From my balcony, I see Tampa Bay’s calm water, the Dali Museum’s distinctive architecture, the Mahaffey Theater’s empty parking lot, the balconies and porches of St, Petersburg, Florida, around me, but I see no people. It is quiet, even the dogs seem to respect the ‘self-isolation’ I find myself practicing. The COVID-19 pandemic is like a leitmotif of fear in the air this morning; recurring but neither visible nor silent. I live in a space in which the virus does not yet seem real, but I know that it is and that it will be much more palpable soon. It is a strange limbo. I am self-isolating, observing all the protections I can and yet I know the worst is still to come. It gives me a strange sense of both power and powerlessness, competing for my balance. It is this ‘off-balancing’ that most engages and disturbs me. It is the contrast between the beauty of my surroundings with palm fronds and bougainvillea, and the knowledge that millions of people are losing their jobs and have no insurance or future prospects. It is the unreality of the morning as I sit at my computer as I have for so many years, thinking about pandemics, and how this one is unlike any other I have ever researched or taught about. It is unprecedented.
I research and teach about global patterns of infectious disease. My experience with water-borne, water-washed and other water-related diseases such as dysentery, cholera and dengue hemorrhagic fever gives me a view of how people respond to a health crisis. Yet this COVID-19 is the ‘novel corona virus’ because understandings of its properties and behaviors are still unfolding. What is shared between my disease experience and this ‘novel’ current one is that their control hinges on a most difficult, intractable and recalcitrant variable, human behavior.
During the 1990s cholera pandemic, the World Health Organization (WHO) and its Latin American sister organization, the Pan American Health Organization (PAHO), worked collaboratively with the national governments of the affected countries. Together they developed strategies to strengthen public health systems, increase paraprofessional and professional medical staff and provide necessary supplies – the Three S’s (systems, staff and supplies) of disease control.[i]
Cholera is a bacterial, oral-fecal transmitted disease. To break the transmission chain, accessible and reliable water supply and effective sanitation are required. Both systems take time and money to put in place, but are possible. In 1990s pandemic, the disease was well known and means to control it were established and well tested. Its presence stemmed from the failure to provide facilities for basic hygiene. COVID-19, on the other hand, is a viral, droplet-borne disease, not well understood, and there are no established means to cure or control it. However, both pandemics depend on human behavior for their spread and continuance. And human behavior is very difficult to change.
In the 1990s pandemic, the behavior in question was immensely personal and private: defecation patterns and individual hygiene. To curb the spread of the pandemic, large population centers imported portable toilets and bottled water, endured massive education campaigns and, as people changed their behaviors, succeeded in controlling the spread of the disease. However, in extremely isolated, remote, geographically dispersed populations with well-documented distrust of authorities, the necessary change was much less responsive to public health interventions about behavior and the ‘invisible’ disease. While urban centers controlled the spread of the disease, in the rural areas of the high Andes, cholera continued to extract terrible human costs, especially among those least able to recover. Those are the communities where anthropology made a difference. Then, as now in the COVID-19 pandemic, disease makes starkly visible the underlying social cleavages embedded in history and constantly reified in social, economic and political structures. Even in these early stages of the COVID-19 pandemic, its costs are being borne disproportionally by those least able to recover.
My balcony view of the COVID-19 pandemic forces me to recognize how little has changed since the 1990s crisis. Once again, human behavior is the target of policy makers’ attempts to control the spread of a disease. Only now physical proximity is the behavior targeted by authorities, rather than addressing the underlying social and economic drivers that make social isolating behavior impossible for many to achieve. I am set off-balance by the apparent peace and calm afforded by my privilege, knowing that it comes at the cost of others’ well-being.
During the 1990s I was an outsider, a professional brought in to lead a team of researchers. The team spent a total of 18 months in the field studying people’s responses to living in the midst of a pandemic, and learning how difficult it was for people to change their behaviors even when their lives depended upon those changes.[ii] In the 2020s pandemic, I am an insider practicing social distancing and observing. The dissimilarities are striking: the 1990s pandemic was an age-old bacterial disease, its mode of transmission, duration, cause and cure well understood. Today COVID-19 is a new, previously unknownand evolving viral disease, with massive global social and economic consequences and no known cure or prevention.
The pandemics are similar because in both cases, control mechanisms target peoples’ beliefs and behaviors in order to change cultural practices and along with them, the trajectory of the disease. I am writing this in the hope that some of the lessons learned from the 1990s, particularly when seen through an anthropological lens, can guide personal and policy responses to the COVID-19 outbreak.
People responded positively to health messages during the 1990s pandemic when four conditions were met: 1) they recognized that behavior changes directly improved their own vested interests; 2) the desired behavior changes were easily and transparently measured; 3) community-based change assessment tools were developed; and 4) an end-time was identified.
The El Tor strain of cholera killed an estimated 120,000 people during the 1990s pandemic.[iii] In the first three months of 2020, 18,552 people worldwide had died from COVID-19, and at least in New York “the rate of new infection is doubling every three days” (italics added).[iv] London’s Imperial College has estimated that 2.2 million people might die from COVID-19.[v] The pure scale of the current pandemic sets it apart from anything that has ever preceded it. Never before have humans witnessed a disease spread as quickly or as widely as COVID-19. As of this writing, only Antarctica remains untouched. It is possible to scale up the lessons from the 1990s pandemic, and scale down the powerlessness of individual and groups of people by building on the following strategies:
Enfranchise people to activate their own agency. Give them something to become vested in so that behavior changes for the ‘common good,’ (for example practicing social isolation), can be seen as in their own best interests. Initiate long-term and policy changes to equalize peoples’ rights and diminish health and economic disparities, but also empower people to see the consequences of their own actions. During the 1990s pandemic, we worked with communities for 18 months initially, and then conducted a follow-up after another 12 months. The time required was not a luxury, rather, a necessity. As things fall apart, the spaces for change become available if people are ready to use them; they are sustainable only if measured and accountable.
Develop appropriate and accessible measurement tools. Anthropologists are particularly skilled at uncovering local meanings and translating them into units of measurement that reflect local understandings. This allows people to direct their attention to behavior changes within their control. Until people can measure behaviors around them, it is difficult for them to assess those changes as they occur. “Barefoot epidemiology,’ or informal tracking of the local, on the ground determinations and distributions of the pandemic provides individuals with a critical sense of efficacy and control.
Engage the community. Long-term policy changes are amorphous and abstract; in contrast, community-based actions can stimulate the community to enact immediate change. When people sharing a workplace, condominium or neighborhood see themselves as part of a community, social isolation is reduced. For instance, I am practicing social distancing both as an individual and as part of a larger, identified community looking out for one another. That combination of individual and group engaged in sharing information and resources, while not face-to-face, strengthens resolve to practice changed behaviors and normalizes those actions.
Finally, the 1990 pandemic showed that people change their behaviors and endure difficulties when they know what to expect and for how long they are to be in a crisis – both close to impossible to achieve in an evolving situation. However, temporal framing can scale down the immense to a quotidian unit that people can imagine, even if it changes.
It is now evening and I am still on my balcony, still at my computer and still social distancing. My sense of being off-balanced by the COVID-19 pandemic has diminished slightly by positioning this pandemic in its history of being one among many. Its magnitude is undoubtedly unprecedented, but the social cleavages it lays bare are not new. Nor is the human ability to change.
Linda Whiteford, PhD, MPH, is emerita professor of anthropology and a founding co-director of the World Health Organization Collaborating Center for Non-Communicable Disease at the University of South Florida. She also helped develop an innovative dual MA program with anthropology and public health. She has consulted for WHO, PAHO, USAID, the World Bank and the Canadian Agency for International Development, among other international development agencies. Her research and consulting have encompassed many countries including Cuba, Bolivia, Ecuador, Guatemala, Nicaragua, Argentina, Ghana, Cameroon and Malaysia. She is author/editor of eight books, including Global Health In Times of Violence (edited with Barbara Rylko-Bauer and Paul Farmer), and Primary Health Care in Cuba: The Other Revolution (with Laurence Branch). She is currently engaged with the University College London RReal Project applying qualitative methods to global health care, and with the Global Rapid Response Team working with highly infective diseases.
This piece was originally published in Anthropology Now (Vol. 12, issue 1, June 25, 2020). Thank you to the editors of Anthropology Now for permitting this re-publication.
Acknowledgements: My thanks to the editors of Anthropology Now for putting together a special section on COVID-19. I am also grateful for the invitation to contribute to it.
[i] Paul Farmer. “2016 Malinowski Award Lecture: The Second Life of Sickness: On Structural Violence and Cultural Humility. Society of Applied Anthropology,” 2016. Presentation, Society for Applied Anthropology Conference, Vancouver, Canada.
[ii] Linda Whiteford & Cecilia Vindrola-Padros. 2015. Community participatory involvement: A sustainable model for global public health. Left Coast Press.
[iii] Jason B. Harris, Regina C. LaRocque, Firdausi Qadri, Edward T. Ryan, & Stephen B. Calderwood. 2012. “Cholera.” The Lancet: 379 (9835):2466-76.
[iv] “Trump Expresses Outrage at Having to ‘Close the Country’ to Slow Virus.” 2020. New York Times. 3/24/2020.
[v] Neil M. Ferguson, Daniel Laydon, Gemma Nedjati-Gilani, Natsuko Imai, Kylie Ainslie, Marc Baguelin, Sangeeta Bhatia, Adhiratha Boonyasiri, Zulma Cucunubá, and Gina Cuomo Dannenburg. 2020. “Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand.” London: Imperial College COVID-19 Response Team, March 16.
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