Sustaining policy promise: rhetorics of disease elimination and sustainable development

Abstract

The focus of this paper is the discourse of the ‘endgame’ of disease elimination linked to the 2030 Agenda of Sustainable Development Goals (SDGs). The aim is to explore how policy promise is sustained in the face of faltering progress, such as when targets are missed or appear unreachable. Viewed via Lauren Berlant’s work on the ‘cruel optimism’ of unmet promise, with Ben Anderson’s work on affective attachments, the analysis looks first at the 2030 SDGs and then at disease elimination through the examples of hepatitis C and HIV. The materials for analysis include political declarations, global progress reports and strategy documents. These materials sustain imaginaries of a universal endgame promise as if there cannot be an otherwise. We see how ‘crisis’ is enacted to account for failure as well as to sustain promise. We also see that the threat of failure gives rise to recalibrated promise in what might be described as an emerging ‘elimination otherwise’. Here, the figure of crisis affords increasing attention to disease elimination as a ‘problem of the social’. Discourses of the disease elimination endgame act as sites of potential, even in crisis.

Introduction

Hope for millions of people in the developing world affected by HIV is no longer utopia but evidence-based… My message today is really one of hope. Not mere optimism, but hope, based in reality, such is the real progress we have now made in expanding global access to HIV treatment… Hope, but not complacency, that with the resources and knowledge and the political will we now have, we can rise to the challenges ahead of us and finally end the AIDS epidemic. (Kazaktchkine, 2008)

In his keynote address at the 2008 International AIDS Society conference in Mexico, Michel Kazatchkine, who was at the time Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, accentuated the technological promise of scaled-up HIV treatment as a concrete ‘evidence-based’ hope, not mere utopian imaginary. 5 years earlier, the WHO had launched its ‘3 by 5’ initiative rooted in a target to treat 3 million people living with HIV in low- and middle-income countries by 2005. These targets were missed, with less than half of those targeted treated. While ‘progress was made’, ‘momentum built’ and ‘invaluable experience’ gained (WHO 2006), the missing of targets drew attention to the social and structural complexities of delivering on technological promises to end AIDS as well as the ‘danger of jumping from one ambitious target to another’ (Lancet Infectious Diseases 2006).

HIV has emerged as a significant driver and symbol of disease elimination promise in the field of global health (Sandset 2024; Parker 2024). But the disease elimination endgame has a much longer history (Packard 1997; Greenwood 2009; Staples 2024), and brings together multiple diseases—malaria, tuberculosis, leprosy, hepatitis C and so on—into a singular space of elimination promise (Adams 2016). Moreover, the endgame of disease elimination connects with, and is made possible by, a wider discourse of endgame linked to global Sustainable Development Goals (SDGs). Global declarations to end diseases are flagship features of the United Nations 2030 Agenda of 17 SDGs, which pledge, among other things, to end poverty, violence and hunger in the world by 2030 (United Nations General Assembly 2015). SDG 3 aims to end the epidemics of AIDS, tuberculosis and malaria, and other communicable diseases, as well to combat viral hepatitis, by 2030. The WHO has framed the end period of the SDGs as ‘the decade for disease elimination’ (WHO 2019; Khawar et al. 2023). Through its global health sector strategies (WHO 2015, 2016a, b, 2022), and linked progress reports (WHO 2021, 2024a, b), WHO coordinates efforts to achieve the elimination of hepatitis, HIV, malaria and tuberculosis globally by 2030. A mix of technological and pharmaceutical innovation, intervention investment, science-based projection and policy promise has given rise to an affective atmosphere of anticipated disease elimination in global health. As 2030 nears, there is an opportunity to investigate how the rhetorics of global policy promise—indexed to disease elimination as well as wider SDGs—work as a discourse of endgame.

Enacting disease eliminations

In epidemiology, disease elimination is held distinct from eradication. Whereas disease elimination is usually defined as the deliberate reduction of a disease to zero cases in a specific geographical area, eradication is the reduction of a disease to zero cases worldwide (Dowdle 1998). In the case of global efforts to eliminate hepatitis C—a prime focus of our analysis here—epidemiological definitions of disease elimination have been tweaked towards more flexible predicates as the elimination of ‘public health threat’ and are not defined in terms of a threshold of absolute cases or as the absence of disease (Hellard et al. 2020). The global elimination of hepatitis C as a public health threat was defined, in 2015, by the WHO in population percentage point targets to be reached by 2030, as 90% of people living with hepatitis C diagnosed, 80% of people living with hepatitis C treated and 80% of new infections reduced (WHO 2016a).

Disease eliminations are open to multiple interpretations. National strategies to ‘end AIDS’, for instance, may aim to ‘virtually eliminate’ HIV (where the target threshold for cases is above zero) at the same time as ‘ending HIV transmission’ (where the target is eradication to zero cases) (Sandset 2024; Khawar et al. 2023). The evidencing of disease elimination targets also draws on indirect and uncertain indicators, usually modelled projections affording considerable latitude (Rhodes and Lancaster 2021a; Staples 2024; Sandset 2024), and are sometimes immeasurable (Grietens et al. 2019; Artenie et al. 2022), even contested as fabrications (Lockwood 2002; Meek 2021). Even while quantifiable metrics are imagined to ‘offer uniform and standardized conversations’ in global health, they are ‘frequently impossible to get and frequently misleading’ (Adams 2016, 6–8).

The disease elimination endgame, it has been said, is also made up of ‘eradication dreams’ (Henderson 2006; Whitty 2015; Packard 1997). The ‘eradication dream’ can appear as an ‘absence-presence’ of disease elimination discourse. The promissory narratives of disease elimination in science and policy—‘ending AIDS’, ‘eliminating hepatitis C’ and becoming ‘malaria free’—invoke notions of eradication and the absence of disease even as they are evidence-based on targets otherwise defined (such as projected reduced cases against modelled estimates of populations at risk). Despite smallpox being the only human disease eradicated, and past disease elimination efforts falling short of promise—with malaria and leprosy elimination failures among the best documented (Greenwood 2009; Li et al. 2019; White 2020; Staples 2024)—the disease elimination endgame is infused by a utopian impulse anticipating a world that is free of disease. The affective lure of targets as forms of promise in policy counts for at least as much as their veracity as calculable measures (Callon and Law 2005; Rhodes and Lancaster 2021a).

The promise of disease elimination furthermore presents as a compression of unprecedented opportunity with immense challenge. The disease elimination endgame calls for an intensification of effort to keep countries ‘on track’ in a ‘final push’ to ‘get over the line’ (White 2020; Lancaster and Rhodes 2022). This means that the endgame hones attention towards the contingencies of elimination promise (Whitty 2015). In global health, the disease elimination endgame is generally understood as the ‘final stages’ when the ‘goal seems in sight’, but when ‘operational targets typically become time-limited because the intensity of the effort required is too great to be maintained indefinitely’ (Klepac et al. 2013). It is often said, for instance, that it is in the endgame of disease elimination that the social and structural contingencies of pharmaceutical promises—such as the scale-up and impact of test, treat and vaccine interventions—are made apparent (Whitty 2015). The discourse of the disease elimination endgame is a site in which promise and expectation are recalibrated in relation to challenge (Michael and Rosengarten 2013; Rhodes et al. 2009, 2024), including of governance through failure (Lancaster and Rhodes 2021).

This analysis

The analysis here reflects on how the discourse of the endgame enacts promise, especially in the face of challenge or failure, such as when targets are missed or appear unreachable. This is a timely question to ask when so many pledges, goals and promises in global health and sustainable development appear to be faltering. Looking at the cases of faltering progress in relation to SDGs and disease elimination targets to 2030 (UnitedNations 2023, 2024a, b; WHO 2024a, b; Cooke et al. 2024), the analysis builds on scholarship attending to how targets in policy make, rather than merely describe or represent, realities (Rhodes, Lancaster 2019, 2021b; Lancaster and Rhodes 2021; Grek et al. 2024). Attention is drawn to how the discourse of the endgame ‘works’ as a site of reflection and resource in the affordance of promise. The discourse of the disease elimination endgame, as past stories of disease elimination show, is incorporative of failure, and this is critical to how the performance of promise, as well as the endgame itself, is sustained. The analysis below traces how failure is put to use as an engine of promise. It suggests that the discourse of endgame does not necessarily signal an ‘end’ but the promise of an end; that there is rhetorical play afforded in the end-game.

Materials

Quantifiable targets are prime materials in the enactment of disease elimination promise and wider SDGs (Rhodes and Lancaster 2021a, b; Grek et al. 2024; Sandset 2024; Adams 2016). The analysis focuses on three case examples: the wider case of SDGs, and disease eliminations in relation to hepatitis C and HIV. The discursive materials for analysis include political declarations, policy progress reports and strategy documents, as these are used to sustain promise, anticipate futures, justify investments, and account for progress. The prime materials are: the United Nations General Assembly Political Declaration of the High-Level Political Forum on Sustainable Development (United Nations General Assembly 2023); WHO’s Global Progress Report on HIV, Viral Hepatitis and Sexually Transmitted Infections (WHO 2021); WHO’s Global Health Sector Strategies on, respectively, HIV, Viral Hepatitis and Sexually Transmitted Infections for the Period 2022–2030 (WHO 2022); WHO’s Global Hepatitis Report (WHO2024a, b, c); Australia’s Sixth National Hepatitis C Strategy (Department of Health and Aged Care (DHAC) 2023); and the UNAIDS progress report against 2025 targets The Urgency of Now—AIDS at a Crossroads (UNAIDS 2024; United Nations General Assembly 2025).

Analytical approach

Discussion of the above materials is shaped by the theoretical work of Berlant (2011) and Anderson(2023a, b) on attachments as forms of promise. Attachments are ‘enduring trajectories that bring closer something which comes to feel necessary to a way of life’ (Anderson 2023a, 392). The ‘objects of attachments—whether a person or a place, a song, or a nation, or anything else—come to be encountered as promises’ (Anderson 2023a, 392). Attachments are a ‘special type of relation, through which an ‘object’ becomes promissory’ (Anderson 2023b 209). Attachments thus circulate in an ‘affective atmosphere’ (Anderson 2014, 2023a). Crucially, attachments enact optimism ‘even when those attachments might be cruel’ (Anderson 2023b, 214). In Cruel Optimism, Berlant (2011) writes that ‘a relation to cruel optimism exists when something you desire is actually an obstacle to your flourishing’, and that, importantly, ‘these kinds of optimistic relation are not inherently cruel’. A relation of ‘cruel optimism’ occurs when attachments do not realise their promise, and in so doing, reproduce a harmful situation or damaging potential, which can contribute to a sense of ‘latent’ or ‘exhausted’ agency. Attachments are a way of enabling life to be lived, even when the promise of something better appears fantastical:

Even when it turns out to involve a cruel relation, it would be wrong to see optimism’s negativity as a symptom of an error, a perversion, damage, or a dark truth: optimism is, instead, a sense of negotiated sustenance that makes life bearable as it presents itself ambivalently, unevenly, incoherently. (Berlant 2011, 14; Anderson 2023b, 215).

Attachments are hard to give up, and sometimes impossible to detach from, even when the promissory object feels out of reach. This is because attachments serve to sustain (Anderson 2023b). Cruel optimism comes about in a situation of ‘stalled detachment, a holding on too long, as the relation itself becomes sustaining and harmful, and as threat and promise blur and are rendered indistinct’ (Anderson 2023b, 2017). While hard to give up, attachments are also ‘a continual movement that continually (re)constitutes the promise of an object’, and this can become noticeable in a crisis situation (Anderson 2023b, 215). The goals and targets of global health policy are considered here as attachments of promise. In the face of challenge—when targets appear unreachable—there is the potential for cruel optimism. It is in these moments—when threat and promise entangle—that we can treat the discursive materials of policy as sites for tracing how promise is (re)constituted as the performance of ‘negotiated sustenance’(Berlant 2011). How is promise sustained in failure? How do objects of promise—here, disease elimination targets and SDGs—attach or detach in moments of crisis? These questions are important to ask because they relate to the capacity for agency in moments of crisis (Berlant 2011). While universal targets in global health might be seen to circulate in a discursive world of imaginaries some distance from the ‘real worlds’ of the everyday, they cannot be pulled apart from, and impact on, what is thought possible and made doable (Meek 2021; Grek et al. 2024; Parker 2024; Sandset 2024).

Case 1: sustaining promise in sustainable development goals

In September 2023, the United Nations Summit on the SDGs met to consider progress at the halfway point to 2030. None of the 17 SDGs, set in 2015, looked to be met. The official website of the United Nations devoted to the monitoring of targets linked to the SDGs declared that ‘promise is in peril’, with the SDGs ‘disappearing in the rear-view mirror’, as was ‘the hope and rights of current and future generations’ (United Nations Department of Economic and Social Affairs Statistics 2023). A ‘global rescue plan’ to ‘save humanity’ was launched, with a new Political Declaration published by the United Nations General Assembly which sought to ‘re-affirm’ commitment to ‘realise the vision’ of the 2030 SDGs, despite not one of the goals looking achievable by 2030 (Tollefson 2023; United Nations 2023).

Taking the Political Declaration as our source material (United Nations General Assembly 2023), the first rhetorical device that we can see at work is repetition. Promise is sustained by repeating it into continued existence: ‘We reaffirm our commitment to effectively implement the 2030 Agenda and its SDGs, and uphold all principles enshrined in it’ (2/12). ‘We reaffirm’, ‘We commit…’ and ‘We recommit…’ reiterate different aspects of promise throughout. Repetition in the redelivery of promise intensifies the ‘urgency’ to act between ‘now and 2030’. There is particular emphasis given to the theme of ‘acceleration’ with promise of action becoming ‘immediate’, and with efforts ‘scaled-up’ to make them ‘transformative’. The language of reproduced promise is escalating, with the voice of commitment becoming more urgent and louder.

The prime rhetorical figures mobilised in the Declaration are failure and crisis. Rather than being neutralised, resisted or excused, as sometimes happens when governing institutions are called on to account for their faltering progress, failure is here, within certain limits, constituted as an affordance. Progress is in ‘peril’, ‘slow’ and ‘reversing’, and there is ‘alarm’. A ‘crisis’ is enacted. Crucially, crisis is invoked at once in relation to the faltering progress of the 2030 Agenda and of the world more generally. While failure is put to use to re-energise promise, there is a causality by implication that situates faltering progress in uncontrollable crisis conditions. Not only are the SDGs in crisis (‘The achievement of the SDGs is in peril’; ‘We are alarmed that the progress has slowed on most of the SDGs’), but the world is in crisis too: ‘Our world is currently facing numerous crises. Years of sustainable development are being reversed’ (2/12); ‘[There are] multiple interlinked crises that are pulling our world to the brink’ (4/12). The ‘multidimensional impacts’ of Covid and of pandemic receive special mention, alongside the ‘cascading global crises’ of climate change, conflicts, displacement, cost-of-living, food insecurity and gender inequality, and we are told that ‘the world was already off track in achieving the majority of the SDGs before the COVID-19 pandemic’ (4/12). The narrative of crisis produces a looping effect of reciprocal causality, offering a framing for why SDG goals are failing while reaffirming the SDG goals as the solution to crisis: ‘Without immediate course correction and acceleration of progress toward achieving the SDGs, our world is destined to face continued poverty, prolonged periods of crisis and growing uncertainty’ (4/12). Dystopian imaginaries are never far away in the narration of utopian ones (Thaler 2019; Moylan 2020).

2030 as an endpoint is here not unsettled by crisis but further entrenched. The Declaration makes a ‘call to action’ framed in relation to ‘turning our world towards 2030’, as if 2030 is a certain kind of ‘known’ future that is perhaps already made and waiting, were the world to find out how to get there. In narrative terms, a singular benchmark of calendar time, 2030, stands in as the utopian threshold, a target endpoint, meaningless without its discursive context, to materialise a transformed world universally shared. At the same time, this is a future which cannot be known, and which appears doomed to fail, according to the science-based reports giving rise to the crisis that the Political Declaration of the United Nations General Assembly seeks to navigate. It is in these narrative looping effects that the sustaining of the SDGs in themselves becomes aims and ends as much as the ‘actualities’ of sustainable development in practice. The Political Declaration is a call for survival of the 2030 Agenda as an infrastructure in the sustainability of promise. As has been noted of the SDGs:

Even when targets are unachievable, drawing the goals themselves, specifying the parameters that need to be measured to achieve them, validating and harmonizing them across contexts and datasets, are all critical material underpinnings for expanding and sustaining the SDG infrastructure well into the future (Grek et al. 2024).

At the same time, the Political Declaration detaches from the science-based report (UnitedNations 2024a, b) on the empirical particularities of targets and their faltering progress, to which it links as a ‘rescue plan’, to accentuate a meta narrative of affective attachment in relation to ‘global solidarity’, and ‘cooperation at all levels’, to ‘promote a systemic shift’, to ‘benefit all’. The science-based evaluations contained in the SDG progress report halfway to 2030 question the endpoints and potentials of targets: ‘Of the 36 SDG targets reviewed […], only two were on track as of 2023’; ‘Moving back the deadline by a decade or two won’t help—on the current trajectory, model projections suggest that the world will not achieve any of the SDGs even by 2050’ (Malekpour et al. 2023, 251). The 2024 progress report on the SDGs is framed in relation to three intersecting themes—‘promise in peril’; ‘a world in great upheaval’; and ‘a moment of choice and consequence’. The report claims that ‘progress has ground to a halt or been reversed across multiple fronts, despite reaffirmed pledges’ (italics added) (UnitedNations 2024a, b). It therefore argues that the ‘time for words has passed’. It calls for ‘the Political Declaration [to be] translated into actions’. Despite its own projections of targets being missed or unreachable, the report holds on to the possible: ‘It is still possible […] but the clock is running out’ (UnitedNations 2024a, b). Likewise, other global actors indicate that despite ‘wiped out advances’, there are ‘reasons to be optimistic’, in an ‘ongoing SDG push’ to ‘show what is possible’ and that ‘the future is hopeful’ (United Nations Development Program 2023). Attachments to promise under challenge move from the probable to the possible.

The Political Declaration extends beyond, and largely avoids, the technocratic language of targets and calculus to speak of generalised hope. The crisis performed in relation to the SDGs is put to use to reiterate a grand promissory narrative of common vision, ‘for the common future of present and coming generations’, ‘for all nations and peoples and for all segments of society’ and ‘for people, planet, prosperity, peace and partnership, leaving no one behind’ (United Nations General Assembly 2023). Goals and targets fold into, and intensify, stories of affect and hope, including here in the absence of precision or calculus. And while they falter—that is, while there is still time before failure has come to be—targets circulate in the atmosphere of the ‘as if’. The Political Declaration holds on to the promise of a transformed world by 2030, offering a narrative of carrying on, more or less as if the same. The endgame is a discourse of sustainability because it enables promise and action to carry on, even in the face of crisis.

The danger in this, of course, is the doubting of governing institutions and their legitimacy, including of science and its credibility. A ‘science-based’ approach claims accountability to an actuality via robust measurable and actionable targets. Otherwise, targets and goals can become problematised as nothing more than ‘fictional expectations’ (Beckert 2016), as nothing more than politics, things that are simply said. For some, political declarations and global pledges have become a ‘theatrical charade’ of ‘cliches’ and ‘platitudes’, and even ‘lies’, that ‘recycle ancient promises’ (Horton 2023). Sustaining promise in the face of faltering progress is not without risk.

Case 2: recalibrating promise in disease elimination targets

In a similar pattern, global science and policy progress reports act as sites of reflection in relation to disease elimination targets at their halfway point to 2030. Looking at the specific case of hepatitis C, progress towards elimination is said to ‘have stalled’, with efforts ‘not on track’ (Lancet Gastroenterology & Hepatology 2024). In 2024, WHO’s Global Hepatitis Report indicated 58 million people living with hepatitis C, with those dying of viral hepatitis as a leading cause second only to COVID-19 (WHO 2024b). Around 36% of people with hepatitis C have been diagnosed and around 20% treated, well short of the 2030 diagnosis and treatment targets of 90% and 80%. There are 18% reductions in new infections against WHO’s original elimination target of 80%. Only 11 countries are ‘currently on track’. For instance, the proportions treated at the end of 2022 were estimated at 3% in the African region, 9% in the European region and 15% in the southeast Asia region. WHO’s progress report makes clear that ‘the world is still far from achieving its elimination by 2030’ (WHO2024a, b, c, vii). Global projections, revised in 2024, are that ‘targets will not be realised’ (Heath and Hill 2024).

A characteristic response in the field was that: ‘We must not fall into despondency’ and that ‘there remains a short window of opportunity in which to act’ (Lancet Gastroenterology & Hepatology 2024). The endgame narrative in the face of challenge is a familiar one: projected failures of ‘not being on track’ and of being ‘behind’ are mobilised to ‘accelerate progress’, to ‘scale-up’ and to ‘act now’ (Tollefson, 2023; Malekpour et al. 2023) The missing of targets, and even the improbability of these being reached, co-exists with elimination promise sustained as ‘a challenge, but within reach’ (Lancet 2022). And here—in the invocation of elimination improbability—there appears to be a subtle discursive shift towards recalibrating promise in the hepatitis C endgame. Progress reports give emphasis to using the next monitoring period of 2024–2026 to ‘regain the trajectory to achieve the SDGs’ (WHO 2024b, vii). Recognition of time and opportunity lost sits alongside reiterated promise. We are told that ‘the global response is off-track towards 2030 goals’, but that ‘if action is taken now’, there will be ‘major public health impact’, including ‘reducing incidence by 90%’ and ‘mortality by 65%’, as per 2030 targets, and we are also told that the ‘benefits of achieving global targets will be apparent by 2030’, with their full impact realised ‘looking towards 2050’ (WHO 2024b, vii, 11). The ‘window of action to regain the trajectory to achieve the SDGs’, while not appearing to alter the promise of elimination by 2030, recalibrates expectation, including by reference to 2050 as an extended endpoint linked to 2030 targets. The language of ‘regaining the trajectory’, and of ‘getting back on track’, enables the rationing of expectation linked to opportunities lost even while 2030 targets are reiterated as reachable.

As with reaffirmations of commitment to the SDGs, the recalibration of promise in hepatitis C’s endgame is linked to a ‘backdrop of crisis’, especially the COVID-19 pandemic (WHO 2021, 1). The latest strategy documents emphasise that: ‘The COVID-19 pandemic has altered the landscape of global health by shifting resources, drawing attention to the gaps in health systems, and exposing and exacerbating the disparities and inequalities that make some populations more vulnerable to disease’ (WHO 2022, 7). Global progress reports introduce COVID-19 as a ‘disruption’ which has ‘hampered progress’ but which offers ‘lessons’ in addressing the ‘setbacks caused by the pandemic’ (WHO 2021, v; WHO 2022, 3). While the pandemic is the prime character in this crisis narrative, ‘climate change, population displacement and economic insecurity’ also give context to our ‘unprecedented time’ (WHO 2022, 8). Critically, the narrative of crisis, and the figure of the pandemic specifically, serves to connect disease elimination promise with inequalities and inequities. In recent strategies shaping the final years of elimination effort to 2030, such as ‘End Inequalities. End AIDS’ by UNAIDS, the causal connections between inequalities and eliminations are less implied, and there is an explicit move ‘to use an inequalities lens to close the gaps that are preventing progress’ (UNAIDS 2022). WHO 2024b Malaria Report likewise situates elimination as contingent on ‘addressing inequity in the global malaria response’ (WHO 2024b). In hepatitis C’s endgame, biomedical promise entangles with social change in the lessons learnt from COVID-19: ‘Rapid progress on COVID-19 vaccines has re-energised the global health community and has provided renewed hope for other innovations; yet it has also exposed deep inequities in access to such innovations’ (WHO 2022, 7).

Disease elimination as a problem of the social

Faltering progress thus enables the recalibration of elimination as a problem of the social. In the opening paragraphs of WHO’s global health sector strategy 2022–2030, it is made clear that an approach is required ‘to remove structural and systemic barriers to accelerating progress’ (WHO 2022, 2). Explicit linkage is made between inequities and disease elimination in the achievement of wider SDGs (WHO 2022, 2). The language of a common and collective effort, driven by ‘rights’ and ‘equity’, where no populations are ‘left behind’, becomes more prominent in the global health sector strategies as 2030 nears (WHO 2022, 9). Disease elimination as a ‘problem of the social’ is performed through the infusion of the ‘social and structural’ in a ‘person-centred’ approach. This move decentres disease in the elimination effort:

They [epidemics] are also shaped in similar ways by social and structural determinants of health, such that communities facing poorer socioeconomic conditions, or discrimination, including discrimination experienced by key populations, experience greater vulnerability to infection and worse health outcomes. Putting people at the centre of rights-based health system responses—by organising services around people’s needs rather than around diseases, and by promoting integrated patient-centred approaches and linkages with primary healthcare services—is the key to ending these epidemics. (WHO 2022, 5)

We are moving from disease to dis-ease in the endgame, even if articulated as an intervention of person-centred care within health system responses, rather than as a broader sweep of transformative social action as imagined in the goals of sustainable development. The ‘ending of stigma’ enters as a prime figure of promise in the move towards what we might term ‘dis-ease elimination’ strategy to take us to 2030. The endgame to 2030 is calling attention to scaling up disease-based interventions as not enough:

The large expansion in services that is required to achieve 2030 targets will not be achieved unless it is accompanied by efforts to address the stigma, discrimination, inequalities, and criminalization of key populations which exacerbate the risk of infection and prevent many people from accessing essential services. (WHO 2022, 8)

In WHO’s envisioning, ‘addressing stigma, discrimination and policy barriers’ is action which largely takes place ‘within the health setting’ (WHO 2022, 8). Action 8 of WHO’s 2022–2030 strategy to end epidemics is to ‘eliminate stigma and discrimination in health care settings and strengthen accountability for discrimination-free health care’ (WHO 2022, 31). It is the ‘health sector’, and ‘communities’, that are responsibilised to act through raising awareness, delivering training and monitoring standards in efforts to overcome discriminatory or stigmatising behaviour (WHO 2022, 7–8). Research in the time of hepatitis C’s endgame has emphasised how ending stigma is contingent on actions which extend beyond health systems to include other legal, insurance, employment and policy infrastructures (Seear et al. 2023; Fraser et al. 2022). Qualitative studies informed by critical theoretical approaches call for an elimination approach which looks beyond the disease, for instance, calling attention to the ‘residual stigma’ which does not end ‘post-cure’ and stigma which locates more generally to drug use and dependency (Kagan et al. 2023). While locating disease elimination as a ‘problem of the social’, the ‘key operational shifts required to eliminate’ in the WHO 2022–2030 strategy to end epidemics are not unfamiliar, and in relation to hepatitis C’s endgame, largely accentuate more of the same, through ‘massive expansion’ and ‘continued investment’ to ‘increase treatment access’ and ‘promote simplified service delivery models’, alongside efforts to ‘address the barriers’ and ‘strengthen community and civil society engagement’ (WHO 2022, 5). The recalibration of promise towards eliminating dis-ease as a contingency of disease elimination, and specifically, the operationalisation of elimination as a ‘problem of the social’, are moves in the making. The ‘elimination otherwise’ is a project in progress.

National strategy in the face of failure

We can also trace recalibrations of promise in national hepatitis C strategy. Australia is an interesting case because the country demonstrated early progress in the endgame, with declarations of ‘being on track’, and even ‘ahead’, as an ‘international leader’, in the global hepatitis C elimination effort (Dore and Hajarizadeh 2018; Kwon et al. 2019). Australia anticipated elimination sooner than global targets, by 2026 (Kirby Institute 2017). But Australia’s anticipated elimination ahead of 2030 targets is a troubled project, with progress slowing in the endgame. Australia looks ‘no longer on track’ (Kwon et al. 2021; Razavi et al. 2020). Modelled projections suggest that targets may not be reachable by 2030 (Scott et al. 2020). The evidencing of progress has not been without controversy (Rhodes et al. 2024). In reflections among experts, the COVID-19 pandemic features as a ‘set-back’, from which there is opportunity to ‘re-engage’, to ‘get to the other side’ of elimination promise, having ‘laid the foundations’ (Dore 2021).

In accounts reflecting on national elimination progress and future strategy, there is a shift from ‘more of the same’—a focus on the challenges of ‘finding the missing’ through upscaling, simplifying and decentralising community-engaged ‘test and treat’ services—towards an ‘elimination otherwise’; a reflexive negotiation which recalibrates the biomedical promise of ‘treat and treat’ in relation to the contingencies of social and structural change. There is a detectable shift from epidemiologically-infused questions of ‘who’ is missing and how they might be reached, towards more sociologically-infused questions of ‘what’ might be missing in service systems and responses and how conditions are created in which people are missed, marginalised and failed (Treloar et al. 2024).

The opening claims of the latest Australian national hepatitis C strategy covering the remaining years from 2023 to 2030 do not hedge their bets: ‘By 2030, hepatitis C will be eliminated as a public health threat in Australia’ (Department of Health and Aged Care (DHAC) 2023, 1). ‘Everyone will have equitable access’ to services. People impacted by hepatitis C ‘will live free from stigma, discrimination and racism and lead healthy and productive lives’. The stated intent of the Strategy is to shift from ‘a disease and transmission-centric focus to one that also considers quality of life and the needs of people post-cure’ (Department of Health and Aged Care (DHAC) 2023, 1). Disease elimination is made contingent on ‘interventions which remove discriminatory social, structural and institutional conditions’ (Department of Health and Aged Care (DHAC) 2023, 4). Elimination goals ‘will not be achieved without addressing the inequalities that drive the hepatitis C epidemic’ (Department of Health and Aged Care (DHAC) 2023, 4). In the Australian example, we see how strategies are materials which not only respond to contingency but which constitute the narrative terms of the endgame; devices which make noticeable as well as re-make particular versions of elimination possibility.

Afterword: endgame promise in a field of crisis

While this paper has been under peer review, there has been increasing attention, since January 2025, to the crisis of international funding that threatens disease elimination progress and the promise to ‘end AIDS’ (Brink et al. 2025; Sibanda and Phillips 2025; Matanje et al. 2025; Ooms et al. 2025). Most critical is the withdrawal of US funding support for PEPFAR, the President’s Emergency Fund for AIDS Relief, alongside reductions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNAIDS has estimated an additional 6 million new HIV infections, and 4 million AIDS-related deaths by 2029 if the pause on PEPFAR’s funding becomes permanent (UNAIDS 2024; United Nations General Assembly 2025). Modelling shows that the most optimistic of estimates anticipate a 50% increase in new infections in the next 5 years in sub-Saharan Africa, with upper estimates projecting increases as high as 280% (Brink et al. 2025; Sibanda and Phillips 2025). In South Africa, for instance, the funding cuts are projected to result in 500 000 new HIV infections and a life expectancy loss of 3.7 years among people living with HIV (Gandhi et al. 2025). Global modelling projections suggest the ‘potential for all the gains made since the year 2000 to be reversed’ (Sibanda and Phillips 2025, e317). The crisis of funding could make it ‘impossible to achieve target 3 of Sustainable Development Goal 3 [to] end AIDS as a public health threat by 2030’ (United Nations General Assembly 2025, 3/19).

At the halfway point to 2030, global targets to end AIDS, like those of viral hepatitis, were ‘not on track’ (UNAIDS 2024; United Nations General Assembly 2025, 4/19). Despite ‘remarkable gains’ towards 2025 targets, ‘the world will fall short of these targets’ (United Nations General Assembly 2025, 4/19). There were 39% fewer new HIV infections in 2023 than in 2010, but three times as many as the 2025 target, and there were around 50% fewer AIDS-related deaths in 2023 than in 2010, but twice as many as the 2025 target (UNAIDS 2024). Global policy reports present the ending of AIDS as at a ‘crossroads’ (UNAIDS 2024). The figure of ‘funding crisis’ looms large in deliberations at the United Nations General Assembly in June 2025. Key targets for 2025 were said to be ‘within reach for some countries’ but this was ‘prior to the recent seismic shifts in funding for the global HIV response’ (United Nations General Assembly 2025, 3/19). There is a revision of expectation: ‘The goal of ending AIDS as a public health threat by 2030 was in sight; we had made tremendous progress. All of that is in serious jeopardy’ (Burki 2025, 1). At the General Assembly, progress otherwise judged to be falling short of targets is heralded as ‘one of the most powerful health success stories of our time’ with the crisis of funding said to ‘shatter the possibility of achieving the 2030 goal to end AIDS’ (United Nations 2025a). Faltering progress against 2025 targets is presented as ‘nearing the finishing line’ since ‘the world is tantalizingly close to ending the AIDS by 2030’ yet at risk of ‘backsliding due to shortfalls in funding, lack of political will and intersecting inequalities’ (United Nations 2025a). Progress, while not on track, is ‘cause for celebration, for hope and for inspiration, at a time when many of the other Sustainable Development Goals are wildly off track’ (UnitedNations 2024a, b). We are also reminded that the ending of AIDS is no ‘mystery’ but a ‘choice’ made in ‘solidarity’; a call for action in which we have collective control. Endgame promise is recalibrated in the face of fiscal crisis as a need for urgent reform to ‘international financial architecture to massively increase affordable finance’ alongside efforts to ‘increase domestic revenue collection’ and an ‘expansion of national health and HIV investments’ (UnitedNations 2024a, b). We are told that ‘we cannot let short-term cuts destroy long-term progress’ (United Nations 2025b). In the face of threats to the sustainability of promise, progress is made to matter multiply, at once faltering and not enough at the same time as ‘immense’, ‘remarkable’ and ‘tremendous’ (UnitedNations 2024a, b; United Nations General Assembly 2025; Burki 2025).

The progress reports at the halfway point to 2030 do not let go of elimination hopes to end AIDS by 2030, as defined in the primary target of reducing the number of new infections and deaths by 90% compared with levels in 2010. But they contain qualifications as to what ‘elimination’ means and how targets recalibrate in relation to time. It is said that ‘even if the world achieves the 2025 targets and sustains those gains, there will be almost 30 million people living with HIV in 2050’ (United Nations General Assembly 2025, 15/19). It is also acknowledged that ‘if HIV programmes remain on their current course’ there will be ‘about 46 million’ people living with HIV in 2050; that is, ‘17 million more’ in 2050 ‘if the HIV response is not boosted to meet the 2025 targets’ (UNAIDS 2024). The rhetorical values and affordances of the 2025 targets do not wane or fall away as they are missed or as time moves on, but rather, they are re-made as features of the present and future, as targets going forwards. In looking ahead to ‘the final five years leading to the culmination of the 2030 Agenda’, it is noted that ‘political, financial and programmatic sustainability will require immediate, medium-term and long-term visions for meeting the 2025 targets’ and that this is about maintaining and accelerating progress ‘through 2030’ as well as ‘beyond 2030’ (United Nations General Assembly 2025, 17/19). Elimination is further qualified as not the end of AIDS, should it be the case that 2025 targets are achieved in the future: ‘Even if the 2025 targets are met, it will not amount to ‘the end of AIDS’. The world will still be contending with a major public health challenge’ (UNAIDS 2024, 218). Ending AIDS as a public health threat is qualified further as ‘strong progress towards ‘disease control’’ (UNAIDS 2024, 219). Here, the language of ‘disease control’ is said to ‘avoid a misleading and premature sense of success’ (UNAIDS 2024, 219). Recalibrations towards disease control feel like a far cry from the affective lure of earlier elimination claims.

Discussion

As 2030 nears, we can investigate how rhetorics of global policy promise are themselves sustained in the face of challenge. The materials considered above—global declarations and reports of progress in relation to targets of disease elimination and sustainable development—allow us to see promise as a ‘discursive-material’ accomplishment (Barad 2003). Tracing how discursive materials work to sustain promise in the face of challenge attends to promise as an emergence that is open to being reproduced and remade (Anderson 2023b; Berlant 2011). Just as utopian visions of future—in narratives of science, policy and beyond—need dystopias in order to be performed (Thaler 2019; Moylan 2020), we get to see how the figure of crisis is put to use as an engine in the sustainability of promise; an evidence-making event not merely of disruption and loss but of ‘negotiated sustenance’ (Berlant 2011).

Promise out of failure

Crisis emerges as a prime rhetorical figure in political declarations and policy reports accounting for progress in relation to 2030 targets. Invocation of crisis works to diffuse, and account for, the sense of faltering progress linked to missed, and even unreachable, targets. The crisis enacted in policy materials presents as a moment of our time that affects us all. It is at once extraordinary and everyday (Berlant 2011). While global and multidimensional—linked to pandemic, finance, environment, climate, conflict and so on—it presents as a shared state of exception, a ‘commons’, that extends beyond the local particularities of policy goals and targets. Rather than deflecting the spectre of failure, the crisis narrative polarises attention to dystopian alternatives of lost hope to restate utopian imaginaries of the sustainable disease-free world. Global progress reports do not hold back in their articulation of threat, talking of promise ‘in peril’, of progress ‘reversed’ and of the urgency to ‘save humanity’. Promise and progress are here tied to crisis (Masco 2017). This performs as an agency of sorts because projections of threat seek to unleash a ‘process of acceleration’, which calls for ‘urgent mobilisation for action’ and ‘collective synchronisation’ in response (Wigen et al. 2021, 1). In a crisis, ‘everyone starts to move faster, run and yell’ (Wigen et al. 2021, 1). We see these traces in the repeated calls for ‘accelerated’, ‘urgent’ and ‘immediate’ action, and calls for ‘action’ and not only ‘words’, as well as in the affecting language of global reports, as 2030 nears.

Carrying on ‘as if’

Most significantly, the invocation of crisis enables policy promise to carry on, ‘as if’. Crisis governs by holding in place existing promises, goals, targets and infrastructures. Targets are binding attachments for a better future that cannot be let go (Anderson 2023b). Just as crisis drives policy, and promise, at least as much as ‘actual progress’ (Masco 2017; Jordheim and Wigen 2018), the discourse of the endgame does not necessarily signal an ‘actual end’—to world affliction and disease—but affords the promise of an end. Endgame rhetoric allows for play, an end-game. The endgame stories of disease eliminations, and their failures, evolve over years, even decades, and may never reach an end (Greenwood 2009; Parker 2024; Meek 2021). The disappearance of leprosy, for instance, is enacted as an immanence of the perpetual near future no matter how much time passes, with WHO’s initial elimination target of 1991 long since passed (Meek 2021). The endgame is a special type of discursive-material relation, a promissory attachment, which must be held open. In Excitable Speech, Judith Butler draws attention to how discursive acts derive their energy from their own in-built failures in order to perform anew (Butler 1997). Berlant notes how genres of promise incorporate room for failure—‘moments of potential collapse that threaten the contract’—as matters of their convention (Berlant 2008, 4; Duschinsky and Wilson 2015). This is how unmet and utopian promise gets sustained as cruel optimism in lived constraints (Berlant 2011). The discursive materials of the endgame are, in a way, making ‘good out of crisis’ (Wright 2022), to sustain a ‘transformative utopian impulse’ of global policy; a ‘necessity of hope in today’s global order’ (Moylan 2020; Basso and Krpan 2022). Endgames allow for the incorporation of failure to keep promise alive ‘as-if’; a holding on to attachments as if they are not in existential trouble or open to alternatives.

Reproducing the present

It is well known that crisis framings tend to homogenise by simplifying the multidimensional spatial and temporal elements of complex and incalculable events—like wars and pandemics—into singular configurations which call for collective actions (Vigh 2008; Roitman 2014; Masco 2017; Anderson 2021; Wigen et al. 2021; Wigen 2022). Presented as a moment of diagnosis in the face of incalculable truths, crisis eludes precision and determinacy and does not require these to work rhetorically (Roitman 2014; Anderson 2021; Wigen et al. 2021). The claim to crisis does not need empirics (Roitman 2014). The materials of policy promise, as we have seen, detach themselves from the technical language and empirical complexities of target measurement. Threat, rather than the details of progress, serves to carry on promise (Berlant 2011; Anderson 2023b). In this way, crisis framings of disease elimination detract from opening up more nuanced understandings and reproduce existing responses over experimenting otherwise (Wigen 2022; Anderson 2021; Anderson et al. 2025). Here, crisis can threaten agency by creating stasis and repetition in a narrative of ‘perpetual’ threat (Masco 2017; Vigh 2008; Roitman 2014, 2022).

Berlant emphasises how the ‘ongoingness’ and ‘ordinariness’ of crisis relates to a ‘latent’ and ‘exhausted’ agency as a kind of ‘slow death’ (Berlant 2007). It is possible to see how the ‘ongoingness’ of unreachable elimination targets enacts a relation of cruel optimism. Previous work has emphasised how universal targets are damaging in their simplifications, including the fantasy of zero disease (Arora-Jonsson 2023; Beckert 2016; White 2020; Grietens et al. 2019; Sandset 2024; Staples 2024). Most obvious is the indexing of the endgame to 2030, a singular point in calendar time. This might work as aspirational rhetoric to garner collective action as time is running out, but is an imagined synchronisation with far-reaching consequences. Disease eliminations (should they be possible and measurable) do not evolve in time predictably as singular events but generate a multiplicity of lifetimes; of entangling viruses, humans, institutions and policies as well as social effects with afterlives (Wigen 2022; Staples 2024). The reproduction of promised targets is a carrying on ‘as if’ which reduces heterogeneity, limits experimentation and encourages a reflex of precaution by holding on to existing attachments (Barker 2012; Masco 2017; Rhodes and Lancaster 2023). The perpetuation of disease elimination as an immanence no matter how much time passes—as targets are missed and promises unmet—can contribute to inaction, disinvestment and loss of hope, as the cases of leprosy and malaria show (Meek 2021; Staples 2024; Greenwood 2009).

The elimination otherwise

Yet, faltering progress in the disease elimination endgame to 2030, as we have seen, also affords recalibrated promise as a contingency of the ‘problem of the social’ giving rise to an ‘elimination otherwise’. The ‘elimination otherwise’ de-centres disease and its pharmaceutical management as a contingency of social and structural conditions. Crisis draws attention to disease elimination as a matter of eliminating dis-ease, prompting new and revised targets which orientate towards the ending of inequalities, discrimination and stigma (Treloar et al. 2024), and the building of infrastructures less reliant on the aid of wealthy nations (Matanje et al. 2025). Experts say of disease elimination that it is ‘the last stage where technical, biological, social and political problems occur’ (Whitty 2015). The ‘last mile’ of the endgame is said to be ‘the longest mile’ (Klepac et al. 2013). From zoonotic interactions, emergent drug resistance and the unpredictable effects of climate change, as in the case of malaria, to systemic challenges and stigma, as in the case of hepatitis C, disease eliminations are ‘off track’, beyond pharmaceutical control and even made impossible, given ecological contingencies. How faltering progress is performed as a ‘problem of the ecological’, and how ‘the social’ is incorporated as a tool of governance in crisis technology, as well as hope for change, is an important element of the endgame (Anderson 2021). Our conception of disease elimination endgame is shifting, from disease to dis-ease, from the promise of pharmaceuticals alone towards the belated realisation of necessary social change. Here we see the potential for detachments in how objects are recalibrated as promise in moments of crisis (Anderson 2023b). The endgame is an opportunity to embolden structural interventions in ‘dis-ease elimination’ efforts. The decentring of disease in an ‘elimination otherwise’ starts to ‘up-end’ 2030 targets of zero disease as fantastical attachments.

Positive alternative futures

Joseph Masco suggests that instead of a ‘crisis-utopia circuit’ that situates future as caught between narratives of ‘collective collapse and constant improvement’, that crisis now, post twentieth century, features in a ‘crisis-paralysis circuit’ which privileges imaginaries of catastrophe (Masco 2017, S65-S68). In Masco’s analysis, there is a ‘crisis in crisis’ today because configurations of perpetual existential danger totalise existing conditions as the experience of repeated failure rather than generate positive futurities. In the materials of global health policy linked to SDGs and disease elimination targets, we can still see traces of a ‘crisis-utopia circuit’, with universal promise sustained in the ‘in-between’ of failure and hope for the better (Anderson 2023a). At the same time, it is true that global targets and progress measures are caught up in a rhetoric of perpetual crisis that has become extraordinary and ordinary at the same time, and in which improvement via structural change is hazy (Berlant 2011; Roitman 2014). The reproduction of unreachable promise becomes a cruel optimism if this suffocates the potential for acting otherwise, for instance, by generating ‘nonutopian but positive futures’, of ‘non-crisis-riven everyday life’ and of ‘not yet cruel optimism’ (Masco 2017). We need to get the balance right.

Getting the balance right

In endgames of global health promise, targets are aims and ends in themselves (Grek et al. 2024; Tichenor 2017; Rhodes and Lancaster 2021b). Reaching targets constitutes disease elimination and drives action, at least as much as measured actualities of disease (Rhodes and Lancaster 2021a). The 2030 Agenda is an uncomfortable mix of the aspirational and actionable, elusive and attainable, abstract and measurable. Part of the challenge is methodological. Targets are missed and unreachable, but also often immeasurable. Targets of disease elimination, for instance, have been described as ‘pseudo measurements’ in the sense they are ‘real in their adherence to paradigmatically valid methodologies’, yet ‘fake’ and ‘empty of empirical significance’ (Grietens et al. 2019). An evidence ‘as if’. In hepatitis C’s elimination, science carries on ‘as if’, in the service of sustaining promise, even as scientists knowingly engage with models and measures as ‘currency’, in a ‘conversation’, to do the ‘right thing’, and with targets that can feel ‘arbitrary’, ‘unrealistic’, ‘unachievable’, as well as ‘impossible to measure’ (Rhodes and Lancaster 2021a). This is one aspect of ‘virtual elimination’; a disease elimination state that comes to be ‘as if’, in the performances of calculations and claims. Leprosy elimination declarations offer one such example (Lockwood 2002; White 2020; Meek 2021). The incredible latitude afforded by universal targets—which reside in vague predicates and projections which can ‘stand in’ as data (Sismondo 1999) —might serve to sustain utopian imaginaries, for a time, but they also threaten the credibility of science and policy. When targets become questioned as ‘pseudo measurements’ of ‘fictional expectations’ or as ‘virtual’ or ‘fake’ (Beckert 2016; Grietens et al. 2019; Lockwood 2002), and even as forms of ‘platitude’ in endgame gameplaying (Horton 2023), there is an urgency to reflect on fundamental yet often side-stepped questions about what kind of policy and science is produced in the performativity of promise. There are collateral effects, fundamental to trust in science, policy and other institutions, in the reproduction of unreachable promise, an endgame perhaps of its own:

From the glorious Arcadia of the Sustainable Development Goals to the Promised Land of prosperity and security, political leaders have created a stage for dishonesty dressed up as vision, for pretence robed in conceit. And we in academia aid and abet. (Horton 2022, 1571).

Conclusion

We can consider the genre of the endgame as an affective scene in which there is a cluster of promises that shapes agency in the dialectics between the lived and the fictional (Berlant 2011; Anderson 2023a). While performed as holding on ‘as if’ to an ‘evidence-based’ expectation, the endgame is a site of affective attachments negotiating the in-betweens of the elusive and the attainable. Targets constitute an endgame because they bring into the present a difference in a trajectory of optimism; a moving on, an ‘ending’ anticipated, a new state of being (Anderson 2023a). This is why we cannot talk about targets without also talking of affects. The affective lure of targets-as-promise affords their power-of-acting at least as much as their scientific claims to calculability and universal commensurability (Callon and Law 2005; Rhodes and Lancaster 2021a). The endgame cannot be handled simply ‘as if’ an observable event of factual progress made but is an embodied sensorium (Berlant 2011). In addition to investigating targets and goals as measures of evidence-based standard and quantifiable progress, we can seize the moment of the endgame to enact the discursive materials of science and policy otherwise, as affective attachments. Doing so is part of the reflexive work necessary to detach from the ‘as if’ of policy promise and move towards attainable futures of the ‘elimination otherwise’.

Data availability statement

No data are available.