Almost 25 years ago, P.M. Strong observed that a major outbreak of novel, fatal infectious disease was frequently accompanied by social epidemics of fear, panic, suspicion and stigma, together with mass plagues of moral controversy, maverick science and searches for personal salvation. In principle, the threats from emerging infectious diseases could be handled in a co-ordinated fashion, with a cool and sustained focus on the problem at hand, a shunting aside of many other issues, and a sustained mobilization of programs, recipes and resources. Alternatively, they could result in contagious waves of panic, disrupting all manner of everyday practices, undermining faith in conventional authority and feeding on themselves to produce further, more intense panic.
This paper was set in a long, and half-forgotten, tradition of sociological studies of crowds, rumors, fads and panics, going back to the earliest years of the discipline. It was intended as the prologue to a book on the societal reaction to HIV/AIDS: sadly Strong’s early death in 1995 meant that this work was never completed.
However, his analysis reminds us that epidemics are not just biomedical events. The societal reaction to infectious disease outbreaks determines whether or not they will turn into existential crises. The response to Ebola can readily be contrasted with the response to HIV/AIDS – and more generally with well-established understandings of how infectious diseases came to be eliminated as a significant cause of deaths between 1850 and 1950 in developed countries. The World Health Organisation (WHO) must be called to account for its failure to remember these fundamentals and its abdication of leadership.
The critical thing to grasp is that social interventions are the first line of defense in disease outbreaks. As Thomas McKeown showed more than 40 years ago, infectious diseases had ceased to be significant causes of mortality in developed countries long before biomedical science offered any effective interventions. Infectious disease declined because social conditions and behavior changed. This was still evident with HIV/AIDS. There is a nice story about an early meeting where Margaret Thatcher asked how long it would take to produce effective therapies or vaccines. The great and the good of UK biomedical science huffed and puffed and thought this might take 10 to 20 years. The one social scientist present observed that an effective investment in social and behavioral research could start saving lives immediately.
AIDS did not sweep the planet on the scale initially feared because governments remained calm and supported the development of evidence-based social interventions that interrupted the transmission of the virus, slowing its spread to the point where biomedical science could catch up. This is Public Health 101 – but WHO seem to have forgotten and governments have certainly not remembered.
Ebola has long been recognized as having a potential for major outbreaks if not effectively contained. WHO failed to read the warning signs from the 2009 influenza pandemic that some African states were simply not up to that job. The relatively mild nature of the H1N1 virus created a false sense of security. In the conditions of West Africa – and parts of Central Africa – hemorrhagic fever viruses were still a disaster waiting to happen. This is not a matter of biomedicine but of basic political science: weak and chaotic states cannot be expected to respond well to unexpected crises of order, like an emerging infectious disease. Why was this issue not on the table in global forums, especially following the experiences of 2009?
As an international organization, WHO is obviously constrained in its ability to criticize the national governments that fund it. However, it is instructive to compare the leadership that it showed in the time of AIDS with the present. The travel bans, screening and quarantines being introduced by the UK and the USA are clearly costly and irrelevant. Indeed, they are probably hindering the effective management of the disease epidemic and magnifying the societal epidemics that Strong described.
Where is the WHO criticism of the political perversion of public health science in the UK and the USA? Why, for example, is WHO not declaring that cutting direct flights to Freetown is making UK and US citizens less rather than more safe? This measure simply means that travelers go a long way round, pass through international aviation hubs and disappear from tracking systems? The UK recognized in the mid-19th century that quarantines were useless, although the US has always been obsessed with the belief that disease can be kept out through border controls. How effective have these ever been at keeping people out?
WHO has just made a big fuss about the likely availability of a new vaccine next year. We have a positive epidemic of therapies and vaccines, just as in the early days of AIDS. Many of these represent formidable technical and scientific achievements. However, even if they are shown to work, they still need to be delivered into the affected populations. Why would people who have already shown themselves to be distrustful, for good reason, of their own governments, and reluctant to change traditional mortuary practices, line up to be vaccinated? All developed countries are grappling with the challenge of vaccine refusal, let alone the resistance to polio immunization that has been shown in neighboring parts of West Africa. Public Health 101 again: vaccines do not save lives, vaccination does. Vaccine development is a challenge to biomedical science: vaccination is a matter for the social and behavioral sciences.
Emphasizing biomedical interventions is an alibi for the failure to manage the social interventions effectively. The key to controlling any epidemic is reducing the number of people affected by each sick person, the R0 number. If this number can be brought below 1, the epidemic will come to an end fairly quickly. Control involves the winning the co-operation of affected populations, engaging them in changing behaviors and social practices that transmit the virus and supporting them through the disruption. If you close markets, you have to feed people or provide them with alternative sources of income. If you want to cremate the dead rather than burying them, you have to respond to local beliefs about what this means for the relationships between this world and the next.
These are not problems to be solved in the laboratories of the developed world. HIV/AIDS showed that they could be handled. Gay groups altered their sexual practices and developed mutual aid networks. Drug users were offered safer alternatives to needle-sharing. Prostitutes were supported in condom use. Many of these lessons have since been forgotten – but WHO is the kind of organization that should be expected to preserve them.
WHO is supposed to be a global health organization, not a global biomedical organization. The Ebola crisis reveals the extent to which it has lost sight of this mission. If it cannot rediscover that purpose, and recognize the need for partnership with the social sciences – and advocacy for their work, where necessary – then we must ask what service it is really performing for the citizens of the world.
Robert Dingwall is co-editor with Lily M. Hoffman and Karen Staniland of Pandemics and Emerging Infectious Diseases: The Sociological Agenda, Wiley-Blackwell, Oxford, 2013.