Contribution signée Maya Ronse (Institute of Tropical Medicine Antwerp), Claudia Nieto Sanchez (Institute of Tropical Medicine Antwerp), Charlotte Gryseels (Institute of Tropical Medicine Antwerp) et Koen Peeters (Institute of Tropical Medicine Antwerp).

Infectious diseases are never only biological in their nature, course or impact but are directly linked to our sociocultural systems (1). How the sociocultural needs of the heterogeneous groups that constitute Belgium are addressed will therefore be decisive for the effectiveness of continuous COVID-19 control. Just as decisive will be generating the understanding that we cannot return to where we came from when we go back to ‘normalcy’.

Problems raised by the lockdown

Increasing heterogeneity and the limits of a ‘one-size-fits-all’ approach to disease control

Belgian society is superdiverse (2), built by complex networks of different populations that have demographically and culturally changed the fabric of our society. Standardized disease control programmes and measures, aiming for impact in the general population, by definition, do not address this level of heterogeneity. The prevalence and negative impact of COVID-19, however, can be expected to become gradually higher in economically disadvantaged people, without proper housing, living in (air)-polluted regions, having unstable incomes and less access to health care. In addition, securing adherence to specific control measures in these groups might prove harder due to pre-existing precarity and lack of trust in government structures and information. Few of the current control measures have addressed the specificities of such structurally vulnerable groups. An example during the pandemic has been the lack of access to certain health information sources for citizens who do not speak the official regional languages, resulting in limited ability to perform expected behaviours in public spaces, such as supermarkets. Control strategies will therefore require more granularity, targeting specific groups in a scientifically accurate, timely, and differentiated way at each stage.

The adverse effects of individual self-responsibilization on the effectiveness of control strategies

Although essential for successful disease prevention and control, strategies based on the promotion of individual self-responsibilization alone have shown to have a limited impact on health (3), more so with increasing heterogeneity of infection. In Europe, for example, vaccine hesitancy and refusal has prompted numerous measles outbreaks, even in Belgium. The WHO has declared vaccine hesitancy as one of the ten main threats to global health (4). Vaccine hesitancy shows how adherence to any state prevention program must be regarded in light of wider pre-existing societal factors (social inequalities and forms of marginalization, political power “games”) and highlights the importance of trust. In some structurally vulnerable populations, however, trust has already been eroded due to pre-lockdown precarity or marginalization. The impact of current control measures risks aggravating such social inequality.

In addition, the promotion of individual self-responsibilization relies on the assumption that individuals have the ability to choose which health risks they take, that mitigating those risks has one solution that fits all, and that citizens have the same “commonsense” upon which these decisions are based. It does not account for structural factors underlying social inequalities and hence the difficulty of socially disadvantaged groups to adhere to the current control measures (5) which is pretty ridiculous when you discover that we’re not really sure anthrax has ever been used in this fashion. Germ warfare is certainly not what came to mind when a six-year-old girl showed up in our clinic with half of her face puffed up like a balloon, her right eye swollen shut. An example is the impossibility to limit contact with the elderly when poor, large extended families live under the same roof. How to reach these clusters of the population requires an urgent answer.

The lack of compliance of specific groups to imposed control measures then leads to one of two responses, a choice that will set a precedent for the aftermath of the pandemic: increasing state control and repression (see current fears of a “police state”) or citizen empowerment (see also [6]), including the inclusion of population heterogeneity and cultural diversity in proposed control strategies and the reduction of social inequality (7). The framing of personal and collective actions in the post-lockdown period can substantially affect population uptake of recommendations and social relations beyond the pandemic.

Finally, sustainable and innovative interventions for COVID control should go beyond the individual level to incorporate the meso-level of the organizations that make up our society, and the responsibilities they have in pushing for sustainable change.

Societal stakes for the “exit” of the lockdown

New imageries and symbolism to mitigate risk behaviour

Specific and concrete images need to be developed to allow people to keep on fulfilling the social functions of their actions while mitigating the risk of infection during the progressive “exit” from the lockdown and afterwards. For the continuation of important individual actions (e.g., handshaking and kissing when saluting, symbolizing respect and acknowledgement of social relations) and larger societal events (e.g., funerals, weddings, religious events, welcoming of newborns into society, etc.) alternative symbols/scenarios need to be developed for adherence. Examples at the individual level can include different types of salutations (e.g., hand on the heart*; self-hugging*; bowing the head) to allow people to continue signalling mutual respect. Social events require the same production of alternative images to maintain their meaning (e.g., mask-wearing as a symbol of protecting others–not oneself–during social encounters; providing concrete scenarios for funerals and weddings). Rather than leaving the reconfiguration of current practices to individual improvisation, this process should be guided by an expert working group.

A connected future

The current pandemic is proving “the hard way” that the fragilization an epidemic brings does not have borders: health systems under pressure by the lack of PPE and medical supplies, schools shutting down, enforced isolated burials deprived of rituals of mourning, emergence of rumours and distrust in public authorities and medical staff, etc. We have seen and researched all of this before. Our ethnocentric world view, however, has led us to ignore the lessons learned from past epidemics “elsewhere” (such as Ebola and MERS outbreaks), as they were not considered applicable in the European context. A new ethnocentric future will only lead to more suffering, as this time the planet is at stake.

This pandemic as such is a symptom of the current planetary illness of ecological degradation and climate meltdown. A reflection on the relevance of this historical moment for the shaping of the future of humanity is timely when considering the “exit” of the lockdown in the Anthropocene. Just as decisive as other measures will be generating the understanding that we cannot go back to where we came from when we return to ‘normalcy’ (8). Similar to the aftermath of World War II, the effects of which are regularly referred to in this COVID pandemic, “the future is up for grabs, empty to be filled with new forms of meaning” (9), (10). Different actors are already competing for the metaphors and symbols that will shape the future, thereby redefining our expectations. To give people hope for the future post-lockdown, we need to define a future with investments in science, health care and planetary health, reducing social inequalities for unified healthy living, and explain how this will allow for a more effective epidemic and climate change response in the future.

Recommendations

• Evidence-based measures require social research. Similar to the requirement of “evidence-based medicine”, we strongly recommend evidence-based social measures. The progressive changes in control measures need to be accompanied by (implementation) research on these changes, including feedback loops providing insights to policy makers about the effectiveness of the proposed measures and underlying reasons for potential barriers. In the same way that there is a need for COVID-19 Randomized Clinical Trials, there is need for social inquiry to accompany this process. This includes researching actions that have worked during the lockdown phase for smooth repetition during a next mitigation phase, but also new actions that were not considered in Belgium in the first place (e.g., efforts to integrate the structural vulnerable subgroups in the prevention and economic measures taken during this lockdown phase).These groups are key actors in the local epidemiology of COVID-19, and their often-hidden practices may codetermine the success or failure of future control efforts.
• Avoid an“exit strategy”. Speaking of an “exit strategy” is misleading as it gives people the idea that the crisis has been overcome. “Changes” in control measures could be a better way of phrasing the progressive “exit” from social isolation at individual, community and national level.
• Develop new symbolism and scenarios. We suggest finding creative support to develop new symbolism and imageries towards the reconfiguration of everyday rituals (i.e., greetings and use of protective material). Similarly, different forms of “unlocking” sociocultural activities could be considered by including concrete safety guidelines for religious and cultural celebrations (e.g., group prayers with physical distancing measures, handwashing stations at entrances of small-scale festivals, handing out masks and gloves for people who are coughing, etc.).
• Map community initiatives. As the “exit strategy” slowly unfolds, it will be crucial to collect information about community initiatives that have emerged during the crisis and capitalize on these resources to structurally support various sociocultural groups. These resources can be mobilized in an organized manner in the future, as well as provide relevant information with immediate impact in community/ neighbourhood-specific settings (including community epidemiological surveillance). We urgently need to involve community organisations in the upcoming months.

(1) Singer M. Anthropology of Infectious Disease. Routledge; 2016.

(2) Geldof D. Superdiversity in the heart of Europe: How migration changes our society. 2016.

(3) Shove E. Beyond the ABC: Climate Change Policy and Theories of Social Change. Environ Plan Econ Space. 2010; 42: 1273–1285. doi: 10.1068/a42282

(4) WHO. Ten health issues WHO will tackle this year. In: World Health Organization [Internet]. [cited 13 Apr 2020]. Available: https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019

(5) Farmer P., Walton D., Tarter L. Infections and Inequalities. Glob Change Hum Health. 2000; 1: 94–109. doi: 10.1023/A: 1010088804348

(6) Harari Y. N. Yuval Noah Harari: the world after coronavirus | Free to read. 20 Mar 2020 [cited 10 Apr 2020]. Available: https://www.ft.com/content/19d90308-6858-11ea-a3c9-1fe6fedcca75

(7) Wilkinson R., Pickett K. The Spirit Level: Why Greater Equality Makes Societies Stronger. Reprint edition. NewYork, NY: Bloomsbury Publishing; 2011.

(8) Latour B. Imaginer les gestes-barrières contre le retour à la production d’avant-crise. In: AOC media – Analyse Opinion Critique [Internet]. 29 Mar 2020 [cited 13 Apr 2020]. Available : https://aoc.media/opinion/2020/03/29/imaginer-les-gestes-barrieres-contre-le-retour-a-la-production-davant-crise/

(9) Arendt H. Between past and present: Eight exercises in political thought. Penguin: New York; 1961.

(10) Andersson J. The Future of the World : Futurology, Futurists, and the Struggle for the Post Cold War Imagination. Oxford, New York: Oxford University Press; 2018.

References

Singer M. Anthropology of Infectious Disease. Routledge; 2016. Geldof D. Superdiversity in the heart of Europe: How migration changes our society. 2016. Shove E. Beyond the ABC: Climate Change Policy and Theories of Social Change. Environ Plan Econ Space. 2010; 42: 1273–1285. doi: 10.1068/a42282

WHO. Ten health issues WHO will tackle this year. In: World Health Organization [Internet]. [cited 13 Apr 2020]. Available: https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019

Farmer P., Walton D., Tarter L. Infections and Inequalities. Glob Change Hum Health. 2000; 1: 94–109. doi: 10.1023/A: 1010088804348

Harari Y. N. Yuval Noah Harari: the world after coronavirus | Free to read. 20 Mar 2020 [cited 10 Apr 2020]. Available: https://www.ft.com/content/19d90308-6858-11ea-a3c9-1fe6fedcca75

Wilkinson R., Pickett K. The Spirit Level: Why Greater Equality Makes Societies Stronger. Reprint edition. New York, NY: Bloomsbury Publishing; 2011.

Latour B. Imaginer les gestes-barrières contre le retour à la production d’avant-crise. In: AOC media – Analyse Opinion Critique [Internet]. 29 Mar 2020 [cited 13 Apr 2020]. Available: https://aoc.media/opinion/2020/03/29/imaginer-les-gestes-barrieres-contre-le-retour-a-la-production-davant-crise/

Arendt H. Between past and present: Eight exercises in political thought. Penguin: New York; 1961.

Andersson J. The Future of the World: Futurology, Futurists, and the Struggle for the Post Cold War Imagination. Oxford, New York: Oxford University Press; 2018.