Breaking out of sustainability impasses: How to apply frame analysis, reframing and transition theory to global health challenges

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Breaking out of sustainability impasses: How to applyframe analysis, reframing and transition theory to globalhealth challenges

Anne Jerneck1, Lennart Olsson ∗,1

Lund University Centre for Sustainability Studies (LUCSUS), Box 170, S-22100 Lund, Sweden

a r t i c l e i n f o

Article history:Received 22 June 2011Received in revised form 5 October 2011Accepted 7 October 2011

Keywords:Boundary workCritical researchProblem solving researchSustainability scienceTransition management

a b s t r a c t

We combine frame analysis and transition theory into a thinkingtool in sustainability science and analyse three serious and persis-tent problems in global health subject to sustainability impasses:HIV/AIDS, malaria, and indoor air pollution. Frame analysis iden-tifies how problems are encased by scientific understandingsand captured by transition barriers: policy cooptation, techno-institutional lock-in, and knowledge trap. Transition theory locatesthe transition barriers on a temporal scale and a conceptuallevel: landscape, regime, and niches. Frame analysis reveals howproblems are embedded in particular narratives while refram-ing stimulates alternative understandings and problem solutions.Boundary work facilitates knowledge integration across units andtransition management promotes actor oriented problem resolu-tion. The thinking tool unites critical with problem solving researchand ties reframing to analytical and temporal understandings ofsocial change. The aim is dual: to advance methodology while stim-ulating critical problem solving in the quest for environmentalinnovations, social justice and sustainability.

© 2011 Elsevier B.V. All rights reserved.

1. Theory, methodology and research questions for sustainability science

Sustainability science strives to bridge knowledge, theory and methodology across disciplinarydivides in search of solutions to integrated problems confronting humanity (Clark and Dickson, 2003).

∗ Corresponding author.E-mail addresses: [email protected] (A. Jerneck), [email protected] (L. Olsson).

1 The authors contributed equally to the paper.

2210-4224/$ – see front matter © 2011 Elsevier B.V. All rights reserved.doi:10.1016/j.eist.2011.10.005

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To that end it seeks and suggests integrated approaches for dealing with social–ecological causes andconsequences of climate change, biodiversity loss, land use changes, water scarcity, major epidemicsand other sustainability challenges (Jäger, 2009). As an emerging field it recognises multiple per-spectives and approaches in science and society for tackling urgency, spatial scales, temporal inertias,non-linearity and functional complexity between actors, sectors and structures in a range of processes.In addition, it has a trans-disciplinary ambition to span disciplines, cross boundaries between science,policy and practice, and transcend science itself into stakeholder dialogues (Kates et al., 2001).

In reaction to scientific specialisation and disciplinary fragmentation (Sherren et al., 2009) sus-tainability researchers collaborate in broad interdisciplinary initiatives to overcome methodologicalbarriers (Leach et al., 2010). Furthermore, sustainability scientists structure knowledge in new ways(Kumazawa et al., 2009; Ness et al., 2010) and attempt to bridge critical research with problem solv-ing research (Cox, 1981) in order to deal better with sustainability challenges (Jerneck et al., 2010).Inspired by this, we explore how progress towards sustainability is hampered, but can be promoted,in the case of three serious, widespread and persistent problems in global health: HIV/AIDS, malariaand indoor air pollution (IAP). The three selected examples are interesting and relevant for social jus-tice (particularly HIV/AIDS), environmental management (particularly malaria) and poverty reduction(particularly in-door air pollution). They all represent global health challenges where progress, weargue, is hampered by the current scientific framings and their corresponding actions and interven-tions. They also have implications for climate change and the environment, especially malaria andindoor air pollution, thereby reaching beyond global health and into the structuring of knowledgeon environment and climate change. In terms of data and research design the article is based on sec-ondary data that we generated from multiple methods such as policy and text analysis, a bibliographicsurvey and an extensive literature review. Our primary data is rooted in repeated field work in Kenya(2007–2011).

Climate change, land use change and land degradation affect the well-being of large populationsin the global south and the situation is predicted to get worse (IPCC, 2007; Andersson et al., 2011). Inaddition, there is a mounting burden of disease in these areas (Patz et al., 2005). In response to suchsustainability challenges, and as a sign of functional complexity, climate change policy is increasinglyinterlinked with food and energy policies. In parallel, there are signs that global health policies arecurrently changing profoundly with implications for how climate change-induced health challengescan be met. The international development community has acted forcefully on the fact that manypeople in developing countries are plagued by three major diseases: HIV/AIDS, malaria and tubercu-losis (McCoy et al., 2009; Ravishankar et al., 2009). Meanwhile, a range of widespread but neglectedtropical diseases have not yet benefited from such political and financial support and interventions(Hotez et al., 2007; Esser and Bench, 2011). As an example, every year over 1.6 million people globallydie of respiratory diseases from in-door air pollution (IAP) from cooking over open fire and the victimsare mainly women and children (WHO, 2002; Ramirez-Venegas et al., 2006). This demands action andresearch.

In this article, we use global health as an example to demonstrate a “multiple method of inquiry”(Saunders, 2003) for dealing with sustainability impasses. In our view, the term sustainability impasserefers to a situation of inaction owing less to lack of awareness, knowledge, technology or resourcesand more to a suite of other reasons like economic priority or human cognition, social neglect anddenial (Rees, 2010). In the analysis we study three sustainability impasses by combining frame analy-sis and reframing with transition theory and transition management. The examples on HIV/AIDS andmalaria relate to transition theory while the example on IAP relates to transition management. Tran-sition theory is already at the core of sustainability research (Grin et al., 2010) while frame analysisis now developing in this context (Leach et al., 2010). Our findings show how the three persistentproblems are subject to sustainability impasses resulting from, among other things, inadequate useof science; competing interests and values; a disconnection between science, practice and policy; orany combination thereof. In the analysis, we give priority to the three persistent problems but wealso identify four strategic organisational shifts in global health which may have serious effects on theenvironment and on adaptation to climate change.

In research, we first apply frame analysis and then transition theory to identify and locatethree types of multi-layered barriers to progress, which we conceptualise in both descriptive and

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explanatory terms: policy cooptation, techno-institutional lock-in and knowledge trap. The idea of policycooptation is not new and here we use it to describe a situation where a particular policy is seized forthe sake of advancing a particular interest that it was not intended for in the first place. One pertinentexample is when seed companies seize policies and discourses on poverty and famine for promotingthe use of genetically modified seeds such as in the case of AGRA (Alliance for Green Revolution inAfrica) (Holt-Gimenez et al., 2006). The concept of techno-institutional lock-in can be found in theliterature on transitions and socio-technological systems (Foxon, 2007; Smith and Stirling, 2010).Here we show how it can be used in a slightly different way. The concept of knowledge trap is rathergeneral and has many meanings. We use it to describe the gap between available versus necessaryknowledge for solving a particular problem. In the frame analysis and the reframing process wediscuss alternative frames and then locate where boundary work can translate emerging knowledgeinto action that opens up sustainability pathways out of impasses.

Below, we introduce our multiple method of inquiry by briefly engaging with the literature onboundary work, frame analysis, transition theory and transition management. Then we analyse threesustainability impasses in global health and draw conclusions from that.

2. Boundary organisations

A mismatch between science and society can be foreseen when interdisciplinary knowledge meetscleavages and compartmentalisation in institutions and organisations. Two examples from the UnitedNations show that the FAO divides its organisational responsibility for agriculture into major but sep-arate food and fibre production systems while the WHO divides its organisational responsibility forglobal health primarily into major diseases. This compartmentalisation goes against the complexity ofcrosscutting sustainability challenges, which call for new types of multilevel governance/governingfor sustainability (Adger and Jordan, 2009; Biermann et al., 2009). As an additional element of theproblem, scientific and other knowledge producing communities in society may apply different cri-teria for what counts as ‘reliable evidence and convincing arguments’ (Cash et al., 2003). For effectivesustainability transitions, we may thus need boundary organisations to promote communication andperform boundary work between science and society (Clark, 2003).

The concept of boundary organisations was coined by Guston (Guston, 1999) for the task of align-ing the ‘relatively distinct domains of politics and science’ (Beratan et al., 2004). In theory, boundaryorganisations span the realms of science, practice and policy as well as the gaps between agenciesand organisations informed by and adhering to strong but different knowledge frames. Via mediation,translations, and the creation of arenas for debate, boundary organisations can engage in buildingresponsive, trust-based and long-lived relationships between science, policy, practice, stakeholdersand the general public (Beratan et al., 2004). In so doing, boundary organisations should meet the sus-tainability requirement of performing iterative and collaborative processes. Thus, they must keep theinterest of all parties in mind, while being accountable in distinct ways to each of them, and remainingstable against external forces. The dependence of a boundary organisation is thus as important as itsindependence (Guston, 2001) meaning that its mandate is to be ‘partially responsible to both – but notexpected to operate fully by the norms of either’ (Clark, 2003). Yet, in reality, many scholars point tothe difficulties in ‘meshing different knowledge systems for collaborative research and policy making’(Larson et al., 2009).

The increasing research on boundary networks reflects the complexity and high demands on flexi-bility in boundary work (Schneider et al., 2003). The literature refers to boundary spanning individualswho facilitate interaction within and between actors (Miller, 2009) and who serve as brokers, inter-preters and policy entrepreneurs in linking knowledge to action (Williams, 2002). In sum, boundarywork performed by individuals, organisations or networks serves several functions: it facilitates thebridging of organisations; it filters information and thereby buffers organisations against externalexposure; and it feeds information flows to the outside in order to exert external influence. In case ofstress, conflict and ethical dilemmas boundary work can cause friction or imply powerful gate-keeping(Aldrich and Herker, 1977; Fennell and Alexander, 1987). In our analysis, we refer to boundary workthat is facilitating.

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3. Frames, framing and reframing

Analytic frames emerge from theory and serve as starting points for generating questions, hypothe-ses or propositions. Frames influence the choice of research design which guides data construction andinterpretation (Ragin, 1994). Without frames research would proceed slowly. Frames tend to be fixedin quantitative research, flexible in comparative research and fluid in qualitative research (Ragin, 1994).We use a flexible analytical frame and transition theory to investigate and compare how sustainabilityimpasses emerge and can be resolved.

In social research the way in which a research problem is formulated in relation to theory is calledthe act of analytic framing (Ragin, 1994). Similarly, within psychology, the way in which a partydescribes or defines a conflict is known as problem framing (Spangler, 2003). Methods for interpretingand translating empirical observations into research questions can also be seen as framing. Fromthe 1930s, several scholars have offered insights into the meaning and use of frames (Burke, 1936;Mills, 1940; Bateson, 1955; Goffman, 1974; Coyne, 1985). Frames can be descriptive, explanatory orprescriptive; perpetuated, modified or changed. They can be distinct, rigid and static or ambiguous,open and dynamic. Frames are often embedded in narratives that start defining the problem andthen elaborate its consequences and outline its solutions (Roe, 1994). Frames and their narrativesare scientifically and politically important because they define how we understand the issue at hand,which may, in turn, have implications for the policy options and interventions that we choose (Leachet al., 2010: 49). In sum, analytic framing is the practical use of theory on a certain topic, for somepurpose and for the sake of: asking certain questions, including or excluding certain aspects or linkingsometimes unrelated issues and concepts.

When we observe frames and then reframe issues in this article, we follow Lakoff (Lakoff, 2006a)who suggests that ‘frames are mental structures that allow human beings to understand reality’. Thismeans that frames are fundamental to our thinking and equally important in everyday life, politics andscience. From this follows that reframing, whereby issues are shifted between frames, is fundamentaland has real social implications. We proceed from the idea that frames are more than a system ofconcepts; a frame is ‘a conceptual structure used in thinking’ (Lakoff, 2006a). This underlines dynamicinteractions between language (words, concepts) and cognition (thinking) meaning that words evokeframes; language evokes moral and conceptual frames; the negation of a frame evokes the frame;and the evoking of a frame reinforces it (Lakoff, 2006b). Lakoff and Ferguson stress the importance offraming and remind us that ‘each framing defines the problem in its own way’ (Lakoff and Ferguson,2006). Lakoff also points to how framing is used for supplying alternative stories and scenarios thatcan help change and replace existing views (Jarratt and Mahaffie, 2009). Hence, we see that frames,like theory, come from somewhere, serve a purpose and are never neutral (Cox, 1981).

Framing builds on constructivism meaning that the world can be described and understood invarious ways with each frame resting on certain assumptions. From this follows that reframing isa process of shifting one’s thinking into a different system and structure of concepts, language andcognitions. It is also clear that reframing can trigger redefinitions of problems, dilemmas or conflictsand thus reveal new facets that may support resolution. Well-known questions can be reformulatedwhereupon hidden aspects emerge while the fundamental meaning and certain facts remain (Spangler,2003). Problem solving and the posing of questions are therefore generic to reframing. This makesreframing powerful because it changes perceptions of what to ask, how to investigate, and how toact upon a subject. Thus, it has performative implications. If no single available frame is optimal forunderstanding or solving the problem, then reframing can serve to show the complexity and diversityof an issue; point out possible driving forces and interpretations; and shape practical solutions to actupon. In reframing the capacity to associate across theoretical, empirical and disciplinary divides istherefore highly valued.

Owing to strong paradigms in the natural sciences, reframing may therein be seen as alien or evenunscientific. However, in history and the social sciences reframing is a common research strategy forreconfiguring core problems, dilemmas or clashing paradigms. Take the polemic development debateas an example where development can be seen as a stage in a linear process (modernisation theory),or as an asymmetrical relationship (dependency theory), or as an invention of the West imposed on ‘theRest’ (post development theory). In addition, questions on how a country grows rich (modernisation

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theory) can be turned into an inquiry of why a country stays poor (structuralism) or why a countryends up in a downward spiral of getting even poorer and underdeveloped (dependency theory). Thedistinct variation between frames in development theory emerges from the underlying ideology andontology of grand theory. But despite the consensus across many development theories that develop-ment should entail a broad vision of liberation, freedom and poverty reduction (Martinussen, 1997),a stiff analytical frame may still emerge and give rise to competing goals, means and targets.

In sum, the ‘acceptance of a frame allows its user to perceive, identify, and label the events that areoccurring, but it may also involve taking a particular attitude toward them’ (Coyne, 1985) (337–338).This means that frames can offer distinctly different perceptions of and answers to the question ‘whatgoes on here’. The act of formulating a frame for an ambiguous situation is therefore not neutral and thishas ‘important implications for what follows’ (Coyne, 1985: 338). This resonates with Lakoff and Fer-guson (Lakoff and Ferguson, 2006) who show how the rhetoric around an issue, i.e. an issue-definingframe, includes certain aspects while precluding others, thereby pre-empting many considerationsfrom entering the debate and blocking fuller understandings. An observer viewing through a nar-row frame may think that all aspects are included in the discussion while reframing would disclosethat the problem runs (much) broader and deeper. Such context stripping means that the issue isnot properly contextualized in time, space and theory thus leading to deliberate or non-deliberatemisinterpretations (Guba and Lincoln, 1994).

Overall, we distinguish three types of reframing: interpretative approaches in conflict resolu-tion (Spangler, 2003), semantic approaches in discourse analysis (Doremus, 2000) and structuralapproaches for uncovering underlying themes, stressing suppressed aspects and tracing power con-tents. Drawing mainly on Lakoff (Lakoff, 2006b), and by combining semantic and structural reframing,we will change the ontology describing the problem (what exists?) and the epistemology explaining it(what and how can we know about it?). We thus shift issues from dominating or competing frames intoa new analytical or empirical context that may offer new scopes, data and results that challenge pre-vious understandings. Moreover, and as a further analytical step, the transition barriers that hamperprogress will be located on/between the analytical levels (and temporal scales) of transition theory.

4. Transition theory and transition barriers

Social and economic change entails profound alterations in structures, institutions and social rela-tions and as a result, society, or a subsystem thereof, starts operating according to new assumptions,rules and practices. Rooted in social theory and technology systems studies, transition theory is anapproach, i.e. a middle range theory, for understanding long term social transformation (Rotmanset al., 2001; Foxon, 2007; Grin et al., 2010; Geels, 2011). Transition research comprises three impor-tant components, the multi-level heuristic (landscape, regime, niches), the multi-phase scheme(pre-development, take-off, acceleration, stabilisation) and transition management. The multi-levelheuristic deals with structural arrangements and interactions in transition problems and processeswhile the multi-phase scheme deals with the sequencing and temporal aspects in transition processes.Transition management refers to how actors obstruct or promote change and how they adapt to andlearn from transition processes. (Loorbach et al., 2010). A multi-level perspective and the transitiontheory heuristic can be used to identify overall institutional arrangements, locate deep structures orpatterns and analyse the dynamics between ideas, values and interventions (Geels, 2011). It has threeinteracting analytical levels: landscape, regime and niches.

The landscape involves slowly changing bio-geo-physical, political and social structures such asthe natural environment, infrastructure, international institutions and macro-economic conditions.Structures on this level are not easily changed by any single actor or event. The politics of globalhealth, as discussed here, is mainly defined and located on this level.

The regime level interacts with the landscape level and consists of a complex web of actors, struc-tures and institutions governing, supporting and reinforcing the predominant practices. In our casethe implementation of health care is located and thus defined on this level through health care systemssupported by science and education.

The niches level refers to actors, groups of actors, whole professions or technologies operatingaccording to particular knowledge and practices (Rotmans et al., 2001; Geels, 2002). While niches

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belong to the system, they embody the possibility of change and thus have ability to mobilize resources,power, for the sake of challenging dominant actors, practices, institutions and structures (Avelino andRotmans, 2009, 2010). Changes on the landscape level can facilitate or trigger such niche initiatives, orvice versa, thus an example of multilevel interaction and dynamics in transition theory; often for thepurpose of challenging the regime level. In our example health care clinics, practitioners and those oftheir technologies that challenge the dominant practice represent niches.

Regarding the persistent problems in global health that we observe here, interactions trigger pro-cesses that result in sustainability impasses. Inspired by transition theory, transition heuristics andtransition management, we show in the analysis how impasses in global health result from interac-tions within and between levels and at different temporal scales. As described in Section 1, we suggesta typology of three types of transition barriers causing the sustainability impasses: policy cooptation,techno-institutional lock-ins, and knowledge traps. The barriers can coincide and reinforce each otheras we will discuss in the analysis.

We argue that policy cooptations take place at the landscape level when new interests interferewith, divert or take over a particular policy area and subsequently influence the regime. A policycooptation will influence the regime and orient it towards specific goals and issues while ignoringothers. The fact that international trade and commercial interests influence global health policies is anexample as we show below. Techno-institutional lock-ins will develop between the regime and thedominant practice and technology that they support. Lock-ins involve mutually reinforcing interac-tion regarding technology, infrastructure, knowledge and institutions. Techno-institutional lock-insare primarily driven by path-dependence of sunk costs (Pierson, 2000; David, 2001) or increasingreturns to scale (Unruh, 2000; Foxon, 2007). The large scale development intervention of distributinginsecticide treated bed nets as malaria prevention (WHO, 2009) serves as a telling example. Knowledgetraps are primarily found between a niche and the regime level where researchers and practitionersoperate within certain scientific disciplines, organisations, paradigms or knowledge realms, and mayresult from too much disciplinary and/or organisational specialisation, or what we called compart-mentalisation in the introduction.

For the purpose of change and transformation, the transition management cycle encompasses asequence of tasks starting from the initial strategic and tactical phase of (re)structuring the problem,envisioning sustainability pathways and setting up a transition arena followed by the operationalphase of organising and performing experiments in the transition arena. This, in turn, is followed by areflexive phase serving to evaluate and feed new learning into the cycle to be repeated and monitored(Loorbach and Rotmans, 2006; Loorbach, 2010). Proceeding from these concepts we move on to theglobal health discussion.

5. Reframing three sustainability impasses in global health

Given that social change starts at different spatial and temporal scales in society we need a rangeof theories to locate, interpret and explain such emerging change. Here framing and reframing enterthe picture as they help us switch between perspectives and give prominence to a variety of theoriesand scientific understandings. In the analysis we will identify frames, locate transition barriers andshow how reframing can be used on sustainability impasses in global health using HIV/AIDS, malaria,and Indoor Air Pollution (IAP) as illustrations. As an entry point, we offer a brief account of the currentframes in global health policies.

International health policy is a relatively recent phenomenon initiated by the World Health Orga-nization (WHO) in the late 1970s (Kickbusch, 2000). Since then it has shifted to become Global Health(GH) referring to health needs of all peoples regardless of nationality. This shift increased both thescope of health issues that society deals with and the range of actors involved, from governments toa wide range of private, public, private–public partnerships and non-governmental stakeholders ofnational or international origin (Brown et al., 2006). There are competing views, in fact frames, on GHas illustrated by a range of metaphors that describe and frame global health policies: GH as security;GH as foreign policy; GH as a market; GH as investment; GH as public health; GH as charity; GH as socialjustice; and GH as human rights (Stuckler and McKee, 2008; Kickbusch and Told, 2009). Using transitiontheory we identify four instances of policy cooptation at the landscape level:

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0%

5%

10%

15%

2009200720052003200119991997199519931991

Occ

urre

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of 'w

ar' m

etap

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War on Disease

War on HIV/AIDS

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Fig. 1. The occurrence of three war-related metaphors in scholarly documents 1991–2010, expressed as the percentage of theaccumulated number (1991–2010) of occurrences for each metaphor respectively. There were 242 titles containing the phrase‘War on Disease’; 461 titles containing the phrase ‘War on AIDS’, and 93 titles containing the phrase ‘War on Malaria’.Source: Google Scholar, 3 March 2011.

First, there has been a shift from national and publicly funded health care systems towards privateactors (Ollila, 2005; Prah-Ruger, 2007) who act independently or in public–private partnerships (Reich,2000). Secondly, there is a shift in global health policy from health organisations, such as the WHO, tofinancial organisations such as the World Bank, the IMF and the WTO (Koivusalo, 1999). This is reflectedpartly in the fact that the World Bank in 1993 devoted the World Development Report, called ‘Investingin Health’, to the issue of how improvements in global health should be financed (WorldBank, 1993).In addition, the influential Commission on Macroeconomics and Health (CMH), initiated by the WHOin 2000 (Sachs, 2001), resulted in a comprehensive and concrete plan for advancing a global healthpolicy resonating with the World Bank view from the WDR 1993 (Waitzkin, 2003). While only threepersons in the CMH represented medicine and health, fifteen of the eighteen commissioners wereeconomists or business people, and fifteen of the commissioners had ties to international or nationalfinancial institutions (Sachs, 2001).

Thirdly, the USA is becoming a dominant player in global health policy, especially since the 9/11event in 2001 when the US turned global health into a national security issue (Kickbusch, 2002). Themetaphor ‘war on disease’ was coined already in the 1990s but was used increasingly after 2001,inspired by George W. Bush’s ‘war on terror’ (Fidler, 2004). In Fig. 1, we show the increase in theoccurrence of the ‘war’ metaphor in scholarly documents related to health, since 1991.

Fourthly, from 2000 the Millennium Development Goals (MDGs) influence the framing of globalhealth policies. The MDGs have been instrumental in shifting the emphasis of health policies frombroad based systems of health services aimed at general disease prevention towards focused inter-ventions on a few infectious diseases, notably HIV/AIDS, malaria and tuberculosis (Ollila, 2005; Marchalet al., 2009).

In addition to these policy cooptations – wherein GH has been framed, focused and financed in certaindirections – GH is characterised by several techno-institutional lock-ins. They have all emerged dueto enormous sunk costs in laboratory and other research infrastructure and the long term nature ofvaccine research requiring at least eight to ten years of clinical trials for each vaccine candidate (Cohen,2008). This, in turn, triggers knowledge traps that prevent alternative understandings and practices.We now proceed to our reframing of three sustainability impasses in global health. In Table 1, wesummarise the dominating frames, the transition barriers and the new frames that appear after thereframing process.

For our purpose here, we have identified four main strategic and organisational shifts regardingglobal health, which may have serious consequences for adaptation to climate and environmentalchange. Firstly, the shift from comprehensive to specialised health care focusing on specific diseases(Ollila, 2005). Secondly, the shift from preventive to curative health care (Esser, 2009). Thirdly, the shiftfrom state actors to public–private and private actors as agenda setters and funders (Ollila, 2005; Prah-Ruger, 2007). Fourthly, the shift from health agencies to financial actors as policy drivers (Koivusalo,1999; Birn, 2009).

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Table 1Reframing: dominating frames, transition barriers and new frames.

Sustainability challenge Dominatingframe

Policycooptation

Techno-institutionallock-in

Knowledgetrap

New frame

HIV/AIDS proliferation Pharmaceutical X X X Violenceagainst women

The fight against malaria Chemical andpharmaceutical

X X X Integratedvectormanagement

Rural energy crisis Deforestation (X) X Indoor airpollution

5.1. Reframing HIV/AIDS from a medical to a social challenge

The global HIV incidence probably peaked in the late 1990s but is declining very slowly and at a veryhigh cost. With the current trend, costs will increase threefold and there may still be one million newinfections by 2030 (Hecht et al., 2009). Even if effective treatment is available, the cost of universalaccess to it is unrealistic (Bongaarts and Over, 2010). This calls for new ideas for approaching theHIV/AIDS pandemic.

In industrialised countries, HIV/AIDS is mainly contracted by individuals, of both sexes, who aredrug users and sex workers or by men who are homosexual whereas none of these groups dominatesin the HIV/AIDS statistics in sub-Saharan Africa (UNAIDS, 2009). If HIV/AIDS is an infectious diseasethat is theoretically fairly easy to avoid compared to an airborne disease like tuberculosis or a vectorborne disease like malaria, then it is pertinent to find out why HIV/AIDS is so widely spread throughoutthe population in sub-Saharan Africa.

As an infection, HIV/AIDS is caused by a virus that is transmitted from person to person throughexchange of bodily fluids, mainly semen and blood. Prevention can thus be a matter of using vaccineand/or condoms. This is reflected in the overwhelmingly strong consensus in the medical researchcommunity that we should address the HIV/AIDS pandemic by promoting the use of male/femalecondoms and ultimately by developing a vaccine. Even if all medical expertise seems to agree thatfinding a vaccine for HIV/AIDS will be enormously difficult, time consuming and expensive, there seemsto be an agreement that a vaccine is the only solution (Desrosiers, 2004; Simon et al., 2006; Titti et al.,2007) as clearly illustrated by Walker stating that ‘the global need is absolutely desperate, and this isan endeavour that must be pursued, now with greater passion than ever’ (Walker and Burton, 2008).The debate on vaccine is thus epitomised by Bernstein’s claim that ‘there cannot be any alternative’(Bernstein, 2008). In transition theory terms, the regime consists of a strong alliance between medicaland pharmaceutical research, funding organisations, health services and corresponding governancesystems such as ministries, regional authorities and/or NGOs.

A closer look at the data on the HIV/AIDS prevalence shows that women in SSA have a much higherprevalence than men and in some countries young women are up to eight times more likely to beinfected than men (UNAIDS, 2010). For biological reasons women are to some extent more vulnerableto HIV/AIDS but this is not enough to explain the staggering figures (Mukherjee, 2007) especially notin South Africa where young women (15–24) account for ninety per cent of new infections (UNAIDS,2007).

In a multi-country study in 2005, the WHO reported horrifyingly high levels of violence againstwomen (García-Moreno et al., 2005). If we reframe HIV/AIDS from a virulent disease only to thesymptom also of a social problem, then the spread of the disease can be seen as the result of violenceagainst women with unwanted sex, even rape, as one way of transmitting the disease (Dunkle et al.,2004; Mukherjee, 2007; Kalichman et al., 2009).

Gender mainstreaming is common in programmes for HIV/AIDS prevention but often with a focuson girls and young women as vulnerable groups while ignoring men as agents. A further reframingalong the lines of intersectionality could shift the focus from girls and young women as victims tomen of all ages as potential perpetrators of sexual violence (Barker and Ricardo, 2005). A focus on law

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enforcement and crime preventive measures for perpetrators of violence against women combinedwith awareness raising among (young) men could be a means to fight the proliferation of HIV/AIDS(Barker and Ricardo, 2005). This underlines the role of governance and legal enforcement and is thus atask for the regime level. A vaccine or a protective gel, which currently seems to be the most promisingtechnology (UNAIDS, 2010), may solve the medical problem but it would leave the social problem ofviolence against women unaffected whereas a feminist perspective may consider the epidemic as anopportunity to rid society of this type of violence against women as a structural problem.

In sum, we argue that fighting violence against women as a preventive measure may be a promis-ing and more persistent way forward than fighting the virus (only). Anti-violence campaigns wouldinvolve many beneficiaries already at the very start while the development and deployment of a vac-cine would bring beneficiaries only in the longer term. This draws attention to temporal aspects anddimensions of social justice. Besides, we would avoid the problem of drug resistance, because withpharmaceutical solutions the race against resistance starts immediately and this is now the most seri-ous barrier for effective containment of the disease through antiretroviral drugs (Simon et al., 2006).Finally, there are enormous ancillary benefits from ridding society of violence against women as along-lasting physical and mental social conflict with multiple causes and consequences.

The occurrence and prevention of a major disease, like HIV/AIDS, can thus, as illustrated here, beconceptualised and understood in numerous ways such as in terms of biomedicine or psychology; cog-nitive and behavioural models; political economy of health and lifestyles; or power perspectives andfeminist theory. Any one frame thus shifts the meaning and generates a different set of key questions,understandings and actions (Zierler and Krieger, 1997).

In the UN system there are at least three main units for addressing violence: the WHO, the UNICEFand UNESCO. We argue that boundary work across these entities could harness the differentiatedknowledge and experiences in the organisations and create effective ways for alleviating the doublemenace of HIV/AIDS and violence against women. In February 2010, the UN appointed the former EUCommissioner Margot Wallström a ‘Special Representative for Sexual Violence’. This position can beseen as one facilitating boundary organisation for fighting the violence against women.

We argue that the general policy cooptation in GH has created a strong regime dominated by amedical understanding involving heavy investments in bio-medical R&D and the promotion of drugsand vaccine. Important as this may be, it also creates techno-institutional lock-ins and knowledge trapswhere alternative understandings of fundamental social relations could have contributed solutionsand important ancillary benefits. From an organisational and institutional point of view, and as apositive note on this impasse, there is a closer connection between the medical and the social analyticalframes of HIV/AIDS discussed above than between the chemical and the ecological frame on malariato be discussed below.

5.2. Reframing the fight against malaria from chemistry and medicine to ecology

Malaria is the most important vector borne disease in the world and as one of humankind’s oldestdiseases it has plagued us for at least 4000 years (Cohen, 2009). The geographical area affected bymalaria has shrunk significantly over the last 100 years, from about 58 to 30 percent of the global landarea (Hay et al., 2009). But in terms of reported cases of malaria in the core areas, mainly tropical Africa,the numbers are a staggering 243 million clinical cases and 863 000 deaths in 2008 (WHO, 2010).

Malaria has been fought within different scientific frames and mostly within one single frame at atime. In a vector borne disease the pathogen is carried from one host to another by a vector such as amosquito, a fly or a worm. From a treatment point of view, vector borne diseases can be approachedeither through the vector and its natural habitat or through the pathogen inside or outside the humanbody. The earliest successful measures were entirely based on land use change and physical planningthat aimed at ridding an area of the vectors including their breeding grounds. Notably, the implement-ing institutions were responsible for land use planning and infrastructure rather than health. There areseveral good historical examples of this like the protection of the town Selinus in Sicily by the floodingof a nearby marshland in the fifth century BC; rural development in southern Italy in the early 20thcentury (Martin and Najera, 1972); the integration of malaria control and economic development inthe Tennessee Valley in USA in 1933–1979 (Gartrell et al., 1981); and pre WW-II integrated measures

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in Malaysia (Field and Reid, 1956) and Indonesia (Snellen, 1988). Improvement in these cases waslong-lasting but costly in terms of capital, labour and time.

The innovation of DDT in 1942 completely changed the malaria fight and its framing from ecolog-ical means to chemical (Sharma et al., 1991). Starting in 1948, the WHO embarked on a wide-spreadinternational campaign to control and eradicate malaria through DDT. The implementing organisa-tions were aligned with science in a common frame wherein the pesticide-oriented eradication policywas informed by an overly strong faith in certain scientific claims, such as: Pasteur’s idea that mancould eradicate all parasitic diseases; Chapin’s idea that any disease that could be prevented in partcould be prevented entirely; or that elimination of a disease from one area could be scaled up indefi-nitely (Najera, 1989). But malaria eradication failed in the 1960s due to widespread resistance, armedconflicts and population mobility (Hamoudi and Sachs, 1990; Sharma et al., 1991; Sharma, 1996).

In the early 1990s, the WHO vaguely mentioned the ecological method of vector control in ‘A GlobalStrategy for Malaria Control’ (WHO, 1993). Yet, the subsequent ‘Roll Back Malaria Programme’ (RBM)starting in 1998 was entirely focused on the use of insecticide treated nets (ITN) and had very meagreif any results; some scholars even argue that the problem worsened (Yamey, 2004). The RBM was atop-down initiative to increase the funding for insecticides, drugs and bed nets as epitomised by theJeffrey Sachs statement on malaria fighting: ‘if you invest money, you get results’ (Carter, 2002).

In 2008, vaccines, drugs and insecticides were combined in a new attempt to eradicate malaria(Roberts and Enserink, 2007; McNeill, 2008; Kappe et al., 2010). The fight against malaria was thusreframed from a chemical into a pharmaceutical and medical issue. Like previous attempts, it is basedon a massive deployment of technology underpinned by a strong conviction that global managementand control is possible and can be executed by a few influential actors. Hence, in the new attemptthere is a tight alignment between different parts of the regime such as funding (the Bill and MelindaGates Foundation), science (bio-technology) and action (the WHO).

However, the evolution of resistance, either among the vectors or the parasites, is a problem when-ever chemical and pharmaceutical solutions are deployed. The risk of resistance can be reduced byrestricting the use of chemicals and pharmaceuticals to a minimum. If the fight against malaria isreframed from a medical issue to an ecological issue we can use the analogy of integrated pest manage-ment in agriculture (Kogan, 1998). Integrated vector management could then become a new frame forfighting malaria. Such attempts are emerging but only slowly. An Internet search on scientific papersin March 2011, gives 770 700 hits for ‘integrated pest management’ and only 750 hits for ‘integratedvector management’.

Integrated pest and vector management is a complex and comprehensive process for managingpest populations but we argue that it offers more opportunities for action against malaria. It includes:planning and managing ecosystems to reduce the breeding grounds of vectors; continuous monitoringfor early detection of epidemics; protecting humans from the vectors in order to break transmissionpaths; early diagnosis; plus careful use of pesticides in order to minimise the risk of resistance. It wouldreduce the proliferation of resistance to chemical and pharmaceutical control measures and create anumber of ancillary benefits for communities in malaria prone regions. Last but not least, history showsthat the only examples of long-lasting elimination of malaria were achieved by combinations of eco-logical, chemical, technical (bed nets) and pharmaceutical measures (Sharma et al., 1991). Moreover,such management would provide the enormous ancillary benefit of turning people who are poor frompassive victims of malaria in need of international aid into active agents participating in preventionwork through ecosystem management.

From an organisational point of view, there are no global agencies today that are suitable for han-dling such integrated approaches. In the UN system there are at least four key units in the puzzle: theWHO for medical and human health issues, the FAO for land resource issues, UNEP for environmentalissues, and UNHABITAT for issues related to human settlements. We argue that scientifically and prac-tically informed boundary work can provide necessary transfer of knowledge, experience, technologyand funds between the entities; thus a simpler and more productive way forward than creating neworganisations for fighting malaria.

We have now seen how the fight against malaria has shifted over time between ecological, chemical,pharmaceutical and technical frames in various attempts either to eradicate the vector and/or theparasite or prevent the vector from reaching and infecting humans.

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A techno-institutional lock-in may develop on the regime level when there is a mutual reinforc-ing relationship between the regime and the dominant practice. If distribution of insecticide treatednets is the dominant practice for fighting malaria, then the regime gears all its efforts into creatingthe necessary infrastructure for effectively manufacturing and distributing these nets, thus blockingalternative practices. As a consequence, a knowledge trap may develop preventing the acceptance ofinitiatives from the niche level because the dominant practice has resulted in too high specialisationof practitioners. This calls for more integrated approaches as mentioned above.

In response to global health issues like HIV/AIDS, malaria and other infectious diseases the inter-national community has reacted forcefully, although not always successfully, with drugs, vaccinesand bed-nets. In-door air pollution (IAP), however, is still a neglected health hazard with very littleprogress as discussed below.

5.3. Reframing cooking from an energy and deforestation issue to a health issue

In-door air pollution (IAP) is a sustainability impasse causing respiratory diseases killing almosttwice as many people annually as malaria (WHO, 2009). Every year over 1.6 million people, mainlywomen and children, die of respiratory diseases from IAP owing to cooking over open fire (Ramirez-Venegas et al., 2006). But the problem is preventable.

A majority of the world’s poorest rural, peri-urban and urban households cook over open fireencased by three stones. In the 1970s and 1980s, the inefficient use of fuel wood was framed as arural energy and deforestation problem (Eckholm, 1975; Allen and Barnes, 1985) and as a result, thedistribution of fuel efficient wood stoves became a popular activity for many development agenciesin their quest for solutions to deforestation (Manibog, 1984). However, low adoption rates of the fuelefficient stoves meant that only marginal progress was achieved (Wallmo and Jacobson, 1998; El TayebMuneer and Mukhtar Mohamed, 2003). We argue that the failure was rooted in the scientific framingof deforestation. Foresters as regime players dominated the field with their knowledge and saw theimproved stoves mainly as fuel efficient energy savers that could reduce deforestation. This resultedin a knowledge trap.

The three stones arrangement is not only fuel inefficient but also smoky. A review of a large numberof improved cooking-stove programmes around the world indicate that many more programmes wereaimed at promoting energy saving for forest conservation than smoke reduction for health purposes(Wallmo and Jacobson, 1998). Although energy use efficiency and forest conservation are legitimatereasons for intervention, this means that science at that time prioritized energy efficiency over healthimprovements by framing cooking-stoves mainly as an energy-issue relating to deforestation. Morerecently, improved cooking stoves are regarded much more favourably by the scientific communitywhen seen not only as energy savers but also as health improvers (Ezzati and Kammen, 2002; Ezzatiet al., 2004; Sinton et al., 2004; Bailis et al., 2007; Sagar and Kartha, 2007; Berrueta et al., 2008). Thehealth effects of cooking in smokeless kitchens compared to the ‘three stones’ are wide ranging and wehere list four of them: (1) decreasing illness, particularly respiratory diseases, and thus lower healthexpenses; (2) less time needed for collection of fuel wood leading to increasing opportunities forchildren and youth to attend school and for women, given the intersectional labour division, to planand perform more productive tasks, or to experience more leisure time; (3) lower demand for woodresulting in less deforestation and reduced greenhouse gas emission; and (4) improved conditions forbiodiversity and other environmental qualities.

Results from our intervention research in western Kenya in 2007–2011, where we collaborate withpeasant farmers in small-scale experiments on domestic energy efficiency, show that subsistencefarmers are eager to adopt an improved stove if reframed from an energy issue (fuel efficient stoves)into a health issue (smoke free kitchens with flue-piped stoves). The project2 that we initiated, buildson local conditions, materials and expertise in subsistence farming and two main conclusions can bedrawn. First, users were more likely to adopt stoves when these were reframed into a health issuewhile energy saving followed as an ancillary benefit. Secondly, we have facilitated the adoption of

2 A film explaining the project can be viewed on: http://vimeo.com/9371888.

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the smokeless kitchen with the help of a local person who performs boundary work. We assisted himin how to combine scientific insights with a community based scheme for financing, installing andfollowing up the social learning generated from the use of the stoves (Olsson and Jerneck, 2010).

Given the severity of IAP and the availability of simple and effective solutions, it may seem strangethat there is no global initiative addressing IAP. At the landscape level of the transition heuristic, thereis a void meaning that IAP is neither addressed nor seized. In a scenario where ‘GH as a market’ isa dominating frame, the lack of a global initiative is logical because no easily defined internationalmarket players can reap the benefits. These benefits would instead be shared by at least one billionpeople who are poor and cook under health threatening conditions. In a scenario dominated by eitherof the frames ‘GH as public health’ or ‘GH as social justice’, let alone ‘GH as human right’, the IAP issuewould be a very worthwhile health initiative.

The project demonstrates that co-production on transition arenas with experiments and learningprocesses (Loorbach and Rotmans, 2006) can be successful but also very demanding. First, and as a pre-condition for co-production, we did intensive field work on subsistence farming as a social–ecologicalsystem. Secondly, and as an outcome of the project, the diffusion of stoves with flue-pipes for thesmokeless kitchen needs sustained support and feed-back from science, practice and policy. Apartfrom its health effects and ancillary benefits the initiative would be highly cost effective (Olsson andJerneck, 2010) and it may have a range of interesting and positive gender effects (Jerneck and Olsson,2011).

Inspired by the transition management cycle (Loorbach, 2010), as mentioned at the end of Section 4,and other iterative social learning processes such as Integrated Sustainability Assessment, ISA, (Weaverand Rotmans, 2006) we set up an experiment with peasant farmers on smoke-free kitchens to addressthe persistent problem of IAP. Participants in our research project in subsistence farming all sufferedthe discomfort from smoke and the health effects of the persistent problem of IAP and everyonearticulated the same problem. Based on this perception, we sought out the underlying causes of theproblem, structured the local knowledge around it and envisioned possible short term and long termsolutions with the smoke free kitchen as a common vision and image.

As researchers cooperating with and drawing on local expertise and competencies we wereinstrumental in problem structuring, in envisioning change, in designing a transition agenda andin mobilizing actors who would work in favour of the image of a smoke-free kitchen. In the criti-cal selection of frontrunners we identified: Rose as a potter for constructing the stove, her husbandLeonardo as a carpenter for building the kitchen, Boaz as a local welder and a tinsmith for welding thefluepipe, a handful of women in the village for testing the new stove with a flue pipe to be installedin their kitchen, and Benson as a technician for coordinating the activities and fine-tuning the actors’individual plans.

According to Loorbach (Loorbach, 2010) transition experiments need continuous monitoringand feedback to participants on their actions, interactions and responsibilities. Equally, monitoringinvolves collective reflections on the process and its progress. In this particular setting we were suc-cessful in identifying the problem by envisioning a more sustainable future with smokeless kitchens,in performing the participatory experiments on the transition arena and in showing how change canemerge on niches level if we build on and support community capacity. However, due to the localcontext of poverty, ill–health and weak physical infrastructure we are not yet able to perform all theprocedures. The longer term idea (and hope) is that participants will learn from the experiment andtranslate this into further problem solving, like water harvesting, and possible up-scaling.

6. Conclusions, implications and procedures

In this article we used frame analysis and reframing as well as transition theory and transitionmanagement as a multiple method of inquiry for thinking and theorising about persistent problemsand sustainability impasses in global health. Moreover, we related the persistent global healthproblems to environmental innovations as well as to climate change impacts and responses. In thediscussion, we used frame analysis to identify how the problems are encased by certain disciplinaryunderstandings. We then used the transition theory heuristic to locate three types of transitionbarriers in relation to the landscape, regime and niches level. Finally, we used reframing to change

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the perspective (ontology, epistemology, theory) from which we study the problems or to relocateand change the empirical context of the problem, or both. Such redefinitions and relocations serve thepurpose of thinking about problems in new ways and uncovering aspects that may facilitate problemsolving. To that end we also identified how boundary work across knowledge barriers may serve asa bridge between knowledge producing units and how transition management, when applicable, caninvolve stakeholders in experiments and social learning.

Concerning frame analysis, philosophers and linguists have discussed the implications of the layer-ing between and within frames as well as the interaction between layers (Coyne, 1985; Lakoff, 2008).The differentiating between frames, their layers, messages and messengers is demanding and timeconsuming. This complexity makes frame analysis somewhat heavy and inaccessible and it can be hardto determine when the full picture of a problem has emerged. In addition, reframing presupposes lat-eral thinking across disciplinary, interdisciplinary and transdisciplinary boundaries. Nevertheless, the‘polymorphous quality’ of frames (Coyne, 1985: 340) is a strong reason for identifying and examiningthe actual frames that circumscribe our thinking and postpone sustainability transitions.

Regarding the process of problem understanding, reframing as a critical method is productive for:seeking its roots; identifying agents; making hidden structures, actors and power relations visible;reaching a fuller scientific understanding of an issue and its drivers; finding alternative explanationsand presenting them within frames conducive for problem resolution. Regarding the process of prob-lem resolution, reframing as a critical method is productive for: revealing incomplete solutions and/orundesirable consequences of incomplete solutions; discovering missed opportunities and identifyingadditional benefits of alternative solutions; assessing potential solutions, identifying agents of changeand suggesting action. Reframing is thus a powerful tool for linking critical research with problemsolving research (Cox, 1981) as we did here. In order to illustrate reframing in practice we include aprocedural scheme in Fig. 2.

On a final note, the article contributes to methodology for sustainability science by combining frameanalysis and reframing with transition theory and transition management into a thinking tool forsustainability challenges. The analysis demonstrated how three persistent problems in global health,impasses, relating to environmental and climate change can be understood in new ways when studiedthrough alternative scientific frames. Thereby, we can conclude that reframing is a creative processthat may open up new pathways towards sustainable solutions.

Acknowledgements

We collaborate in and have received contributions from the Linnaeus Programme LUCID(www.lucid.lu.se) funded by the Swedish Research Council Formas. In the research leading toour results we have received funding from the European Union Seventh Framework programme[FP7/2007-2013] under grant agreement number 227055 (GLOBIS). We like to thank several anony-mous reviewers who offered constructive advice that helped us clarify, refine and focus our argument.The article is a fully collaborative effort between the authors.

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