We have heard a lot about social distancing as a containment measure for COVID-19 in the past few weeks, mostly articulated as practical ‘do’s and don’ts.’ However, there has been little critical discussion about what the term actually means. Social distancing is a multi-faceted practice ridden with inconsistencies, and its implementation as a public health strategy presents many challenges. In this paper, I adopt a comparative approach to consider the very different ways in which social distancing is being deployed as a containment tool in China, Europe, and the United States. These differences, I suggest, undermine arguments of a humanistic, global approach. By way of conclusion I reflect on the situation in Hong Kong, my home city.
As a basic tenet of public health, social distancing has been understood and applied in heterogeneous ways across time and space. Since the late nineteenth century, biomedical science has elucidated the pathogenic agents of disease in ever-greater detail, but prevention measures have relied on time-honoured methods of social control. Even before the WHO’s elevation of COVID-19 to pandemic status on March 12, 2020, epidemiological models generated by public health researchers at the University of Hong Kong indicated that between 60 and 80 per cent of the world’s population might become infected during the course of the outbreak (Wu et al., 2020). As the high transmissibility of the SARS-CoV-2 virus became known, and with no curative treatment, the global health response was to implement social control on affected populations. Social distancing is easy to understand – lower the reproductive capacity of the virus by minimising host contact and transmission risk is reduced, but the practice is so enmeshed in context-specific social and political dynamics there can be no one-size-fits-all approach.
As the point of COVID-19 origin (albeit controversially contested), China’s mobilisation of a total population containment operation in Hubei province was unprecedented, involving the lockdown of some fifty-six million people. At the outset, provincial authorities had compounded a precarious situation by covering up initial details of the novel pneumonia outbreak at the epicentre in Wuhan, losing a crucial window for containment and facilitating rapid disease dissemination within and beyond the city. The central government’s panicked response to growing international condemnation of their handling of the crisis was to impose border closures, quarantine, and stay-at-home policies. Paradoxically, fear was initially the most effective social control mechanism as the public scrambled to protect themselves. A lack of masks and hygiene products fostered self-imposed social distancing, but as the outbreak progressed, orchestrated top-down strategies took over.
Homes became virtual prisons for residents who were only permitted to leave once a day on a strictly monitored quota basis. Pictures emerged of vigilante groups constructing and guarding barricades with an assortment of weapons, to keep ‘dangerous’ visitors, and the virus, out. Fear-mongering and shaming government banners warned people to stay at home, with one reading: “If you hang out in public today, grass will grow on your grave next year”. Leading medical figures such as Zhong Nanshan, who played a key role during the SARS outbreak in 2003, offered a nuanced expert voice but echoed the state dispatch, that staying at home contributed to combating the virus. While some citizens took to their windows to chant patriotic slogans, others directed criticism at the central government and the careless public parading of provincial officials. The unforeseen consequences of radical containment measures also caused moments of outrage among netizens, not least in reaction to the death of a mentally and physically disabled boy whose father was placed in quarantine with no carers.
As photos emerged of rapidly constructed makeshift hospitals and sports halls with rows of spaced beds, the international media drew comparisons with images of improvised hospital camps during the 1918-1919 influenza pandemic. These graphic illustrations presented the reality that despite the talk of preparedness, emergency public health was still reduced to the most basic of measures and provided little separation of the sick and the healthy. Social distancing in the China context, however, has been less about the social and more about prescribed distancing.
China’s approach treated every person as a potential patient, capable of spreading infection. Government directives were non-negotiable and compliance was facilitated by a well-established nationwide surveillance ecosystem. Digital health codes, assigning citizens red, yellow or green designations, were introduced in many provinces to ensure citizens did not violate predetermined ‘healthy’ boundaries, and local grid controllers monitored the already captive population. Theoretically the effectiveness of social distancing in a population can be determined mathematically. But unless measures are strictly enforced as they were in Wuhan and other Chinese cities, the results are likely to be erratic and ineffectual and must be packaged with comprehensive testing and contact tracing. Nonetheless China’s actions have shaped the global response to the outbreak.
As new cases in Hubei started to decline and the strict containment was being lauded by both the Chinese government, and controversially WHO, COVID-19 was on the rise in northern Italy, far removed politically and socially from China but connected through strong business ties. A breakaway region with factional politics, the north has a turbulent past and Chinese investors have increasingly bought into traditional industries as previously tightly held family businesses were sold off. The lockdown imposed on around sixteen million citizens in the Lombardy region on March 8 imitated the Chinese approach, but even as cases rapidly increased it was unable to replicate the state control and social compliance seen in China. Thousands of Italians and foreigners fled the region before the lockdown was introduced, in part due to a leaked memo on the impending social order, challenging authoritarian attempts to restrict personal freedom. The mentality of the threatened population at that point seemed more concerned with distancing themselves from the virus, which appeared location specific, rather than other people.
Like Chinese citizens, Italians sought an emotional release and were filmed playing musical instruments and singing at windows and on balconies. It was an act of solidarity, but also of defiance, against the disease and the social lockdown. A Vatican proposal to close Catholic Churches was swiftly denounced and overturned by Pope Francis who asked priests to find the courage and humanity to go into the community and comfort those in need. At what personal cost though and what risk to others? The Pope himself chose to forgo the traditional mode of delivering mass from St. Peter’s Square in early March in favour of live streaming, to avoid drawing large, tightly packed crowds. As prayer meetings go online the faithful have had to spiritually distance themselves from their pontiff but not from their religion.
Few would have predicted that the outbreak in Italy would escalate to overtake the number of cases in China. The juxtaposition of the two country’s experiences highlight differing sociocultural understandings and acceptance of risk in the practice of social distancing, factors that continue to play out with focal consequences as the pandemic expands.
The message that Chinese citizens took on board, partly through duty and partly through fear (of the virus and the repercussions of not obeying the law), that staying at home was a personal sacrifice to protect the wider population, has been much harder to implement in individualistic societies such as the UK and the US. When the ‘social’ encroaches on the ‘self’, compliance can be problematic.
The UK initially rejected the regimented social distancing model that had been made in China and modified in Italy. Against the backdrop of ongoing political turmoil of decoupling from the European Union (EU) and a strong civil liberties movement the British government initially proposed a fundamentally different approach, to not curb transmission with the aim of building herd immunity within the community, thus implying that social distancing would be detrimental to that goal. Data modelling by the Imperial College COVID-19 Response Team, however, predicted that the policy could overwhelm the National Health Service and result in up to 250,000 deaths (Ferguson et al., 2020) which forced the government to make a humiliating but crucial U-turn. A rapidly revised approach followed more authoritarian EU policies that had been implemented in France and Germany, by banning gatherings of more than two people that could be legally enforced by the police. Europe had entered new territory and social distancing was propelled beyond the realm of personal choice – the reasoning that dissenting behaviour of individuals could endanger many lives. The UK government also imposed restrictions on over 70’s leaving their homes and is now mulling government quarantine for the clinically predisposed. But is this social distancing or social isolation? What might be the direct and indirect consequences for vulnerable members within this demographic and where does obligation meet a sense of duty?
On 16 March the US President, Donald Trump, who had repeatedly downplayed the gravity of the outbreak announced that people should avoid gatherings of more than ten people. Amid the expected panic buying of household essentials a worrying trend of increased gun and ammunition sales revealed an unexpected and dark upshot of the epidemic, as people pre-empted stay-at-home and self-isolation policies. Fuelled in part by a diet of disaster movies, high crime, social divisions and erratic government messaging, some Americans had resolved to take social distancing into their own hands and on their own terms. But while doomsday preppers might feel vindicated, hunkering down for the long haul, the regulations, reception and response to social distancing has varied dramatically across the country. As confirmed cases surpass 100,000, the worst affected regions—New York City, California and Washington State—are getting used to all that social distancing entails, while the government wants to prepare others, including the Midwest farming belts, to open up as soon as possible as an economic band aid. Yet social controls are not only about reducing disease transmission, they instil public order and project state control – mixed messaging can be confusing and dangerous in such a populous country.
Returning to Asia, as a Special Administrative Region of the People’s Republic of China, Hong Kong occupies a rare political and economic mid-section between China and the West. As news of the COVID-19 outbreak was emerging in Wuhan, Hong Kong had already endured months of social unrest with increasingly violent anti-government protests challenging the PRC’s perceived encroachment on the territory’s political and economic freedoms. It was in this politically charged context that the virus entered Hong Kong; the first two COVID-19 cases reported on January 23 and the first death on February 4. Amid ongoing protests and anti-mainland sentiment, calls for border closures came first from newly elected democratic party councillors and public health officials, but pro-Beijing groups later echoed the demands as the outbreak intensified. The imbroglio of protests and epidemic, events both connected to China, has amplified local tensions. Adding social distancing into the milieu is likely to inflict further economic and political instability.
Hong Kong’s government health campaign vociferously declares, “together, we fight the virus”. A paradoxical mantra promoting community cooperation, but as we are being reminded, there is no “together” in social distancing. Here urban high-density living means small living spaces and loss of spatial socialisation can quickly impact both mental and physical health (Ng et al., 2017). For those living in subdivided flats or cage dwellings physical separation is a (dubious) privilege with some preferring to sleep on the streets to avoid infection and/or discrimination. For those in quarantine or self-isolation, social distancing is also proving emotionally arduous, causing concern that isolation fatigue could undermine its efficacy (Stepan, 2015). With a recent surge in cases, Hongkonger’s certainly cannot afford to be complacent.
As Hong Kong enters its toughest phase of social distancing measures, China is gradually ‘unlocking’, and its citizens can embrace the simple pleasures of returning to the outdoors with family and friends. But there is anxiety here too, as to whether the virus might return, a risk heightened by a rise in imported cases from the European and US epicentres and emerging evidence that recovered patients may remain infectious. Fears about personal space and interpersonal interaction will no doubt linger.
UN Secretary General Antonio Guterres declared “COVID-19 is menacing the whole of humanity – and the whole of humanity must fight back”. Strong leadership is paramount to contain this pandemic. Yet the global response has been inconsistent, both politically and from historically neutral health agencies such as WHO. There is still much to learn scientifically and medically about the virus. Social distancing has been enacted in numerous countries as an emergency measure, impacting business, education, leisure and relationships, but it is simply not sustainable. The public is being asked to practice extreme social distancing in some cases, without knowing when it will end. The danger is that societies will become more fractured, more anxious and it will become harder to return to normal, all with no guarantees of eliminating the virus. As social distancing goes global and encompasses ever diverse cultural contexts, new parameters are being set for ways of living and communicating, with long-term implications for us all. We are being asked to conduct our social life in a new and unfamiliar way, a non-social life.
Ferguson N. et al. 2020. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College COVID-19 Response Team. DOI: 10.25561/77482
Ng S.L., Zhang Y., Ng K.H., Wong H., Lee J.W.Y. 2017. Living environment and quality of life in Hong Kong. Asian Geographer DOI: 10.1080/10225706.2017.1406863
Stepan N. 2015. Eradication: Ridding the World of Diseases Forever? Cornell University Press.
Wu J.T., Leung K., Leung G.M. 2020. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. The Lancet 31 January 2020 DOI:10.1016/S0140-6736(20)30260-9
Ria Sinha trained as an infectious disease scientist at Imperial College London and Universiteit Leiden, the Netherlands, and is currently senior research fellow in the Centre for the Humanities and Medicine at the University of Hong Kong. Her interdisciplinary research considers the complex and dynamic sociocultural, ecological, technological, and scientific determinants of infectious disease emergence and management.