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Reflections on the public health response

Prof Daniel Bausch and Prof Melissa Parker reflect on this outbreak.
MELISSA PARKER: Well, my experiences are very much shaped by the work I did with the Ebola response anthropology platform, which ran during the West Africa outbreak in 2014 to 2016. And during that time– reflecting on those experiences– it’s become clear that while policymakers and practitioners made every effort to assess the information that they were being given, whether it was biological, clinical, social, or political, they made every effort to do that in a very neutral and impartial way. The reality is that in the course of an outbreak, that’s little more than impossible. And that, of course, creates huge problems in terms of tailoring programmes to very unique and specific sociopolitical contexts.
DAN BAUSCH: I think what we really need to understand is the connectivity of our planet. And so there is physical connectivity. You have more people travelling than ever before. And then there’s the virtual or media connectivity– more people communicating. And so if we look at the three respiratory disease outbreaks that we’ve had so far in this century, the SARS outbreak in 2003, the 2009 H1N1 influenza outbreak, and now with COVID-19, we have a drastic increase in travel across the planet, and a drastic increase in communication across the planet, which are double-edged swords. They give us the capacity to respond, but they also give us challenges.
So at this point in an outbreak, we need to recognise, first of all, that technology in itself is not sufficient, that these viruses often move faster than us. So a strong public health messaging is important. Policy-wise, we need to make sure that we have an evidence base, that we’re communicating, we’re out in front of the rumours and all the things that flow around. If we don’t communicate effectively, the space will be filled by, often, misinformation. So that’s extremely important. And then I think we’re also looking at a situation where we need to think about prevention, but we also need to think about mitigation.
And what I mean by that is if we fail to contain this virus, if it circulates all over the world, what do we do then? And can we identify, for example, the people who are most likely to have severe disease, prepare in terms of number of beds, health care workers, ventilators? So a lot of tasks to be done.
MELISSA PARKER: Well, it’s a huge challenge for them. You can have the most wonderfully detailed and thoughtful and sophisticated policy in the world, and the very best health professionals that have been trained for a specific disease in the world, but if it is not adapted to the specific context in which a particular programme is being rolled out, it might not work, or it will have much less impact than it ought to have. So I think there’s a huge role for anthropologists in assisting with this kind of work. But it also presents a huge challenge for them, because their understanding is by its very nature very specific to a particular unique sociopolitical context. And how do you generalise from that?
How can you upscale at speed in the way which is necessary if you’re trying to contain an outbreak?
I think it’s quite clear that COVID-19 is taking us all into uncharted territory. But it’s also quite clear that the virus is going to have a very different impact, not only between countries, but also within countries. So I’ve just come back from Uganda, where I’ve been doing work on pandemic preparedness on the DRC-Uganda border. But I’ve also been working at a district level and at a national level. And if I put all that together, I can see how the national policy that’s being designed at the moment is going to rely a huge amount on self-isolation.
And thinking about how that might work out in practise, it’s clear that such a policy might be quite effective in, Kampala, for example, where an urban elite might live in houses where there’s plenty of rooms, and there’s the possibility to self-isolate. But if you take that policy to a village setting, where you have large numbers of people living in a single mud hut, what does self-isolation actually look like? Is it actually even viable or feasible? Where is someone meant to go if they’re sharing a house with 12 other people? I think it also presents problems in terms of thinking about care, and what that will look like.
If you have a moral duty and obligation to visit those who are sick, how on earth, with all the best risk communication in the world, are you going to counter the expectation and the desire to come and see people, to care for them? And the idea that someone’s just going to stand a metre away when there might not even be the physical possibility of being able to do so is hugely unrealistic.
DAN BAUSCH: So there are a lot of things that are already happening in sub-Saharan Africa. One of the strong points is that we have strong leadership and some strong institutions in various places in sub-Saharan Africa. That perhaps wasn’t the case 20 years ago. And so if we look at Africa CDC that has opened in Ethiopia in recent years, the leadership in the African regional office for WHO in Brazzaville, the Nigeria CDC, for example, there are some strong public health institutions regionally and nationally that we didn’t have 20 years ago. And so there’s a lot of good news in terms of preparedness.
But I think mitigation and preparing for widespread circulation, especially in sub-Saharan Africa, especially in some of the places where there are weaker health systems, is really one of the priorities.
MELISSA PARKER: I think the challenge really that everyone needs to engage with is, how do you create and protect a space in which the voices of some of the most marginal people in the world can be heard and brought to the table, and actually fundamentally shape the way in which policies are designed and enacted? It will be really important to move away from the sort of top-down approach of relying very heavily on risk communication and community engagement, not because those pillars have nothing to offer, but because they run the risk of actually accentuating some problems, rather than alleviating them.
I think it would be really helpful if we could create new ways of thinking about how to bring to the table the issues, challenges, experiences of those being affected by the virus, and for policy to be revised and amended in a much more dynamic and iterative way. And in this sense, I think anthropologists can play a really useful and helpful role right from the very beginning as an outbreak hits a country.
Prof Daniel Bausch and Prof Melissa Parker reflect on their experiences in outbreaks (recorded 2nd and 10th March 2020). They share their thoughts on the challenges facing policy makers both in terms of public health interventions, and adapting them to different contexts.
As you watch the video, consider the particular challenges for interventions in response to COVID-19 in your context, and key learning from this so far. For those interested in reading more from an anthropological perspective, have a look in the See Also section at the Forum on COVID-19 hosted on Somatosphere – a collaborative website covering the intersections of medical anthropology, science and technology studies, cultural psychiatry, psychology and bioethics.
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