Crisis in the race to hepatitis C elimination: modelling futures without disease

Background: In 2016 the World Health Organization (WHO) set a goal to eliminate viral hepatitis as a major public health threat by 2030. Such targets and their promise of disease elimination futures generate policy action and justify program investments, with modelling and estimates used as measures of progress. In the wake of Covid-19, models have come to dominate public imaginaries. Science studies scholar Warwick Anderson has conceptualized models as ‘crisis technologies’, that is, as mechanisms for making decisions in uncertain conditions, making certain actions conceivable. In this approach, modelling is understood as a mechanism of governance which works to fill the gap in what is otherwise unimaginable in the immediate present. In this paper, we extend this thinking to the case of elimination science. We critically examine what models do and affect as they are put to use in the race to eliminate hepatitis C, making hitherto unimaginable futures without disease both imaginable and governable through their projections of progress towards targets. 

Methods: Informed by a social study of science approach, we draw on qualitative interviews with 32 experts engaged in the hepatitis C elimination response in Australia, working within federal and state governments, universities, non-government, and advocacy organisations. Our analysis traces an event of knowledge controversy over baseline population estimates used in national surveillance and policy in the elimination of hepatitis C, examining the competing accounts of community, science and policy stakeholders.

Results: In the context of the ‘endgame’ of elimination, binary thresholds of measures of ‘success’ and ‘failure’ or being ‘on track’ or ‘falling behind’, obscure a more complex picture. As prevalence estimates are debated and troubled, the impossibility of numerical precision inherent to estimation nonetheless enacts a continued hope in the possibility of elimination as a future to be attained. The power of refusal of the impossibility of elimination – however modelled and measured – makes a crisis of a different kind, for science, for policy, and for the sector at large. Our analysis highlights how models not only anticipate futures but make-up a sense of time-space, with affective implications. We find that models produce a temporal gap in which elimination is made possible, but in inventing this space, and as the 2030 date draws even closer, the protection of that imaginary becomes a vital concern for stakeholders. 

Conclusions: As the anticipated future of 2030 imagined in the WHO targets approaches, the endgame phase of hepatitis C elimination offers an opportunity to reflect differently on what models and targets do and how they govern, in more complex ways. This analysis prompts consideration of how to live better with uncertainty in the race to elimination and remain open to multiple contingencies.