The data is now being analysed. But it is
clear that, since lockdowns are still in place globally for
fieldworkers and there is a hold on almost all face-to-face public
health research, Uganda may have the only systematic real-time data on
how people in at-risk communities conceptualise and respond to the
virus.
The information the assessments collected
is notable. The interviews lasted between one and three hours, much
longer than a normal health survey. Instead of taking blood samples and
asking multiple choice questions, researchers met participants in their
homes and had structured but wide-ranging conversations about access to
services, about availability of medical care and other health-related
information, and about local conventions, practices and norms —
‘culture’.
Why culture? And why invest time and
effort on things apparently unconnected with health and infectious
disease? Because infectious viruses are about social networks and
cultural norms, as much as about microbes. As science tells us, viruses
are inert, unable to attack us. We transmit viral data though our
social networks and cultural pathways. We give viral information to
each other by how we live and what we do. Otherwise viruses just sit
inert, sometimes for thousands of years. So understanding cultural
contexts is just as important as sequencing genomes in tackling viral
outbreaks.
Culture is nonetheless downgraded. Most
of the time, when medical researchers try to work culture into their
models, they fall back on tired stereotypes about local beliefs as
obstacles to biomedical care, a supposed opposition of culture and
science. In this paradigm, social scientists are lined up to help ‘real’
scientists determine why culture keeps others from doing what’s
medically recommended.
A broader understanding of culture
recognises its varied potential. Though clinicians may see culture as an
obstacle to health, it is also a source of enduring trust. Moreover, it
is not just something ‘they’ have: healthcare providers, scientists and
policymakers all have their own cultures of practice, which inform
their unique perspectives and encourage them to work together.
Cultures of practice
However, the underlying and often taken-for-granted assumptions of
culture about what is feasible can also limit innovative thinking.
That’s why we use the word culture pejoratively to describe the
intransigence of institutional cultures, political, academic or
professional. In this sense, accounting for the cultural contexts of
health and wellbeing is a primary health determinant — why ‘the
systematic neglect of culture in health and healthcare is the single
biggest barrier to the advancement of the highest standard of health
worldwide’. That’s because culture is, in fact, the key to addressing
health equity, especially when providers and target populations operate
under different shared understandings about what matters most
biologically and socially.
Thus, a cultural context of health
approach is critical in responding to Covid-19. Because governments not
previously concerned about health equity feel they must blame others for
the impact of their own negligence. Because thinking of Covid-19 as
only a medical challenge fuels xenophobic fears about outsiders. Because
humanitarian action groups talk about working with communities even as
inequalities within communities are exacerbated by the crisis. And
because, given the socially sanctioned, chronic neglect of citizens
already on the margins, Covid-19 pushes those on the edge into overt calamity coping.
The taken-for-granted assumptions of cultures of practice give us a
sense of belonging and trust, but sometimes blunt creative thinking and
social innovation. For our assumptions help little in times of
uncertainty. We know this because, when a disaster happens, so many show
up late and with outdated equipment.
What can a cultural understanding of
Covid-19 vulnerability tell us? We don’t need more research to recognise
that the elderly, the homeless and unemployed single parents are
especially at risk. They’re already vulnerable socially and
economically, and, to our shame, become even more so when their fragile
survival strategies are even more challenged.
But inequalities are always exaggerated
in a crisis, and then many initially less vulnerable people are also
pushed across capability and opportunity thresholds and into conditions
of real peril.
That is why Uganda can now tell us more
than we might expect. To understand what is happening in real time with
real people, we need, as did David Mafigiri, to assess vulnerability
before a disaster; like his own research team in Uganda, we need an
extant interest in the disadvantaged. Ongoing empathy is critical.
Without that, you have no access to what you should have known and now
can’t. Your belated concern rings hollow in the face of that failure,
which makes you liable to blame others. Indeed, organised humanitarian
action all but stops in Covid-19, as we have little way of knowing
what’s really happening on the ground among those most vulnerable, who
live alone and without access to online services.
In response to such new instability, the
World Health Organisation (WHO) rightly wants a ‘Just Recovery from
Covid-19’. That, of course, is critical. But what we need equally is a
just preparedness before an epidemic. We have to do the hard work
of creating cultures of trust and solidarity in advance, and resist
salvation narratives in which epic actions create save-the-world medical
heroes and destructive villainous viruses.
In welfare states, where trust in
government has remained relatively stable, there are few heroic stories,
because stability and a commitment to the common weal lessened the need
for bombast well before Covid-19 incited it. Initiatives such as Cities Changing Diabetes
(a Danish community engagement strategy sponsored by Novo Nordisk)
demonstrate how prior work around understanding health vulnerabilities
translates, despite its focus on a non-communicable disease, into
actionable understanding in the crisis. That is because the programme
has been assessing global health vulnerabilities since 2015, years
before Covid-19.
New vulnerabilities
Vulnerability emerges variably, at different times and places. This
means that, while already vulnerable populations become even more so
under stress, new vulnerabilities emerge that often outstrip old ones.
Service industry employees without health benefits and dependent on
daily income become more vulnerable, especially where they now have to
go back to work, than those elderly who can stay at home and wait it
out. High-income physicians without adequate protective gear are as
vulnerable as those with chronic pre-existing conditions. Places we
previously thought of as havens are anything but: in Europe and the US,
the most vulnerable are in ‘care’ institutions: nursing homes, shared
housing, prisons.
We failed these vulnerable groups because
their illness experiences are socially driven, and that is too often
separated from health. We look instead for specific risk factors in
isolation without seeing how compounding, already-existing, stressors
push populations into extreme vulnerability during a crisis — especially
those with few choices and nowhere to go. In the UK, ethnic minorities
are dying at higher rates from the virus than the rest of the
population; and in the US, African Americans have far higher mortality
rates than white and Asian American populations. Yet, as crises widen
existing rifts in societies, they also open up opportunities for
communities to come together in ways unthinkable in normal times; in Rio
de Janeiro, for instance, gangs in several favelas imposed
shelter-in-place orders to reduce transmissions.
Communities must often adapt on their
own, because political systems are vulnerable to pandemics too: the
global crisis is making clearer what is important at national and local
levels, and what is less so. It shows us what we collectively value, and
makes us reconsider often-tacit assumptions. Indeed, our judgments of
what is essential have also changed across the globe, providing a
singular opportunity for institutions and governments to rebalance
private gain and public good.
This adjustment can go either way. On the
one hand, speaking of the virus as a foreign enemy incites xenophobia,
with the social category of ‘insider’ — the ‘we’ in ‘we are all in this
together’ — getting smaller and smaller. On the other, the pandemic has
catalysed new alliances, as with Black Lives Matter and anti-police
protests. Mistrust in the institutions of government may be the only
thing uniting the far right and far left in countries like the US and
Brazil.
That is why ‘just preparedness’ matters,
and also why Uganda might lead the way in understanding the human impact
of Covid-19. Because this pandemic is not just about an infectious
threat, but about the urgency of caring beforehand, and about the steep
decline in social trust that emerges quickly in unequal settings where
global neoliberal economics have undermined public wellbeing.
Fortunately, that decline has created
opportunities in surprising places. Gangs in favelas may seem a stretch
when policymakers think about health systems change, but some
far-sighted private companies have been quicker than many governments to
recognise and respond to shifting public sentiment: sending their
employees to work from home, speaking out against racism and calling for
more government guidance. However, not all businesses are equal:
companies less vulnerable to shareholder pressure to maximise short-term
profits are better able to consider their potential long-term future
roles, and not just in the next quarter — recognising that an economy
cannot survive unless nation states and their citizens have stability,
enough income, and access to robust and well-funded care.
Mistrust in business
There have been calls by world leaders, including Ursula von der Leyen,
head of the European Commission, for a new Marshall Plan to improve
abysmal levels of trust in business recorded by Richard Edelman’s Trust
Barometer. But that mistrust can only be reversed by sustained long-term
commitments that are faithful to a range of stakeholders — including
employees, clients and the social and natural environments we all depend
upon for survival.
Divisive political leaders, like Donald
Trump or Brazil’s Jair Bolsonaro, may blame the left, or the Chinese, or
the CIA for Covid-19, based on alternative, often paranoid political
narratives that divide local communities. That is because for
opportunists, big or small, the crisis remains an intractable intrusion
into populist narrative worlds built on political delusion. But the
virus’s deadly materiality resists rhetorical defences and
counter-factual denials, even if some seem intent on taking the ship
down, or watching it sink while drowning in denial. The states lacking
welfare can only blame others.
Social trust and faith in institutions
are therefore crucial for the collective actions required to halt viral
transmission. We have to coordinate our social behaviours in
uncomfortable, inconvenient, and even personally painful ways. They are
vital to collective wellbeing and require sacrifice; a sense of
commonality and social solidarity must be based around shared values —
culture. A crisis in governance, correlates with, and can be directly
mapped onto, a crisis in trust, because where we find trust is key.
As the US pulls support from the WHO,
there is a serious question: where do we go for an independent and
trustworthy adjudication on health risk? The world’s biggest healthcare
charity, the Gates Foundation, has always espoused magic bullet answers
to health problems and is uninterested in the complex social drivers of
our wellbeing. The Centers for Disease Control is a US federal agency
that works well in good times but in bad times is vulnerable to partisan
political nonsense. Without socially trustworthy institutions, how are
we to respond to growing uncertainty?
Sustained uncertainty
And how, finally, can we learn to deal with sustained uncertainty and
the psychological vulnerability it causes? If many governments cannot
lead equitably, and viruses are just information we share, there must be
other drivers of Covid-19 we can act on. Other factors remain
under-represented: the more people there are on the planet, the more
often viruses like Covid-19, which are more contagious but less lethal
than Ebola, will connect us. And that is a big problem, not only because
science, in the absence of a vaccine, still medicalises a pandemic
almost entirely driven by our social responses, but because there are
more of us to circulate and adapt to that viral information.
This really matters with Covid-19, since,
if lasting immunity doesn’t happen soon, we need to rethink the social
contract in ways that run counter to those who advocate for
biodeterminism or xenophobic scapegoating or maximising self-interest.
Otherwise, when the pandemic abates even temporarily, we risk going back
to ‘normal’, forgetting what we might have learned until the next
infectious disease outbreak, when we will again be completely surprised
by what we should have expected. We need to consider the needy before
that happens — to put heart and soul into thinking about both how we
live together with uncomfortable uncertainty, and how we address
together the social and cultural drivers of health vulnerability.
A David Napier is professor of medical anthropology at University College London, innovations lead for Sonar-Global, global academic lead for Cities Changing Diabetes and international chair of the Robert Wood Johnson Foundation committee on the Cultural Contexts of Health and Wellbeing
initiative. Edward F Fischer is professor of anthropology and health
policy at Vanderbilt University in Nashville, Tennessee, where he also
directs the Center for Latin American Studies and the Cultural Contexts of Health and Wellbeing initiative.
Copyright ©2020 Le Monde diplomatique — distributed by Agence Global
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Released: 07 July 2020
Word Count: 2,139
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