As the COVID-19 pandemic rages across the world, one thing is clear: this epidemic, like all others, is a social phenomenon. The dynamics of the virus, infection and immunity, not to mention on-going efforts to revise and improve clinical care, and endeavours to develop medical treatments and vaccines, are a critical part of the unfolding story. So, too, are peoples’ social responses to the disease and interactions with each other. COVID-19 is revealing, reinforcing, and catalysing new social and cultural relations; laying bare inequalities and anxieties, discrimination and division; but also galvanising solidarities and collective action.
These reactions will in turn drive changes in the epidemic curve, and how the pandemic unfolds. As anthropologists who worked on the West African Ebola epidemic, it cannot be emphasised enough that we ignore these social dynamics at our peril. If we do, they will undermine the assumptions on which current plans are being based, and cause us to miss vital opportunities. Instead, we need to understand and learn from them – both in real-time, and from past epidemics.
COVID-19 – the science is not settled
At the end of last week, as debate raged over the evidence for the ‘science-led’ UK government response to COVID-19, Radio 4’s Evan Davis expressed relief on twitter that the government’s strategy relies on epidemiologists and not social scientists, whom he referred to as ‘the amateurs’. Yet this week the UK Chief Medical Officer in a briefing at the Academy of Medicine explicitly acknowledged that ‘the science is not settled’, that models are provisional, and that multiple inputs and contestation are welcome. Now, more than ever, is the moment for embracing a plurality of views, including those of social scientists and of the people experiencing this epidemic and mobilising in innovative ways.
We are told this is a once-in-a-century public health, economic and political crisis. The now infamous Imperial College modelling report concluded ‘no public intervention with such disruptive effects on society has been previously attempted for such a long time’. Yet residents of Guinea, Sierra Leone and Liberia would probably take a very different view. The years 2014-2016 and the Ebola epidemic are startlingly similar to the upheaval Europeans and Americans are going through now and we can learn much from them as we navigate unchartered (for us) waters. Drawing on these experiences, and the shock of COVID-19 arriving in our own lives, three themes stand out as needing broader disciplinary engagement.
1. Navigating the uncertainties of pandemics
Pandemic events, unfolding in our fast-paced, mobile, urbanising world, are characterised by uncertainties, as reflected in the current science-policy controversy. These exist at several levels, and in different public and personal domains, including ambiguities regarding scientific evidence i.e. what it is and how to interpret it, uncertainty regarding health messaging and the public response and individual worries and questions for those vulnerable to more severe disease or with loved ones who are. How to navigate such uncertainty from the perspective of policy makers and frontline agencies is a key question.
Modelling assumptions and uncertainty
Current public health responses are based on epidemiological models, such as the above-mentioned Imperial College model. They make many assumptions, including what is necessary to count or not. For example, the Imperial model focuses on numbers of cases reaching hospital, with the central concern around keeping hospital cases within the ‘surge’ capacity for critical care. With this focus, the only people worth testing are those that gain hospital admission. This in itself incorporates the assumption that hospital capacity and critical care are the key areas for focus.
The use of models in policy also makes assumptions about social responses and people’s behaviour, such as the argument that there would be ‘behavioural fatigue’ with respect to dramatic containment measures. This notion of fatigue, and an evidence base around it, was presented last week by the UK government as informing decisions of what interventions were possible, and when they should be timed, all of which has now been questioned. To date, it is still not clear what behavioural evidence is being used and how.
Inevitably, models miss social issues, such as the patterns through which people interact, or the social issues affecting who gets to hospital, or the ways in which social class influences what measures people are able to take and the extent to which they are able to be cared for, or in turn take care of others.
Used alongside mathematical modelling, social science can certainly nuance the models, and improve their parameters, as well as providing evidence of the gaps between the assumptions and the social realities on the ground. It can explain why things might not pan out as expected, and uncover unintended consequences of interventions.
Learning from the Ebola epidemic
The Ebola epidemic in West Africa in 2014 provides an exemplar of a situation that was shot through with uncertainty, and where modelling assumptions proved to be inaccurate. One CDC model predicted up to 1.4 million cases which thankfully did not occur, in part because the model had not factored in people’s social responses and the large scale behaviour change and community-driven actions which emerged. Instead these models focused on clinical isolation capacity which translated to a huge effort to build beds and hospitals as a key pillar of the response. However, in many locations the curve of the epidemic came down before such beds were built, and by the time they were ready, they remained empty.
It is not new to say that models make assumptions, or that ‘a model is only as good as it’s assumptions’. Even so, the implication is that the model just needs to be tweaked with new evidence or a new assumption. But there is a larger point: in contexts of uncertainty we don’t just need better models, we should question the singular (or dominant) use of models in scientific advice to government. Situations of great uncertainty point urgently to the need for respectful engagement and pooling of diverse perspectives. We need a range of evidence to be brought to bear on the problem of pandemics, and both expert and experiential knowledges. There needs to be space for iterative reassessment and deliberation, where a plurality of views can be brought to bear on the problem, and to define the key questions, the focus and aims.
2. Social vulnerabilities and inequalities
Vulnerabilities to disease are social and political, as well as biological. The framing and consequences of government responses can also have biopolitical implications for those who are vulnerable, as certain groups of people end up being more vulnerable to mortality than others. Outbreaks lay bare social and political inequalities. In some instances, we know who the vulnerable are and can help direct attention towards them. Here in the UK, attention has been drawn in recent days to homeless peoples, as shelters face closure in the face of COVID-19. However, other groups might be rendered vulnerable by the outbreak but not be easily visible. In this respect, attention needs to be broadened from a focus on the medically vulnerable, to those with very limited social networks and/or limited economic means.
Head teachers in Inner London, for example, are concerned that the closure of schools will prevent children currently receiving free school meals from accessing nutritional food, and generate widespread food poverty. We also need to keep an eye out for those whose livelihoods depend on social interactions and relations which make ‘household quarantine’ impossible. Considerations of social differences and vulnerability need to be incorporated into the assumptions about the public’s ability to comply with control measures and advice (e.g. are the current measures much too middle class, given that official advice is to have food delivered if you are in home isolation?). Equally, are important heterogeneities and inequalities further obscured in the averages that are characteristic of mathematical models, hiding pockets of vulnerability?
COVID-19 and global health inequalities
Assuming a global lens, COVID-19 will reveal inequalities in health resources, particularly in countries without universal access to health care. The precarities engendered by the deepening social inequalities of the neoliberal economic order are likely to intensify the suffering that an outbreak brings. What do the models predict for such settings? As the coronavirus has spread from China, to South Korea, to Iran, to Italy, it has already become a dreadful real time case study of the political and social processes that underpin disease preparedness and response. We are seeing how disease outbreaks play out in settings with different histories of public health, with past disease experiences, with differently-resourced and structured health systems, and with different forms of public authority, religious institutions and state-citizen relations. As the disease spreads further, mortality rates are going to vary, and global healthcare inequalities are likely to be laid bare in stark ways.
In contrast to recent epidemics, we see an inversion of the usual outbreak imaginary of the global North rushing to contain a disease spreading from elsewhere – usually a distant, exotic or poor locale. Currently it is Europe posing a ‘threat’ to poorer countries. But with Europe gripped by coronavirus and turning inwards, will there be global solidarity to assist the most vulnerable countries, sharing relevant knowledge for local experts to adapt? Will there be sustained attention to ensure an equitable sharing and access to the global public goods that we are racing to develop, the antivirals and vaccines that we hope will bring greater certainty to this grave situation?
3. Collective action from below
Anthropological analyses, such as that by Paul Richards (2016), have suggested that locally developed and community-level actions contributed significantly to turning the tide in the West African Ebola outbreak. This appears to have happened to some extent through the structure and authority of the chieftaincy, but also in reaction to them in situations where trust in elites, government or foreign intentions was limited. In 2019, Melissa Parker and others demonstrated that there were instances in which villagers resisted formal kinds of public authority, including chieftain authorities. Instead, they organised themselves to provide care, impose locally-acceptable kinds of quarantine and, where necessary, carry out burials. Even in urban settings, there were neighbourhood groups carrying out case identification and organising support. In our Wellcome-funded Pandemic Preparedness Project we are doing real-time ethnographic work to capture such creative responses. We are asking if such local responses to an outbreak can be harnessed by national preparedness initiatives. But underpinning work is the realisation that no response is possible without the requisite resources, the ‘staff, stuff, space, systems’ that Paul Farmer (2014) pertinently referred to for Ebola.
There are lessons from these experiences for COVID-19, and for us now in the UK. Coordination of community initiatives is an essential part of collective response. We have already seen here how COVID-19 has brought spontaneous social organisation. The last few days have seen institutions, trades unions, councils and neighbourhoods taking collective action, partly in response to a perceived lag in government action. How are models factoring in such heartening twists in social dynamics?
Learning and adapting to pandemics
It is key at this juncture to reflect on what we know from past outbreaks in other parts of the world, such as the Ebola outbreak in West Africa or the Avian Influenza event in South East Asia. In a fast moving and changing world, all kinds of uncertainty will emerge. We need leaders who will listen and adapt. Clear government directives from above are key, but we also need good coordination of local action. Let’s also trust people, and their inventiveness, and listen to a range of experience. Participatory action and responses from below will make all the difference, especially in the face of limited local authority resources. Here in the UK, the ‘staff, space, stuff and systems’ are significantly greater than elsewhere, but these resources have also been eroded. We must continue to ensure that the public health responses and the difficult issues related to trade-offs will receive adequate reflection. We have in the UK an environment where scrutiny is possible, and from a range of perspectives. We need to keep up that scrutiny and argue for a plural, deliberative form of politics that can sustain critical voices.