by Amerita Ravuvu

The Pacific region is a leader in progressive regionalism (The Framework for Pacific Regionalism, 2014), and in many ways, the region is a case study of policy success. However, at the same time, progress in integrating key health considerations into national government development plans and key-policy decision-making processes has been patchy and hampered by a range of political-economic and contextual factors, including economic imperatives (Ravuvu, Friel, Thow, Snowdon, & Wate, 2017; Snowdon & Thow, 2013; A. Thow & Snowdon, 2010; A. M. Thow et al., 2011). In this paper, attention is drawn to policy metaphors of two key crisis currently impacting the region – the Non-Communicable Diseases (NCD) crisis and the coronavirus disease (COVID-19) pandemic (Tin, Vivili, Na’ati, Bertrand, & Kubuabola, 2020). The paper describes how political-economic factors framed through economic and war metaphors have defined and constructed the ‘reality’ of the problems currently faced and thus in turn have gained currency and become entrenched in public health policies that support economic growth at the expense of human health. Using the causal layered analysis (CLA) and futures triangle as tools for gaining insight into policy scenarios (Inayatullah, 2005; Inayatullah & Milojević, 2021), a number of issues are explored across these frames and deconstructed to create the possibility for an alternative future.

Metaphors in the Pacific region’s NCD and COVID-19-related policymaking

In 2011, Pacific Forum Leaders declared NCD as a ‘human, social and economic crisis’ due to the significant and growing burden of NCD in the region (Tolley et al., 2016; World Bank, 2014). There have been calls for a more systematic, collective approach to tackle this burden and by 2014, the Pacific NCD Roadmap (World Bank, 2014) created at the request of the Pacific Finance and Economic Ministers, established a menu of interventions and cost effective actions to ‘bend’ the cost curve for NCD treatments. The Roadmap emphasised on the ‘large’ but often preventable financial costs on already overstretched government health budgets and its trickle-down effects on the well-being of Pacific populations.

Efforts to strengthen NCD prevention and control measures have been side-tracked and impacted by another pandemic – the COVID-19. At both the international and regional levels, a war has been declared on this pandemic (Business Wire, 2021; International Committee of the Red Cross (ICRC), 2020; The Interpreter, 2021), which is now threatening human health globally and completely transforming the way people live (Win Tin et al., 2020). For the Pacific region, this latter crisis has serious implications for its already NCD prevalent populations given the mounting evidence that NCD increases the risk of dying from the COVID-19 and other viral infections such as seasonal influenza (Guan et al., 2020; Hong et al., 2014; Tin et al., 2020; Yang et al., 2020). While much of the Pacific has kept health impacts of this pandemic under control, the two economic giants of the region, Fiji and Papua New Guinea (PNG) are seeing large spikes in cases (Crawford School of Public Policy ANU; Radio New Zealand, 2021). No doubt, this presents policymakers with a troubling situation of weighing the costs of economic imperatives against public health wellbeing. Public health campaigns in both these settings are now using the economic and war metaphors to solve their immediate crisis (Bohane, 2021; Talebula, 2021).

The ‘economy as a body’ metaphor at work in NCD-related policies across the region

Since the early 2000s, high-level political support for addressing NCD has been strong with ministerial endorsement for several global and regional commitments^[1]. In 2007, the region embarked on the ambitious five-year Pacific Regional 2-1-22 NCD Programme (2007-2011) under which many PICTs developed, costed, and prioritised strategies to reduce NCD (Tolley et al., 2016). Despite this initiative, economic and social burdens caused by NCD continued to grow, leading to the declaration of a crisis by leaders in 2011 and the development of the Pacific NCD Roadmap.

Post Declaration and endorsement of the Roadmap, the framing of NCD repeatedly uses the ‘economy-as-a-body’ metaphor to frame the issue of NCD as a burden on Pacific economies. The region’s “growing NCD burdens threatens the health and wellbeing of Pacific populations and combined with modest economic growth, will inevitably further squeeze ministry of Health and national development budgets and undermine national economic productivity that will result from premature death and disability” (World Bank, 2014). Framing the debate as such where economic growth (the body) is the focus has supported calls for an urgent and effective multisectoral response (Tuitama, Young-soo, Clark, Tukuitonga, & Beaglehole, 2014; World Bank, 2014). Using CLA and analysing key political commitments that regional leaders have supported (see footnote 1), the issue of NCD across the Pacific region has been constructed as a ‘burden’ upon the Pacific economy as shown in Table 1.

Table 1: Causal layered analysis of NCD crisis response in the Pacific Region

	Frame
Litany level (visible problem)	The Pacific region is overwhelmed with a NCD prevalent population (Number of NCDs, premature deaths related to NCD, cost of NCD, epidemiological data)
Systemic level	Underlying determinants for the crisis are outside the health sector therefore a multisectoral response is required
Worldview or discourse	Economic, Political, Public Health
Myth and metaphor level	The Blue Pacific Plague

While the framing of NCD as an ‘economic burden’ has been effective in gaining political momentum and development partner support for an articulate plan to combat the Blue Pacific Plague, ‘bend the cost curve’ and put countries on a path to more sustainable financing, a major challenge remains. The translation of regional commitments into national policies and policy implementation with policies adopted at national level has been inconsistent across Pacific countries. The impacts have also been negligible for beneficiaries at the community level. Even in cases where comprehensive NCD-related policies exist, policy implementation and enforcement remain weak and monitoring and evaluation almost absent (Win Tin et al., 2020).

More so, while this framing demands for a multisectoral response, the reality is siloed activities across government policy sectors and across governance levels. The facilitators and barriers to consideration of NCD prevention and control efforts in non-health sectors, with respect to actor interests and influence, the framing of policy issues and dynamics, governance structures and capacities are not analysed and understood well enough to enable more effective policy making and its implementation. Concrete ways to bring convergence to upstream factors that drive delivery – for example, engaging with governments and donors to address siloed budget lines needs to extend beyond the health sector to address broader drivers across multiple sectors. Given that the activities of different sectors and ministries within governments – such as agriculture, education, trade and sports – can affect NCD prevention and control, budgetary contributions that these different sectors make to the prevention and control of NCD needs to be measured. A framework for the actions that can be taken by non-health sectors to affect NCD prevention and health promotion can be mapped out using a futures triangle (see Figure 1) to understand better the weight of the past, the push of the present, and the pull of the future of a ‘whole-of-government and whole-of-society response that the economic framing of NCD calls for.

Figure 1: Drivers of change in a ‘multi-sectoral response’ futures triangle

Across the region, there is a great need to understand the fundamental forces that shape policy making and implementation at the national levels to enable healthier environments. Key political commitments in the region show that there is a mutual understanding of drivers of change developing the present and shaping the future of a multi-sectoral response as illustrated in Figure 1. However, a more nuanced understanding of the convergence of drivers of change anchoring the past remains limited and requires unpacking. Policy implementation, enforcement, monitoring and evaluation largely rests on these deep structures and fundamental forces that resist change, act as barriers to change and continue to hinder multi-sectoral efforts. Additionally, more investment needs to be made to empower affected communities and civil society to engage in policy making, implementation and monitoring progress – an area of focus that the region has yet to mobilise.

The martial war metaphor at work in public health policies: the Fiji Case

The ongoing COVID-19 pandemic has been likened to a “zombie apocalypse” given the mutation of the virus (Inayatullah & Black, 2020), deaths reaching proportions equivalent to a world war and references to ‘hospitals in the trenches’ and ‘heroic frontline workers’ (ArKadia Translations, 2020) who are fighting the enemy that is the Coronavirus. Across the Pacific, the war metaphor has also been used to construct the magnitude and urgency of the outbreak and in Fiji where the spike in positive cases continues to spiral upwards (The Fijian Government, 2021e), the Fiji government’s response has been a ‘declaration of war’ on COVID-19 (The Fijian Government, 2021f). Using CLA and analysing 60 government speeches (The Fijian Government) since the April 2021 outbreak, war metaphors have been used to frame the crisis to strengthen public health strategies as shown in Table 2 below.

Table 2: Causal layered analysis of the COVID-19 Pandemic response in Fiji

	Frame
Litany level (visible problem)	“The war against this virus is still winnable” and covid-19 is viewed a virus which the public and officials must ‘fight’ (Number of positive cases, covid-19 related deaths, covid-19 deaths with underlying conditions, cost of covid-19 on the economy, epidemiological data)
Systemic level	“The covid-19 virus moves if people move. If people stay still, the virus stays still.” (Solution: A public health campaign to restrict movement)
Worldview or discourse	To “defeat the virus and keep the country moving and working as much as possible requires a national effort”. (Solution: A targeted surgical approach to reopen the economy, get people back to work, businesses to resume and normal life to resume)
Myth and metaphor level	A deadly war with flashing lights (To combat this deadly virus, all measures no matter how restrictive they may be on civil liberties will need to be complied with to ‘win’ this war, except when it starts to trigger an economic crisis impacting the prospects for jobs, micro, small and medium enterprises, and entire industries)

The framing however appears to be ‘martial’ with daily speeches from the higher echelons, marshalling phrases such as “our most effective weapons so far against this virus are contact tracing and testing” (The Fijian Government, 2021a), “if we don’t win this fight over the next two weeks and this outbreak gets out of control” (The Fijian Government, 2021f), “we’ve added some invaluable tools to our arsenal that will help us expand and quicken our laboratory testing” (The Fijian Government, 2021d), “to combat this virus in a targeted way…defence is our best attack” (The Fijian Government, 2021b) and “the war against this virus is still winnable” (The Fijian Government, 2021c) . While these war metaphors help illustrate the scale of the challenge Fiji has, the borrowing of tenets of effective organisation and coordination from the armed forces, has made the public health response militarised in a literal sense curtailing civil liberties. For instance, Fiji’s current curfew restrictions as a public health response was first imposed from 11pm to 4am since the first outbreak in April of 2020. One year on with the April 2021 outbreak, curfew hours have now been extended from 6pm to 4am and has gone unquestioned. If anything, the ‘martial war’ framing has made people become more accepting that this is a public health effort as a war on a virus and has made it easier to enact policies restricting movement echoing Keiger’s sentiments (Keiger, 1998). While it may be done out of necessity to protect life and quickly respond to the escalating situation (Milojević & Inayatullah, 2021) in Fiji, the war vocabulary used in Fiji’s policy response has been downplaying other concerns that have emerged in the last eight weeks.

When the virus outbreak first started, the government’s response to positive cases was not swift and harsh – although it was using a war framing in its public health response. Following a few weeks of sporadic cases appearing, the government’s response was a non-essential business lockdown, ban on domestic air and international travel as well as inter-maritime travel, ban on domestic road travel beyond containment borders and curfew restrictions limiting movement. These tough measures appeared to be working – although they were starting to chafe. Only 700 hours of embracing these measures, the war framing then laxed measures and took on a ‘targeted approach’ (The Fijian Government, 2021b) using the economic argument that these were “first steps toward reopening the economy” (The Fijian Government, 2021a) and shifting the responsibility to the public to “strictly do their part to prevent the spread by observing restrictions and following the COVID-safe guidelines” (The Fijian Government, 2021a). Despite the increase in cases, the ‘flashing lights’ in this ‘deadly war’ is preventing drastic measures like 28 days of straight lockdown (my emphasis: even though this appeared like the most sensible thing to do at the outset before the cases spiralled out of control) as this would put the country “face-to-face with economic disaster and miserable isolation, people’s jobs may never return, and structural unemployment through the permanent loss of industries” (The Fijian Government, 2021a) would be the order of the day.

Using the CLA in Table 2, the use of war metaphors in Fiji’s government response needs to be cautioned with for a number of reasons. Firstly, it appears now that the government’s response is to justify fighting the enemy at all other costs without any consideration of other concerns including civil liberties, schools closing indefinitely and other matters of national concern. Normal priorities and concerns have all been swept aside and the government has assumed more top-down control with people having to accept the sweeping authoritarian power without them being necessarily appropriate to the vested political-economic interests at hand. Secondly, as a result of the ‘war declaration’, the moral appeal is now about ‘obeying orders’ and ‘doing your duty’. If people go above and beyond their duty, they are considered heroes, and if they don’t, they are traitors. This has framed people, including healthcare workers as soldiers giving their lives for the cause despite fatigue and poor work conditions as proliferation in cases are showing, to pursue the nation’s interest of keeping the economy afloat. Finally, the use of the war metaphor in the government’s response has shifted the focus of fighting a war to protect human health and the wellbeing of its population, to fighting a war with flashing lights where the economy is the body to be ultimately protected. The war metaphor distracts from its intent to strengthen the public health response to one that is appropriated for political-economic interests. The use of the war metaphor to design restrictions appropriated for political-economic interests has consequently downplayed many other emerging issues including the socio-economic frustrations that people are now experiencing with unemployment and reduced work hours, access to food and the overstretched human and infrastructural resources of Fiji’s already fragile health system that is on the brink of collapsing. In Fiji’s current climate of confusion, where the government advice has not always been clear and is constantly changing, the war metaphors are becoming unhelpful because of what it implies as well about the type of leadership that is needed (Milojević & Inayatullah, 2021). The government’s main role is not to fight a war, but to foster trust and community and manage services and support systems responsibly – a far-fetched reality at the moment in Fiji.

So What?

There is a need to shift the public policy discourse for future crisis preparedness in the region using approaches that work (Milojević & Inayatullah, 2021). Using CLA, a preferred future using the polis model – where the framing of problems critically influences the way alternative futures are constructed (Milojević & Inayatullah, 2021), is shown below to create a better, more equitable and all-round healthier Blue Pacific that leaves no one behind.

Table 3: Causal layered analysis of a preferred future for policy framing

	Frame
Litany level (visible problem)	Evidence-based science within a narrative of inclusion “A team of 20 million” (The Pacific’s projected population for 2050 is 19,555 million (Statistics for Development Division, 2021))
Systemic level	A Regional Health Awakening where the five ‘p’ health model – prevention, precision, participation, partnership and personalisation become the norm for strong health systems across the region that serve all populations.
Worldview or discourse	Collectivist – Focussing on Regional solidarity, Political leadership, Social Inclusion (Focussing on the vulnerable, the marginalised, using the region’s solidarity to mobilise the region’s abundant resources and treating young people as the present and not the future)
Myth and metaphor level	The Blue Pacific: Reaching the furthest behind first

Policy is about “storytelling, ideas and argument” where “community is the major unit of composition” and not individual interests (Milojević & Inayatullah, 2021). Rather than focusing on a cost-benefit analysis approach where public policy responses that yield the best results are chosen, or where the whims of political leaders are informing public policy (Inayatullah & Black, 2020) , which is a common sight across the region, the polis model focussing on “hidden storylines” to create alternative strategies (Milojević & Inayatullah, 2021) should be promoted. There is a need to better understand fundamental forces anchoring the past at the decision-making level as these impacts the measures/interventions that are taken for the benefit of most, including the most vulnerable in society.

Conclusion

Using the CLA framework, this paper has argued that the use of the economic and war metaphors has constructed realities differently and naturalised and perpetuated particular worldviews which influence the identification and consideration of solutions through the particular framing and construction of the issues at hand. The futures triangle tool used in this paper has also brought into perspective how the role of actors, processes, relations, and systems are erased from the focus of policy responses when an economic framing is used.

The policy responses for both these crises have been limited to a range of responses that can be argued to view economic growth positively despite its negative impacts on both human and environmental health. Through the CLA analysis, this paper illustrates how the use of these metaphors also shift responsibility, magnify the crisis at hand and effectively supports claims about the urgency and extent of required intervention.

 

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Non-Communicable Diseases Programme

Public Health Division

Pacific Community

Fiji

1. Political commitments include: The WHO Framework Convention on Tobacco Control (FCTC), 2003; The Tonga Commitment, 2003; The Global Strategy on Diet Physical Activity and Health, 2004; The Pacific Framework for the Prevention and Control of Non-communicable Diseases, 2007; The Western Pacific Regional Action Plan for Non-communicable Diseases, 2009; The Global Strategy to Reduce the Harmful Use of Alcohol, 2010; The Honiara Communiqué, 2011; and The Apia Communiqué, 2013. ↑