How one medical anthropologist is boosting our capacity to understand and contend with COVID-19.
In late February 2020, I traveled back to the United States from India and Indonesia where I had been conducting fieldwork. Having researched emerging and neglected diseases for years, I recognized the potential for COVID-19 to become the pandemic that my global health colleagues and I had long dreaded. During layovers in Thailand and Japan—countries on high alert for COVID-19 and experiencing a growing number of cases—I watched nervous Asian passengers, many of whom had no doubt lived through SARS COVID 1 and H5N1 (avian influenza), don masks in the airport. In stark contrast, European and North Americans passengers went about their business, occasionally looking up at a TV monitor to watch a broadcast about a mysterious Chinese disease that had infected passengers on a Carnival cruise ship.
COVID-19 is a near worst-case scenario. By now, we are all aware that COVID-19 is caused by airborne novel coronavirus that, unlike the coronavirus causing SARS, enters the body and reproduces in the upper (not the lower as in the case of SARS) respiratory tract, causes symptoms mimicking common health problems, and is transmitted by pre-symptomatic, symptomatic, and asymptomatic carriers. The disease spreads rapidly and has a significant mortality rate; there is no magic-bullet cure and no promise of a vaccine anytime soon. Notably, we have no idea of the minimal infectious dose (MID) for COVID-19 (the number of viral particles required to start a pathogenesis cascade leading to clinical disease), no idea if and how long one is immune after recovering from the disease, and no clear idea of whether apparent immunity is due to cell-mediated immunity or antibody production post disease. Not only that, but the disease is evolving with over 30 strains of COVID-19 identified to date, some possibly more dangerous than others.
Recalling pandemics past
During the 32-hour journey home, my mind turned to practical issues. I recalled how important it had been during previous epidemics and pandemics to work with community leaders to change social norms necessary for breaking routes of disease transmission, be this the culling of sick chickens in the case of H5N1, the reduction of mosquito breeding site control in the case of dengue fever, postponing funerals and deferring memorial arrangements in the case of Ebola, or physical distancing in the case of airborne diseases like COVID-19. Kin networks, and community provision of basic resources such as food and water also proved essential when families needed to quarantine or shelter in place during Kyasanur forest disease outbreaks in South India or Ebola outbreaks in West Africa. I also recalled how necessary it had been to move beyond naïve representations of “community” to more nuanced engagement of communal factions taking into account power relations (see Wilkinson et al. 2017). Next, I thought about regions of Asia and Africa where I had recently worked, and imagined the challenges posed by seemingly simple prevention measures such as hand washing and physical distancing in urban slums, water insecure communities, and packed refugee camps sheltering the displaced. Based on past experiences, I also envisioned migrant workers hailing from rural areas fleeing cities seen as environments of heightened risk and food insecurity.
As in the case of all pandemics I have witnessed, I also anticipated an increase in the politics of othering and victim blaming, of ethnic minorities being cast as unhygienic citizens, and foreigners blamed for the origin of the disease. And I worried about the toll that COVID-19 might take on health care systems, collateral damage in the form of falling vaccination rates and rising rates of tuberculosis (TB), and people afraid to come to hospital for safe deliveries and chronic health problems demanding medical attention.
Medical anthropologists working in global health have seen this all before. And here we were again—only this time there were some glaring differences. The world was not mounting a unified and concerted effort to control the spread of this disease as was the case for SARS in 2002. Due in large part to SARS, the World Health Organization regained its leadership status eroded by the World Bank during the 1990s and became the go-to source for pandemic preparedness guidelines and response (Fidler 2004; Heymann 2006). Yet in the case of COVID-19, it appeared that each nation was left to fend for itself, come up with its own plan for dealing with the spread of the disease, and find essential medical resources in a competitive global market.
US response to COVID-19
On my return to the United States, I was quickly brought up to speed by exasperated clinician colleagues who felt woefully ill-equipped to handle a surge of COVID-19 cases and increasingly vulnerable given dwindling supplies of personal protective equipment (PPE). To buy time and not swamp the system, public health officials were calling for “flattening the curve” through “social distancing,” but it was apparent that effective leadership and a clear chain of command was lacking in our politically polarized country. Moreover, anti-science and fake news rhetoric challenged basic public health guidelines for epidemic control. I recalled the US response to H1N1 (swine flu), well-documented by Katherine Mason (2010). China abided by our Centers for Disease Control and Prevention (CDC) recommendations to lock down the country, while the United States refused to follow the same guidelines because it would threaten core American values related to liberty and personal freedom. I also remembered the anti-mask demonstrations that occurred in the United States during the 1918 flu pandemic (Canales 2020). I wondered how social distancing, the mandatory wearing of masks, and quarantine might play out this time around given the effectiveness of this strategy in Asian countries for mitigating COVID-19.
I also recalled the article that Charles Briggs and I wrote during H1N1 calling for anthropologists to pay close attention to biocommunicability (2009); that is, the competing ways of framing a disease favored by stakeholders as well as factors influencing the circulation of these representations in the press and social media, inclusive of conspiracy theories that index deep-seated social divisions. I was struck by the sheer volume of disinformation circulating about COVID and the increasing influence of trolls and bots populating online platforms and serving as echo chambers fostering polarizing mistrust in scientific data about COVID-19 (see Brennen et al. 2020; Bursztyn 2020; Health in All Matters Podcast 2020; Krause et al. 2020; Perlow 2020).
Also new in the case of COVID-19 in the United States, the federal government did not step up to the plate early as the agent promoting public health guidelines, but rather flip-flopped on the necessity and reach of evidence-based recommendations directed toward saving human lives. Greater concern appeared to be focused on the health of the economy and political fortunes. Rather than being a reassuring voice of reason, messages from the White House became a major source of misinformation, disinformation, and gaslighting with politicians undermining the advice of their scientific advisors (see for example, Roston and Taylor 2020; Sarkis 2020). As a result, our CDC ceased to be seen as a global public health leader. Indeed, I received messages from members of my transdisciplinary network located all over the globe asking me why the CDC seemed to have little influence even in the state of Georgia where it was located. The answer was simple; staff were muzzled and prohibited from talking to the press (see Kuznia, Devine, and Valencia 2020).
Being useful in a time of crises
Given this debacle, let me briefly share where I chose to focus my attention as an engaged anthropologist (Nichter 2006), and explain my reasoning for doing so. This entailed balancing “anthropology in” pragmatism with anticipatory “anthropology for” engagement, and seeing COVID-19 as an opportunity for systemic health care reform. As for a critical “anthropology of” perspective, I appreciated the efforts of colleagues exploring the biopolitics of COVID-19, but decided (like my colleagues had during Ebola [see Abramowitz 2017]) to wait until after the crises passed before doing so myself. For the moment I felt a sense of urgency amplified by personal circumstances. One of my sons developed a fever and acute respiratory symptoms that I feared might well be COVID-19. He was not able to be tested for COVID and tested negative for the seasonal flu. My family, like many families across the nation, experienced some degree of anticipatory anxiety as we watched and waited while he self-quarantined alone far from home. I also listened with compassion as health worker friends vented both about the distress they felt related to infecting their families and the difficulty they experienced expressing vulnerability within a public discourse that framed them as superheroes. Then, an African American community activist in Tucson, and former PhD advisee, contracted the virus and died. Her death profoundly affected our local community.
So what practical collaborations can a medical anthropologist contribute to during lockdown? With dual training in anthropology and public health, I decided my efforts were best spent on four endeavors. The first entailed translational research toward increasing public understanding of COVID-19. Given continuously evolving COVID-19 information streams muddied by misinformation coming from both high and low places, there was a need for a primer that kept abreast of the science and made it accessible to the public. The COVID-19 primer I created and update was initially designed for university professors to better enable them to confidently talk with their students about the disease, explain why public health recommendations about physical distancing need to be taken seriously, and offer advice about how to prevent the disease and respond in cases where mild to moderate symptoms might be indicative of COVID-19. This entails explaining public health concepts germane to an understanding of pandemic mitigation, answering questions about contagion, and highlighting lessons learned from other countries ahead of the United States in the COVID-19 trajectory.
The primer soon began circulating on several university campuses in the United States as well as overseas. I enlisted the aid of epidemiology PhD students at the University of Arizona to assist me in reviewing and fact-checking scientific articles and news summaries. Questions began pouring in, ranging from queries about the effectiveness of wearing and cleaning different types of masks to reasons for ethnic and gender differences in mortality rates, from the difference between COVID-19 tests to what is actually known about COVID-19 immunity. The primer began appearing on blogs such as Medanthcovid-19.org.
A second endeavor entailed highlighting what medical anthropology could bring to the COVID-19 research table. I began working with colleagues Kristin Hedges and Liz Cartwright as well as other members of the Anthropological Responses to Health Emergencies (ARHE) special interest group of the American Anthropological Association, to create working lists of high priority research issues. One list focuses on community and health care settings. Issues highlighted are largely gleaned from action-oriented ethnographic research conducted during previous epidemics and pandemics. Another highlights issues demanding critical “anthropology of” research. It draws attention to such issues as how COVID-related programs are framed by different stakeholders, and the ways such framing influences how interventions are rolled out; how prevalence and mortality data is being presented, misrepresented and suppressed; and how disparities in mortality rates are revealing underlying conditions of structural vulnerability. These lists along with the COVID-19 primer are available on the AHRE website, and are currently being crowdsourced.
Third, I became involved with university- and state-level COVID-19 working groups examining how best to prepare for COVID-19 testing, contact tracing, and symptom monitoring when employees and students return to work. As an anthropologist, I have tried to make the case that before introducing interventions to “the community” at large, trust must first be established within vulnerable groups (see Mason et al. 2020). Reaching out to diverse community leaders in a respectful manner and training peers to do outreach is likely to prove essential in a border state such as Arizona. The same goes for working with the leaders of different industries to assess working conditions, safety needs, and challenges to public health recommendations beyond providing one-size-fits-all guidelines and checklists. As for symptom monitoring, I have stressed the importance of monitoring shifts in subjective states of well-being, not just established signs of COVID-19. Subjective states and anticipatory anxiety need to be taken into account for many reasons, from the impact they have on blood pressure, sleep patterns, appetite, and the senses to the manner in which they influence health care seeking and self-medication.
The fourth endeavor addresses a serious gap in pandemic preparedness and response: health care worker (HCW) support. During both COVID-19 surge and disease mitigation conditions, HCW face protracted periods of time during which they place their families at heightened risk to infection. During these times, it will be necessary for many HCW to self-quarantine to keep their families safe. Little thought has been given to what kinds of support HCW will need during and after the pandemic. Such support has to be planned for with care and compassion, bearing in mind challenges for HCW and their families that go well beyond safe housing. The needs of HCW, their partners, and children include material resource acquisition, social connectivity, attentiveness to well-being as an important factor in coping with stress, and mental health support.
Along with a group of colleagues and civic leaders, I helped launch HCW HOSTED, a grassroots coalition mobilized to meet HCW needs during COVID-19 as well as future pandemic threats. It serves as a one-stop portal for all existing community and institutional support resources for HCW and their families. The health status of all HCW who sign up is monitored daily, which HCW and their families find reassuring; triage and shifts in housing are facilitated if and when necessary. HCW HOSTED is designed to be iterative and to identify emerging needs as they arise before proactively mobilizing community resources to meet these needs. It shares information about ways community members can support HCW through donations in cash and kind. And, it provides a well-documented model for community-based pandemic preparedness that may be adopted and adapted elsewhere.
In closing, let me make two points with respect to anticipatory anthropology. I view HCW HOSTED as an opportunity to do more than just support HCW during a pandemic. COVID-19 provides an opportunity to build alliances and momentum for significant health care reform. In the United States, COVID-19 has rendered transparent the fault lines of our health care system and the structural determinates of this nation’s unequal health. This is clearly evident in high COVID-19 mortality rates among minority groups, the poor, and those working in occupations with limited safeguards (see; Bailey et al. 2020; Choo 2020; Kendi 2020; Menon 2020; Rosen 2020). It is also a watershed moment when HCW and the public are bonding in a way I have rarely seen happen. Doctors, nurses, and allied HCW are being hailed as heroes. They are seen as entering precarious work environments often without proper protection and risking their lives for the common good. They are also seen and see themselves as victims of a failed health care system. Any and all ways of facilitating this bonding between HCW and the public builds critical mass needed for real-world change of our failed health care system.
COVID-19 is a health care transition tipping point. Our future is unpredictable, and it is likely we will have to learn to live with COVID -19 and its sequalae for quite some time to come. Our for-profit health care system and poorly funded community hospitals are not well positioned to respond to a scenario of public health crises and falling revenue streams. We have already witnessed health staff furloughs, salary cuts, and hospital closures mid-crises. Rallying the public in support of HCW may embolden them to be more outspoken and proactive in pushing for systemic change in this election year. We need HCW to speak up and speak out en masse in ways they have not done in the past.
COVID-19 also marks what I hope is a swing from disenchantment with science to a greater appreciation for and public interest in science. Will COVID-19 signal the end of anti-science, fake news forms of tyranny? Despite sensational new coverage to the contrary, I am hopeful when I see massive public support for Dr. Anthony Fauci and state governors who make health decisions after conferring with scientists. Organic intellectuals (see Susser 2011) and those engaging in practical, yet value-driven phronetic social science (Flyvbjerg 2001) will have a role to play in bringing about this shift, anthropologists among them.
Mark Nichter is Regents Professor Emeritus and former coordinator of the Graduate Medical Anthropology Training Program at the University of Arizona. He holds joint appointments in the Departments of Family and Community Medicine and the College of Public Health. Nichter has over 40 years of experience conducting community- and clinic-based health research in Asia, Africa, and North America. He has been the recipient of several prestigious awards including the Margaret Mead Award, the Society for Medical Anthropology’s Career Achievement Award, and the Robert B. Textor and Family Prize for Excellence in Anticipatory Anthropology.
Charlotte Hollands created artwork as well as spot illustrations of experiences from social distancing life for AN’s pandemic issue. Hollands is an illustrator, artist, and ethnographer who is developing new ways to use illustration within social science research and is currently completing her first graphic nonfiction book, written by Alisse Waterston.
Cite as: Nichter, Mark. 2020. “Engaging the Pandemic.” Anthropology News website, June 19, 2020. DOI: 10.1111/AN.1435