisis policy-making look like and how is it changing the way we are thinking about evidence and expertise?

Guests:

Cristina Temenos is a Reader in Human Geography, an urban, political geographer, her current project explores how cities are managing intersecting health, economic and social crises to negotiate more just urban futures. Her research is focused on health inequalities and the politics of access to care in cities globally. Working in the field of policy mobilities, she has developed this work in relation to drug use and treatment, public health, housing, economic austerity, environmental sustainability, transport, and climate change.  She has recently published in journals such as Progress in Human Geography, IJURR and Dialogues in Urban Research.

Read More:
Crisis policy-making and revanchist public health politics
The modalities and politics of crisis urbanism
Urban crisis as infrastructure, not event: A view from Beirut
Crisis and the urban imagination
Austerity co-production

Hosts:

Tom Goodfellow is Professor of Urban Development in the Global Development Institute, and CEO of the African Cities Research Consortium, University of Manchester.  His research focuses on the political economy of urban development and change in Africa, particularly the politics of urban land and transportation, conflicts around infrastructure and housing, and urban institutional change. (linkedin.com/in/tom-goodfellow-0b418441) 

Beth Perry is Professor of Urban Epistemics and Director of the Urban Institute at the University of Sheffield. Her research focuses on the relationships between urban expertise, governance and justice, underpinned by a commitment to co-producing collective intelligence across multiple scales to address complex urban challenges. She has worked in cities in Africa, Europe and the UK. (linkedin.com/in/itsbethperry)

Email feedback to: urbanradarpod@gmail.com

You can also follow us on instagram: @urbanradarpodcast

Thanks to the Universities of Sheffield and Manchester for providing time, resources and equipment to support this podcast. And to Sam Burgum, for post-production editing and promotion.

Transcript

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SPEAKER_00 0:10

Hello, and in this month's Urban Radar feature, we asked, faced with crisis after crisis, how do municipalities deliver public health care in Athens, Santiago and Greater Manchester?

SPEAKER_01 0:22

What forms of experimentation, innovation and alternative provision emerge during crisis? And what does this mean for the role of state and non-state services in addressing the needs of vulnerable populations?

SPEAKER_00 0:33

And what does crisis policy making look like? And how is that changing the way we think about evidence and expertise? Welcome to Urban Radar, the podcast series taking an urban lens on current affairs. I'm Tom Goodfellow, Professor of Urban Development at the Global Development Institute, University of Manchester.

SPEAKER_01 0:49

And I'm Beth Perry, Professor of Urban Epistemics and Director of the Urban Institute at the University of Sheffield. Tom, here we are.

SPEAKER_00 0:57

Here we are.

SPEAKER_01 0:58

Where are we?

SPEAKER_00 0:58

We are in a new studio in the University of Manchester, Humanities Bridgeford Street building, and it's a quite different environment to what we're used to. The walls are more padded, I would say, in quite a jaunty uh not like a prison cell.

SPEAKER_01 1:12

No. Because it's purple and purple is happy.

SPEAKER_00 1:14

Also, we have a guest today who we'll introduce in a moment, and we get to face our guests around a table rather than sort of sitting question time style in a couple of years.

SPEAKER_01 1:23

This is true. This is true. So what have we got coming up today?

SPEAKER_00 1:27

Yes, we've got a feature, and we are joined by Christina Temenos, who is a colleague here from the University of Manchester. She's an urban geographer interested in the politics and social processes of making and moving urban policy. So her research is primarily focused on health inequalities and the politics of access to care in cities globally.

SPEAKER_01 1:45

And she's the co-lead, yes, on poverty and deprivation for the University of Manchester's Healthier Futures Research Platform, and also co-leads the city's politics and economies research group. And we'll hear Christina introduce herself in a moment. But I'm really looking forward to this feature today. I think it's really important because actually, if you look back at the episodes and issues we've covered so far, we haven't really talked about public health. It's always been one of those stories that I come across and then haven't talked about. So whether that's to do with health inequalities, which we know are increasingly spatialized, there's still a massive gap in life expectancy between the north and the south in this country. We're currently locked into industrial action with um medical doctors, and you know, there's lots of negotiations going around about that. You've got people not being able to get doctors' appointments or dentist appointments, and a real kind of like maybe there's healthcare deserts even emerging in parts of the country. So, you know, there's been all these kinds of questions around healthcare, but um today will be the first opportunity we get to talk about them.

SPEAKER_00 2:41

Yeah, and I think obviously because of COVID, you know, there was a lot of fatigue of talking about COVID and its impacts on cities. There's a huge amount of research, but I think sufficient time has elapsed that we can see it in a slightly different perspective in relation to a whole sea of other crises. And we will be talking about the idea of crisis, which again comes up all the time, and uh polycrisis, perma crisis. We'll actually dig into it with somebody who's who's studying crisis and importantly what crisis means to the opportunities and challenges of policymaking.

SPEAKER_01 3:07

Yes, so we should probably crack straight on with the feature.

SPEAKER_00 3:10

Let's move on.

SPEAKER_01 3:20

So we're delighted today to be joined by Christina Tamanos from the University of Manchester to talk about some of these issues. Um, Christina, perhaps I can just turn straight to you and ask you to introduce yourself and some of your current research.

SPEAKER_02 3:32

Yes, hi, thanks so much for having me on today. An invitation to talk about the work that I've been doing over the past few years. So I am an urban geographer. I've been at Manchester for about 10 years now, and over the past four and a half years, I've been looking particularly at how cities are trying to deal with intersecting urban crises and the effects that is having having on access to public health services for marginalized communities, like looking at Greater Manchester, Athens, Greece, and Santiago in Chile. But there have been also a team of researchers who've also been contributing to that as well. So I wanted to shout that out. And we have collected data in all three of the cities, and we've been looking at that across four different areas. So we've been looking at uh the idea around social pharmacies and social prescribing. We've been looking at homeless health care and housing first. We've also been looking at substance use addictions and treatment, and we've been looking more broadly at digital and other health services innovations across the three cities.

SPEAKER_01 4:43

So there's many things we want to pick up with you there, particularly around public health and some of the differences between these cities. Um, but maybe we could just start with this idea of crisis, because crisis is quite in vogue with in social science at the moment and within urban studies, and we hear about permacrisis or polycrisis all the time. And I think the word crisis can get used in very different ways, can't it? Sometimes it's sort of this sudden external shock to a system that is supposed to then reset itself afterwards. Um, but it's also used to denote the structural ongoing crises that take place over time. I was just wondering how you're thinking about crisis in your work and particularly how that manifests at the urban level.

SPEAKER_02 5:19

My thinking on crisis has really changed. We need to really think about who's who's calling something a crisis, how crises, as named, get legitimized, and who's benefiting from that and who's losing out. So sometimes it's about ongoing crisis, and other times it's about thinking of economic and social crisis, the other or also geopolitical crises. What is the kind of political work that it does in terms of moving certain policies forward, uh, certain programs forward, and what does it allow also cities to do in terms of either more progressive urban politics, but also potentially the foreclosing of different initiatives? Oftentimes in sort of the academic sphere, we think about the sort of Marxist ideas around capitalist crises of production and the inherent necessity of crisis within the system. What that tends to intersect with, and what I've really found, is that you know, a lot of the ongoing legacies of austerity have contributed to much more precarity for different populations, uh, and people who are already experiencing poverty and deprivation are also, you know, experiencing that tenfold more. Uh, and so we have sort of this intersection between, you know, what happens to people who are experiencing crisis sort of personally and on a daily basis, and that that often is coalesced around their own sort of experiences of health and well-being and healthcare. Um, but then also what does it mean from a governance perspective and particularly a local governance perspective? So a lot of work on policy making, for example, is looking at how how we might think about implementing certain solutions to problems. But a lot of that work does tend to be done, and some of my own past work has done this too, assuming that there's sort of a non-crisis equilibrium state going on. And it it's increasingly not the case in the global north, and for a long time, cities in the global south that's not been the case. And, you know, other folks have made that uh observation. Mona Harb just has um a piece out in dialogues and urban research.

SPEAKER_01 7:29

Such an important question, isn't it? That sort of normalization or exceptionalization of crisis and also the way in which crisis is politicized. So sometimes we might name something a crisis to draw attention to that which has been ignored or overlooked, but sometimes it may also be a political device to draw attention away from some things.

SPEAKER_00 7:46

There was some echoes in a way of our previous feature where we were talking about Latin American cities and we were talking about volatility and these kind of crises cyclical over time. And these terms polycrisis and permacrisis, I just wonder whether, as someone who's thought about this quite seriously, these these terms are just kind of tossed around. Do you find them useful and constructive? Do you think one is perhaps more relevant and um productive than the other? Because obviously, in some ways they're opposites, right? One is like the this this temporal thing we're permanently in crisis. It's going on, it's it's forever. Whereas the other is more of a snapshot of like what's happening at one point in time where you have these multiple layers of crises. And I don't know whether you actually think those terms are are helpful, are productive, or not.

SPEAKER_02 8:25

I would say the jury is still out on that one for me. Uh, I think they can be a useful shorthand for talking about um what's going on in the present moment. So how are cities or how are people or communities dealing with multiple crises that are that are sort of converging. But then also thinking about this idea of permacrisis, I worry that it there's almost an acceptance that, oh, we're just now going to be in a permanent state of crisis no matter what. So so I I wonder and worry to what extent that forecloses hopeful thinking or more experimental thinking on ways to overcome certain said crises. And and those are things like the climate crisis, like these, you know, uh geopolitical crises, like these uh rising far-right um initiatives where we're actually seeing, you know, there's quite a lot of resistance to that. There's quite a lot of creativity to that. Um, you know, recently, I don't know if you follow American football, but there was just the Super Bowl halftime show with Bad Bunny. It was such a celebration of joy and culture and ways of working through crisis that they really featured the electricity power outages in Puerto Rico that happened after Hurricane Maria. And, you know, and and the ways in which they were to be able to bring that together, I think, was quite inspirational. And I wonder that a lot of the discussion around permacrisis can foreclose some of those really uh really powerful messages and really powerful calls.

SPEAKER_01 9:58

It's really interesting because it speaks to this idea that we're somehow paralyzed in the current moment where sort of crisis invokes this nostalgic idea of the past where things were different and not therefore in crisis, but it also forecloses those future possibilities of imagining a world where things aren't as they always as they are now. Trevor Burrus, Jr.

SPEAKER_00 10:14

But I guess it also creates a risk, right, that you miss specific crises that emerge because you have this sense of generalized crisis. And actually some things can almost get lost.

SPEAKER_01 10:21

Aaron Powell But it's also about the utility of that then, as you were saying, to groups that are trying to fight for social justice, that are trying to reduce inequalities in our cities. So perhaps we can bring it now to the question of public health and like how useful is it to think about public health in relation to crisis and particularly in the different national contexts that you've been working in.

SPEAKER_02 10:39

For me, I think it's a really useful way of thinking through and understanding a notion of crisis because you know, crisis is also scaled as well. So it it can be health in particular can be really embodied. Um, and so those crises can come on and be quite immediate when we're talking about health crises, but it also goes right up to sort of the population level, structural levels, um, thinking about the COVID pandemic, thinking about the HIV-AIDS crisis, thinking about uh the drug overdose crisis as well. I really like the term intersecting crises a bit more because it it allows it to be in a way almost picked apart a little bit more.

SPEAKER_01 11:17

You have to be more precise, don't you, to say which crises are intersecting and in which ways. Exactly. Yeah. And maybe just before we move on to maybe the municipal level, I was reading that we can understand crisis of public health differently in these national contexts. So for the UK, it's decades of underinvestment and a sort of managed and structural decline and a sort of slow policy drift. Um, whereas in Greece, some of the things I was reading was that it was much more about austerity and the economic crisis and financial shock. And then in Chile, it's more a question of kind of institutional design and inequalities that are kind of designed in around the relationship between market-led provision or state-led provision. I don't know if that's accurate, but I'm interested to know how you sort of see the national picture that then is shaping what the capacities are of municipalities to respond.

SPEAKER_02 11:59

Yeah, absolutely. And I I think that's a really good question because one of the big tensions that happens actually in all three of those cities is that all three cities do have national health systems. Um interestingly, the Athens public health system was set up based on the English NHS. But they have they have a two-tiered, a very clear two-tiered public-private system as well. Uh, and so does Chile. Now, all of those, however, um, while they have national public health services, uh, all have local level uh provision responsibility, statutory responsibility for providing uh primary care at the local level, particularly with some of the groups that I've been looking at, particularly around homeless health care, for example, and addictions, treatment, and services. Those are all statutory responsibilities at the local level for all three countries and all three cities. And so that's been a real tension. There's a huge amount of responsibility, but less power in terms of and control over budgets.

SPEAKER_00 13:01

So can we try and take this into, I guess, the space of thinking about the urban as well as the local and how well-equipped cities are to address these challenges. So we've got, like, for example, colleagues at Sheffield like Melanie Lombard, who've been working on social infrastructures in response to COVID. And what's interesting there is uh another term you hear thrown around a lot along with crisis is disorder. And I think in that project they're they're paying quite a lot of attention to how cities are framed as being disorderly, but actually a lot of that disorder either conceals or basically comprises social infrastructures that are not always understood. So I guess how do urban social infrastructures particularly manifest in response to this? And perhaps you can give us some examples.

SPEAKER_02 13:40

In Athens, particularly after the financial crisis there, what you really saw was an outpouring of mutual aid uh approaches. And so it was it was really communities sort of digging in and providing, you know, even basic health care and GP services all on a volunteer basis in social health clinics and social pharmacies as well. Um in Santiago, what you had is um is that a lot of that mutual aid tends to be foreclosed by the state preemptively because they're quite a policy-heavy environment, even at the local level. But what you did have happening is uh, you know, several models coming out of local governments where they are trying to provide, um, in the case of social pharmacies, for example, they are trying to provide affordable medications at cost. Uh, and that is that was a model that sort of came out of Recoleta, which is one of the municipalities, comunas in um the Santiago metropolitan region. And the mayor there was somebody who really brought forward this sort of social pharmacy model. Uh, you have to either live, work, or study in the municipality itself, and you just take the prescription you get from your doctor and you bring it to to the social pharmacy and they will provide you with that medication. That's quite an interesting, it's quite an interesting model in general, but also for Chile in particular, because Chile has very much since the 1970s been sort of a a place of experimentation for neoliberal policy reform and privatization of services. So most of their pharmaceuticals, up until the social pharmacy model came out, have all been through a private pharmacies. Uh, and and the cost of medications there have been quite high. So when this came in, it was enormously successful, and it's a model that spread throughout other Chilean cities. There's also social pharmacies in Athens. So, and those came much more out of this mutual, sorry, mutual aid model of care of volunteer provision where you know you have both individuals but also companies donating uh drugs that they they might have or might be in need. But one of the things that's come out of that um, you know, over that the last 10 years really is that very slowly those models, the models in Athens have been turned into essentially social enterprises. Uh, and the municipalities have taken them on and sort of formalized them.

SPEAKER_00 16:15

Aaron Powell Can I just ask a bit more about that? So that's interesting because uh you you've kind of presented two different versions of what a social pharmacy could be in a way. Like I think uh I I wasn't that familiar with the term before. And the second version, where you're saying community members are getting involved, volunteers, people are donating drugs that they may have, I guess that's what I imagined. The the first version, when you talk about Chile, sounds a bit more like just the idea of subsidized healthcare that we sort of take for granted almost here as part of the NHS, right? So just the fact you're not playing private sector rates for your healthcare. So they're slightly different models. The version in Athens is seems to be much more about that community participation. And I just wonder if you then go to Manchester, where we know we all in the UK, one thing we do take for granted is that we don't pay a full market rate for a lot of drugs, right? Um But what in that context there are still all manner of health crises that need to be addressed. And what's been happening in that in Manchester that would differ from those other two, given that we do already have an NHS?

SPEAKER_02 17:10

Yeah, so I guess with Manchester, the way we sort of looked at that at the time was trying to think about it through other service forms and provisions. So um in the UK, if you think of what a social pharmacy is, because that is a term here, but that just tends to be your any high street pharmacy. So it could be boots um on the high street. One of the things that's emerged out of far out of pharmacies, though, is is over the course of the four years, is the NHS and um working with pharmacies and with these, you know, high street pharmacies, social pharmacies to um try and make them more centers for community hubs and pharmacy first initiatives where certain you can go to a pharmacist first for certain common um common conditions. So like if a child has pink eye, for example, you can just go to the pharmacist and you're exactly an ear. You can just go there and they can have a look at at the person and prescribe or not and advise. That's trying to really build on the community connections they've already had. In other ways, you know, it's also trying to relieve pressures on the NHS system.

SPEAKER_01 18:18

No, I think there's two themes that maybe we want to carry on pulling out of this conversation. So one is around kind of the politics of what's happening here and the politics of the crisis, and the other is around experimentation and innovation. I'm intrigued by what's happening here because the narrative seems to be that crisis has provoked a um reignition of some forms of community level provision of healthcare across these different contexts. But actually, it's also enabling a reach of state services into communities that weren't otherwise there. So, I mean, a piece of work I did with a colleague at Sheffield, Vicky Habermale, um, was looking at the idea of austerity co-production and this idea that under conditions of austerity, the state becomes dependent on services that are being provided by the voluntary sector or by communities themselves, but then integrates it into their offer in ways that are often not always supportive. They are about capturing or sometimes co-opting those groups and responsibilising citizens or community groups for the provision of, in this case, healthcare. So I was wondering whether you feel that's going on because mutual aid and in the during the pandemic, you know, that really did grow in all kinds of different contexts. But to what extent does it become a form of responsibilization of the citizens or non-state actors? And then there's also something about whether there's an explicit politics here to do with pushing back against big pharma. And maybe that's not something you came across. But I am wondering whether the sort of bigger global politics of big pharma and healthcare plays into the politics of what's happening within these social pharmacies, whether you think there is merit in that kind of analysis, but also how it manifests in the different places that you've looked at.

SPEAKER_02 19:55

Yeah, I mean, I think there's definitely merits in that analysis. And what was really interesting in the Athens case is that they were quite explicit about how these social pharmacies are very much a political intervention. And early on, it a lot of it was about, you know, they talked about, and I have quotes from people also being really, really explicit about shaming the government for not providing the care that they were supposed to do, uh, provide. They had these really explicit political arguments around the fact that the government should be providing this. Over the course of the the last 10 years, one of the things that as the social pharmacy model has become more integrated into a more or a more sort of formalized nonprofit model, if we want to put it like that, um, a lot of that politics have been dampened down. And so it has been a way that the state has sort of co-opted something that worked and something that was really popular. You know, it's not saying that this is not a good thing that these have become more um more formalized or more normalized, but the state has been able to sort of co-opt that as a way of delivering on those responsibilities, yet there is still uncertainty, for example, in the supply change. Um the question on big pharma is an interesting one. I think that was a very explicit discussion in the Chilean context, uh, and that's because of the affordability of medicines there. Um, was just so outrageous. I don't have the numbers in front of me, but I think it was something like um up to 20% of uh average income for a Chilean would be spent on medical products, uh, which included pharmaceuticals. Uh that figure is huge. It is huge. And it's 1.2% for the average UK household. But there was definitely a pushback against the pharmaceutical companies there as well. And and I think the pharmaceutical companies felt pressured to enter into some of these contracts with the social pharmacies to buy at level in order to kind of also um you know speak back to that and say, Okay, we hear you, we'll we'll try and try and work with you using this model to provide that. And so they still Have those two-tiered systems. So, you know, in the private in the private pharmacies, the same the exact same medications will be costing triple or quadruple the prices?

SPEAKER_00 22:12

Aaron Powell In terms of that, that um that political pushback, um i I'm wondering about the kind of national or city level discourses, particularly around migrants, rough sleepers, the homeless, particular vulnerable groups that may already have been stigmatized. And as we know, uh you know, many of these groups are becoming more stigmatized. I mean, how does that play into what was happening on the ground? Was there also a political intent to by the, you know, to by those people to push back against these discourses? Um were there conflicts within communities about who had access, who was prioritized, and how that kind of balance between different groups was managed?

SPEAKER_02 22:46

Yes, absolutely. There were in all three cases. So all three cities have had migrant, quote unquote, crises uh in in some way over the past four years. Uh they all looked very different in terms of who was coming and how that how that ended up playing out. But also because those migrant crises were very visible. So a lot of the people who were coming to these cities were ended up uh rough sleeping uh in very visible places. In Manchester, there's a lot of famous pictures of the red tents in front of the town hall with that. But, you know, that really has played into a lot of uh rising far-right politics in general, but a lot of anti-immigrant discourse, but also discussions around, you know, who has access to the NHS, who has access to housing. You know, one of the other aspects of this we've looked at is housing first and the sort of need to think of housing as a health initiative as well. And so, of course, there's already a housing crisis in, again, also in all three of these cities. There have been cases where there have been migrants who haven't wanted to come into the shelters because they're afraid of uh facing violence in the shelters.

SPEAKER_01 23:56

I think that's a really good example of these intersecting crises, as you said. Um, and those are quite tangible in many ways, but just maybe before we move on to the kind of second point around experimentation and innovation. I'm interested in whether or not your research has touched upon the wider kind of crisis of expertise and knowledge. Because of course we've mentioned the pandemic several times. Um and this sort of raised a whole set of questions that were challenging existing scientific evidence or what expertise mattered and the idea of common sense when it came to taking action to do with public health, whether that's about going out or not going out. Um, and I mean, am I right in thinking that also we sort of see through this period that we're talking about sort of increasing conspiracy theories around medicine or questions around anti-vax and all of these sorts of things sort of start to create a wider crisis of legitimacy and public trust in what medicine and healthcare even looks like in the first place? I mean, has that played out in your research? And I guess a follow-on for that for me is to what extent does the localization of mutual aid and social pharmacies and these other kinds of innovations you're looking at provide a more collective understanding of what expertise and healthcare sort of should and could look like?

SPEAKER_02 25:08

Yeah, I mean, that has definitely come up. Vaccine hesitancy uh was one of the biggest issues that came out of COVID, and that's been growing. And, you know, unfortunately, we're seeing that in both the US and the UK just in February became um no longer has the status of being measles-free, I believe. So, you know, so you're definitely seeing the effects of not just vaccine hesitancy for the COVID vaccine, but but more broadly. And that is definitely something that all healthcare professionals are really well aware of at this point. It is a difficult one because of austerity. It's a lot of trying to reach out to these communities. And, you know, one of the interesting things, for example, about the pharmacy first initiative in the UK is that, you know, pharmacists are doing their best and they're and that's great, but there's also pharmacists are very much in the community. The thing about pharmacy first in the UK is that we also need to think about what sort of training the pharmacists have to be giving some of this broader uh clinical advice to people. Uh, there is also a lot of stigma amongst healthcare professionals, not just pharmacists, but more broadly, when it comes to already marginalized groups. And that tends to play out much more when you're out of clinical settings. And so that is something that, you know, on the one hand, it could be a real vehicle for um for educating people. Uh, on the other hand, it might also inadvertently put up more barriers uh to a lot of those folks. So for example, in Greater Manchester, uh, they've started to pilot the provision of naloxone in certain pharmacies, and naloxone is a particular um, it's an anti-agonist, anti-opioid agonist, trying to get that right, uh, because I'm not a medical professional here. Um, but it's, you know, if somebody is overdosing on an opioid drug such as heroin, uh, it's something that is either injected or inhaled uh in order to reverse that, uh, to reverse the op uh the overdose. They've piloted uh providing that within pharmacies. And one of the things that they have talked about very much is that you know, they've had to do certain pharmacies that um are quite open to having that and doing the education and the training. Others very much do not want to become known as a pharmacy where that is available because there's already stigma around drug use and they don't necessarily want to attract uh people who are injecting drug users.

SPEAKER_01 27:41

I mean, perhaps this leads us on to the other theme we wanted to explore with you around experimentation and innovation. And it goes back to that key point that we were talking about at the beginning about what what does crisis mean, you know, and the debates around whether crisis is an opportunity sometimes for a rupture with what was, but in a way that can enable new innovations or experimentations to emerge. And mutual aid is perhaps one of those. But I was just wondering if you could say a bit more about, you know, you mentioned pilots uh or experiments and innovations that have come through crisis in the three different cases that you've looked at.

SPEAKER_02 28:11

How are a city is responding to policymaking in times of crisis and and sort of what what kind of elements are are within that? And you know, sometimes that is a foreclosure of of certain politics. Um oftentimes that that policy making tends to be really quick because something needs to be done or being seen to be done. Uh, and so it is about grabbing that opportunity. Tons of academic work done on how you know more conservative politics have been able to and politicians have been able to kind of grasp on to this idea around crisis talk, for example, and use that to push through certain policies or certain moments to push through policies. Uh, but there are more progressive ways of thinking about um thinking about it and particularly through issues around public health. So, you know, one of the things that's been quite interesting is looking at the social work-led model of care that again is coming up in Athens for um dealing with homeless health care. Uh, and that's been something that's been quite innovative in the sense that um social work-led teams tend to be quite interdisciplinary, but also their training is specifically to understand what a lot of these complex services and systems are and to help people navigate that. There's one team that I know of in in Greater Manchester who's doing that work, but it's it's the exception, not the rule, and also across the UK. Um, but they've had some really great successes as well in terms of implementing a social work-led model of homeless health care. These are people who are experiencing homelessness in various forms, but who have also been excluded from other services. So that could be due to non-attendance at GP appointments. They might have been kicked off lists, um, you know, not being able to be in certain services, food provision services, for example, because of chaotic behavior or substance use. Being able to use the CARE Act in the UK context in order to help reintegrate a lot of folks here. And they're talking about dealing with sort of the most marginalized of the most marginalized. And they've seen a lot of really good successes with that. And that's something that um would be quite, you know, useful to scale up because of course the this particular subgroup does take a lot of uh resource overall. One of the big barriers to sort of innovation uh and to service provision tends to be pilotification around innovation. So Pilotitus, that's another word I've used. I've heard that's a good one. But as you know, you get funding for three, four, or five years, you see something that works really well, and then all of a sudden there's no more funding.

SPEAKER_00 31:10

Can we move perhaps it this seems like a point to to talk a little bit more about how you conceptualize crisis policymaking? So I know you have a sort of framework, a type of policy making, which may have and and does have implications beyond the sphere of public health. So I wonder if you can tell us a bit more about that idea.

SPEAKER_02 31:26

The idea around crisis policymaking has come up from looking for a long time. So my history, not just within this project, but uh but looking back, has been looking at the politics around drug use and and sort of access to healthcare for people who use drugs. A lot of what happens in crisis is again, you have a a group of people who are sort of the most marginalized of the most marginalized. And when crisis hits, what happens to those those folks? What happens to their health care? What happens to maybe what little um stability they might have in terms of access to services? One of the things that has really come out is the idea of an analysis of how do we think about policymaking during crisis times. And so, you know, as I said, you know, there are four elements. There's speed, so crisis happens or policymaking can happen really quickly, things can be pushed through overnight. Um, and you know, at population level, I'd say, you know, we can point to the COVID lockdowns to say, you know, stay in, stay safe, that kind of messaging all of a sudden. It's opaque. So decisions are just taken. There tends to be lack of accountability, lack of transparency. Decisions might be taken just by a particular political leader or someone who steps into that role. So, in terms of revanchist approaches to policy, it comes from the sort of naming something as a crisis. When we're talking about that, and the need to think about doing something. And so oftentimes the revanchism comes out of a politics of visibility. So if you have homeless people sleeping on the, you know, the steps of town hall, the the solution is then a public space protection order that will allow the police to move them on. Or the or, you know, if they're engaging in certain behavior like um drug taking in public space, for example, it will allow the police to move them on. It's not necessarily a policy about fixing a problem. It's a problem it's about fixing the visibility of the problem. Symptoms of the problem.

SPEAKER_00 33:28

Or perceived. Yeah. So there was there was a am I right? There was a fourth element. So you've got speed, opacity, revanchism, and what was the fourth?

SPEAKER_02 33:34

And then experimentation.

SPEAKER_00 33:35

Experimentation.

SPEAKER_02 33:36

And I think that to me is where, you know, I I'd like to think we can look for more hopeful politics because the other side of that from a healthcare perspective is, you know, there are a lot of people and a lot of healthcare providers and a lot of service providers who know exactly what a good solution would be and what might work for their community. And so, you know, one of the things that we've also been able to see is that in those moments of crisis, they have been able to push through policies, certain practices, they've been able to make access more easy and open. Uh, you know, one of the things that came through during COVID, for example, is that most cities globally solved homelessness.

SPEAKER_01 34:22

You know. Well, it's interesting you say that just thinking about crisis policymaking and COVID and homelessness, you know, the position of a mayor enabled certain things to happen during COVID. But it was also exposed the limits. So crisis can also be a way where something gets reset that reveals the actual priorities of government. And in this case of COVID, it was a total recentralisation and a pause of the devolution project. It wasn't the case anymore that city regional mayors were co-decision makers. It was all about national top-down command and control because crisis enabled the reset of what is presumed to be the normal way of making policy, which is central. And I think it was very interesting to think about devolution as the experiment that was only enabled under conditions of apparent normality, but crisis then requiring a total recentralization, opacity of those forms of decision making.

SPEAKER_00 35:13

It's a sort of the state of emergency, isn't it? Like and the permacrisis gives rise to this. And there are many countries where there's been, you know, long-term states of emergency. I think what's interesting as well is that there is that very negative element of it that it results in centralisation, it results to the default and the opacity. But there is that potential there. Because at the same time, we know that cities have found new ways to deploy and strengthen thereby their social infrastructure. So there is that counter-movement as well to the centralization, which hopefully as time goes on, we are starting to see that side of it as well. And I wonder just in terms of this experimentation and it uh aspect, which, as you say, is in some ways more hopeful. But then it also has the the dark side, which is that people in some cases are being experimented on in ways not of their own choosing. But there's also this question of what this means in terms of how we think about evidence, right? Because the the the re the interest in randomized controlled trials, in particular forms of experimental research, um has been very strong in recent years and was given in some ways a boost by by COVID. But there are also all kinds of other forms of evidence gathering that could and should be happening. And I wonder how this tips the balance of how we think about evidence. It comes back to expertise in a way. These two movements of like centralization, the role of the expert in crisis, and then you know, the counter-movement against that, which we also see, and more of an emphasis on kind of lived experience expertise, which we're also seeing come through. Trevor Burrus, Jr.

SPEAKER_01 36:33

And a and a total contradiction in those terms as well, because just going back to that example during COVID, um, there was this command and control recentralization where Andy Burnham as Mayor of Greater Manchester was not able to say what should happen when we should go into lockdown, when we shouldn't, you know, who controlled the data on hospitalizations, who have the truth there. But equally, one of the biggest areas of devolution has been health and social care, in which it is presumed the logic there is that decisions over these kinds of questions are better made locally.

SPEAKER_00 36:58

So, in terms of what that might mean for your work, how have these various forms of crisis policymaking in response to crises, including public health crises, changed the way different forms of evidence and knowledge are prioritized in decision making? Who's doing the decision making and with what evidence?

SPEAKER_02 37:13

Aaron Powell The question of evidence is a really key one, but one of the things that that a lot of researchers are finding, and I think a lot of just observers are finding if you're looking at at policy decisions globally right now. You can have the best randomized control trial and evidence in the world. And if there's not the political will to use that evidence, it's it's worthless. At the same time, I think what's you know what's interesting about that too is we need to frame how we think about certain types of evidence like randomized control trials, um, the evidence base for population health levels in the sense that there is some evidence that we do know certain things work, but then politicians, for example, will often call for pilot projects. You know, here's the the pilotitis again, I guess, um, that they want to make sure that this project is going to work in their local area. So, you know, think use the idea or example of a needle exchange, that's something that comes up, or a supervised drug consumption room, uh, which is another sort of innovative model around harm reduction drug policy. Politicians, because they're already thinking about the sort of pushback that might come from the local community for providing services to a stigmatized group of people who are people who use drugs, uh, are going to often stall and ask for a localized pilot project when they know that actually, if you know, if the goal of this particular service is to prevent overdose death or bloodborne disease, it works. And it doesn't, you know, it doesn't matter where it is. The evidence is almost universal that these things will prevent, you know, a needle exchange, clean, you know, clean needle exchanges prevent blood the transmission of bloodborne diseases. We know that. We don't necessarily need a local pilot to figure out if if that's going to be the case. The other thing that we need to think about, you know, is how are people thinking about expertise, though? Because I I guess that's the bigger bigger question is how do we think about trust and trust in cities and communities as well. Um, and you know, part of that is trust in the medical system sometimes. You know, a a lot of communities who have been disenfranchised have quite good reason to mistrust medical communities, medical professionals. Uh, and so there's gonna be a lot more work that needs to be done in order to build that trust back up again.

SPEAKER_01 39:42

I mean, I think that's really interesting in thinking through what is the function of the pilot at that moment in time, because it's not testing, as you said, whether something works, but whether it will work here. And that goes back to the question of stigma and political acceptability.

SPEAKER_00 39:55

I think also reflecting reflecting on what you just said, it reminds me that there has, of course, been all kinds of hesitancy and refusal of medication uh across parts of Africa, for example. So I don't work on that, but I have no colleagues who do. And much of it has been to do with distrust of the state and the colonial state and the legacy of all kinds of you know terrible things that have been done, particularly through colonialism. Um and there has been really interesting work in places like Nigeria in the context of COVID to see where the messaging which kinds of messaging has the most legitimacy, from which source. And of course it's never the state. What does your research mean for who delivers messages and who has the legitimacy to help address these crises? Because I guess we're at a time where there's always a sense that there might be another public health crisis as well. We hear we hear all about this. And the ability for states to respond has been proven in in some ways through COVID. But there have also been a lot of crises of legitimacy and scandals around, you know, how COVID was managed. So, I mean, who should we look for for legitimate public health information? And maybe what can people do to make sure they're educated and prepared to engage with the next public health crisis, if that's not too depressing to contemplate?

SPEAKER_02 41:02

I don't necessarily know that there's a single answer to that. One of the issues around the sort of underfunding of the health systems and the health systems being overloaded in in all three cities in this research, for example, is that people don't get the same kind of access to their public health professionals anymore. They don't have relations they talk about not having relationships with doctors or nurse practitioners or even pharmacists. And so if you don't have that person as a trusted source of information, if you don't have that interpersonal relationship, um, you know, you might be turning to a another type of community leader who may or may not have the right information there.

SPEAKER_00 41:40

So and well, social media and disinformation. I mean, that this is exactly this does.

SPEAKER_01 41:43

Well, I mean, this is something we're really interested in. And you know, actually, when I was looking for case studies of cities and disinformation, we were talking about it in the um episode in January. Um, many of the existing sets of evidence and cases are around COVID disinformation and what's happening with public trust information at the local level. And the hope being, which is why I was trying to ask it earlier, around like perhaps these alternative infrastructures are ways in which that messaging can be improved. Exactly.

SPEAKER_00 42:11

Perhaps we can kind of wrap up. What would be next for you in terms of does this lead you towards a a new or evolution of your research agenda, doing this work? Where would you go next?

SPEAKER_02 42:20

For me, the the sort of next iteration of this project would be trying to look at some of those other community groups, for example, um, thinking about the role of religious groups in access to healthcare. Uh, and that's something that we've been, we've uh we've seen some calls for papers coming out around the role of of religious groups in in urban politics more broadly, but in looking at uh how they're managing access to healthcare. Uh, trying to think about the different types of connections that service providers are interested in making as well. So one of the things that really came out from this work was just how excited people were to learn about what other cities were doing, not necessarily to implement a best practice policy in the sense of transferring policy, but to know that the their issues were not isolated in their city, that they weren't working alone. Because oftentimes, you know, when you're working in homeless health care, for example, or any other sort of resource scarce environment, it can feel really lonely and really isolating. And so I think looking at ways of making those connections, both at regional, national levels, but also internationally, uh, I think that that's quite interesting. Uh, looking at issues around burnout for service professionals and and the kind of constant churn that a lot of the ways in which pilotification or um also the the sort of sustainability of local government funding, how that causes the sort of both workforce churn and burnout. Another thing that came out, we didn't really talk about this so much, but the uh the relaxation of data sharing rules in the UK and um and in Greece during COVID really allowed the building up of more um lasting relationships. So there was a relaxation of GDPR rules for public health reasons during COVID, which allowed departments and services and local governments to talk to each other in way and share information in ways that they hadn't before. And that was something that I think was quite surprising for me from the research, but also surprising from the people who were who were engaged in that work. And they were talking about it, you know, now we're we're doing some of these interviews five years after the pandemic and they're talking about how some of those relationships had really been sustained. So even when you did have people moving around, you had a much stronger social web which was able to kind of mitigate against some of these issues that we've discussed.

SPEAKER_01 45:12

I mean that's such a critical issue isn't it because when we think about the fragmentation of data and intelligence that's needed to make our cities work for the most vulnerable populations, which is obviously what your research is is doing, we don't always have it because it's split between different national agencies, different departments, but also as you say, between public and private providers. So yeah that data integration point how can cities act if they don't know themselves and don't have access to all of that data is so critical.

SPEAKER_02 45:38

And the amount of time that's spent collecting that data over and over and over again. Because there's a lot of replication of data collection among those services because of that lack of data sharing.

SPEAKER_01 45:48

Well I think that's a good place to end. So thank you very much Christina for coming on. It's been great talking to you. Okay.

SPEAKER_00 45:54

Thank you so much. That's been really interesting and uh yeah we look forward to further engagements now that I'm here at Manchester I can't wait to hear more of the outcomes of this project and thinking about those comparative angles we've been talking about and hearing what you do next.

SPEAKER_02 46:06

Yeah definitely thank you for having me.

SPEAKER_01 46:19

So I think that's a really good start um to our first podcast recording here in Manchester. And a really interesting lens that kind of brings new things to the fore but also creates connections with some of the topics we've been talking about for a long while whether that's about the crisis in social infrastructure and how communities are getting on with delivering their own needs in the absence of state support and state provision even whilst recognising that that's politically difficult because you're filling in the gaps for services that should otherwise be provided by those kinds of state authorities. So on the one hand you have to accept this responsibilisation because particularly when it comes to questions around public health, people's lives are at stake. They will die if communities don't step in, if the voluntary sector doesn't step in and fill some of these gaps. And I think for me there's also that kind of like cross-cutting theme around devolution of municipalities and the extent to which we position cities as sites of potential pushback experimentation and innovation or the extent to which they're actually just replicating and reproducing those same kinds of inequalities that are structurally ingrained within different systems in this case healthcare.

SPEAKER_00 47:22

Yeah and I think the compar- I mean I'm really interested in this comparative aspect of the cases she chose. I mean we we'd have to probably look at the work that comes out to get into this more but I I mean I picked up in this in discussion but the the different meanings of the social pharmacy, the very different context we're talking about in terms of what's expected, what the state would do, the price of drugs, I mean these are hugely different context that she gave some of those really striking figures, the percentage of money that people spend on on medicine, we really take these things for granted of what we have in the UK and yet at the same time we see these really extreme health inequalities unaddressed. So I think the learning between cities, she emphasized as well the exchanges in in terms of maybe her future research interest we take for granted as academics as well that we go to other cities, we learn from other cities, we benefit from these kinds of exchanges of ideas, we have visiting scholars. Now many people do not get to do that and it's so valuable for everyone right you your work is showing that it's certainly learning that through the African cities. And so I think yeah thinking about how people and I don't want to say ordinary people but people who who don't get to have this exposure to other cities experiences can learn from these kinds of things is something that that really got me reflecting on.

SPEAKER_01 48:29

Actually who does make those comparisons and how do embedded contextually relevant examples transfer from one place to another and it's not because someone codifies a best practice model that gets written up in a policy document or white paper and then someone else decides to implement. It is via people learning from each other and being able to exchange those experiences. So yeah I mean on a personal level as well it just made you think about how healthcare has changed in in our own lives. I remember very acutely when you'd get a home visit from a doctor um and now just the other day I was I was listening to a podcast and there was an advert um which was offering as part of their deal if you took out a premium bank account with this bank and you had to have at least £100,000 like up front to start open your bank account but then you would get guaranteed medical appointments and second opinions at least two and it was really interesting because I was thinking about this podcast and just thinking about how you know the elite provision of healthcare and those kinds of circuits feeding back into all these questions around billionaires and global wealth and all the stuff Roland's doing but then right down to the inequalities that that produces in who has access to any of these. Much bigger topic but that's probably not time for today.

SPEAKER_00 49:37

I think so yeah so thank you very much to our listeners and of course Christina and we look forward to many more of these strangers do our features across the pinaries by