One of the consequences of the relentless focus of UK research funders on ‘impact’ is a vacuum in the space where philosophy, sociology and anthropology meet around some fundamental questions about biology in general and medicine in particular. This is not to be confused with the rather narrow part of this niche occupied by bioethics. It refers to the basic nature of the concepts that scientists are dealing with, the clarity with which they are formulated, and the baggage that they carry with them. In the present case, a failure to question these lies at the root of many of the policy troubles increasingly associated with the management of COVID-19. Maybe we need better theory more than additional research.
Let us first understand that ‘disease’, ‘illness’ and ‘infection’ are not categories that are given to us by nature. They are human moral judgements about the undesirability of the impact of certain microorganisms on ourselves, and a few favoured plant and animal species that are particularly relevant to us.
Most of the sciences that study nature do not care about the consequences of the actions of these microorganisms. Biologists use language like mutualism, parasitism or commensalism to describe symbiosis, a close relationship between species. They may help each other out, grow at another’s expense or occupy the same ecological niche without much intruding on each other. There are no moral judgements here. This is just how things are.
Medicine, however, is different. It is founded on the moral judgement that certain physical and biological states of humanity are undesirable and should be prevented, corrected, managed or regulated. Doctors and biomedical scientists are moral entrepreneurs in a way that many other life scientists are not. When we use a word like ‘infection’, we are declaring it to be a problem that is properly owned by medicine, as a form of science directed towards a particular goal. The scale and complexity of that science means that a medical degree has long ceased to be a sufficient source of expertise and there is now a great penumbra of PhD scientists working on the programme of enhancing biomedical knowledge. Nevertheless, it remains a programme directed towards the goal of remedying nature’s failings rather than simply observing nature’s workings.
Much of the time this does not present a practical problem, since there is broad agreement within most societies about the desirability of interventions to bend nature to human wills and purposes. Contests tend to break out at the margins, where the classification of some form of human deviance from a social ideal as a disease to be owned by medicine is disputed. The long-running struggle to remove homosexuality from international classifications of psychiatric disorders is a good example. Current disputes over gender identity might be another: is this something to be determined by medical fiat or by personal choice?
When we are confronted with a novel microorganism, however, there is a different challenge. How should we classify this and who should take ownership of it?
When SARS-Cov-19 first announced itself to humans, its impact was dramatic. It seems that the virus had previously been quite happily co-existing with a bat species – and bats co-exist with a lot of coronaviruses. Bats have no particular significance for most humans, unlike, say, pigs or cows, so it would be inappropriate to use the language of infection to describe this symbiosis. The jump from bats to humans, however, was a moral jump as much as a biological one. Late in 2019, doctors in Wuhan were seeing patients whose pneumonia – a description of symptoms rather than a disease – was being provoked by an unknown organism. Wherever they looked, people seemed to be dying or becoming seriously ill. Whatever was happening looked like an existential threat to the human species. As such, the label of infection and disease seemed fully justified. Our species self-interest fuelled a moral judgement about the undesirability of the condition and the legitimacy of the claims of biomedicine to priority in its management.
The validity of these claims was not, though, questioned. At least in the UK, pandemic influenza planning had always assumed that social interventions would take the lead, to slow the movement of the virus through the population until a vaccine became available. The World Health Organization’s review of its handling of the 2013 Ebola outbreak in West Africa had underlined the lack of early social science input as a critical failure, provoking population resistance to infection control measures. Under Chinese conditions, however, population compliance with infection control was not seen as a problem. Authoritarian strategies were adopted as an exercise of state power informed by public health expertise.
The Chinese approach became a template for others, to the extent that their political cultures permitted. In the UK, compliance was extracted less through naked state power than through the deliberate use of approaches informed by behavioural science to instil fear and anxiety in the population. Thirty years of work to encourage dialogue between science and medicine, on one side, and ordinary citizens, on the other, was abandoned in a flash. Instead we had patrician policymaking, where a scientific and political elite assumed the dictatorial powers of Plato’s Philosopher Kings.
As time has passed, though, it has become clear that the SARS-Cov-19 virus is not the sort of threat that it initially seemed to be. It is much better adapted to humans than first appeared – to the extent that a substantial number of people who contract the virus are never, or only minimally, troubled by it. The more people we test for the presence of the virus, the more cases we find – but those cases will never have any clinical significance. In many respects, the virus looks more like something between a commensal that has not fully co-evolved with its new host and a parasite with some potential to cause damage.
There is still a great deal of scientific uncertainty. However, on some estimates, we might conclude that, in a country with a decent primary care system, as few as 6 percent of cases require hospitalization. How far are we justified in aggressive control measures to deal with a virus that will, at most, be a minor inconvenience to the overwhelming majority of the people who acquire it? Should we, rather, focus on the ability of the health system to deal with a small uplift in the number of patients presenting with this infectious disease?
Simply to raise this question, however, is to confront the other aspect of the moral entrepreneur’s work. It is not enough to promote a social problem. The entrepreneur also promotes themselves as the solution, accruing power, prestige and resources in the process. The institutionalization of the enterprise creates an army of defenders with stakes in maintaining that structure. Having locked ourselves into a particular way of thinking and acting in relation to COVID-19, it is very difficult for this to be questioned – but it must not go unchallenged if we are to balance the moral goals of medicine with the other moral goals that make up a good society.
Very good comment. Will be using from the start in teaching on sociology of health and illness this coming term