28 July 2021 – Mukesh Kapila
When our lives are upended on a massive scale, it is normal to seek sense from shock. Perhaps a special, even spiritual, message in the damage and disruption? Perhaps a hope for something good emerging from a terrible disaster?
We rationalise our fears by constructing complex causality to explain over-whelming or peculiar phenomena. And perversely, we seek comfort by blaming others for our travails – be they failing leaders, institutions, or foreign countries.
We also try to pacify the malevolent gods of our misfortunes by making all sorts of pledges. We promise to live more wisely and behave decently towards others. We resolve to invest more in prevention or science or green growth or correcting inequalities, or whatever fits the scenario of a particular catastrophe.
Regardless of cause, this playbook is true of all mega crises. It involves acres of commentary from which mountains of lessons are extracted. Punching “lessons from Covid” into Google throws up over 4 billion results … and counting.
The extensive narrative around the coronavirus pandemic consolidates around a few key themes.
The first theme is self-congratulatory. It marvels at the speed with which the coronavirus was identified, sequenced, and vaccines invented. Also how quickly treatments have improved. It is all about how clever we are, how innovative, and ingenious. Soon, several scientists will be woken up in the middle of the night to hear about their Nobel Prizes.
The second theme is heroic. It showcases desperately sick patients gasping for breath. It applauds health workers battling against the odds. Also social workers caring for the most vulnerable. And humanitarians helping isolated or forgotten people. The kindness business has thrived. Hopefully, they will also get medals and certificates.
The third theme is of astonishment. This is around how governments and international financial institutions have over-turned economic orthodoxy to print trillions of dollars to prop-up businesses and expand social safety needs. We marvel at the many adaptations that companies, communities, and families have made to carry on as best as they can – be it home-schooling or zoom-connecting. It seems that we are surprised at our own adaptive resourcefulness. That includes our willingness to tolerate lockdowns and other extraordinary limitations to basic freedoms.
The fourth theme is exhortatory. This appeals to the better angels of our nature because “we are in it together”. So we are urged to show solidarity. To be altruistic. But as that does not work on a large-enough scale, it must be mixed with self-interest. Wear masks to save others but also yourself. Share vaccine stocks equitably because “no one is safe until all are safe”. Pharma are exhorted to share their intellectual knowhow to scale-up vaccine manufacturing.
We are goaded to improve the way we live. To better organise our health and social systems so as to avoid or deal better with future disasters. Even a new international Pandemic Treaty is proposed to tackle Covid-19’s successors although we are not too good at honouring numerous existing agreements.
The fifth theme is of lamentation. It mourns the many tragic losses of lives and livelihoods. But above all, it regrets the passing of an old ‘normal’ which will never return. Will we shake hands or kiss again? Will vaccinations and passes be mandatory to go to a restaurant or shopping mall? We grieve for lost freedoms that we took for granted, even as despots around the world rejoice in the legitimacy that the coronavirus has provided to curb basic liberties.
The sixth theme is retro-projecto-scopic. Becoming wise after the event is a thriving industry. There are several sub-texts. One is the launching of investigations into the origin, cause, and mishandling of the pandemic. Another is on forecasting the future. These help to defuse criticism of present difficulties by time-travelling to a safely-forgettable past, or to a safely-distant ‘built-back-better’ future.
Often these analyses have a a comparative aspect. They look at the relative performance of cultures, governance systems, and institutions. As there is always someone worse than us, it helps to shift blame. Another way to divert us from current realities is to invoke distal influences that are so broadly cast as to render real-time decision-makers un-accountable.
So, we can blame uncontrolled environmental change for boosting zoonotic transmission, over-crowded urbanisation for magnifying vulnerabilities, Chinese authoritarianism for the original unleashing of the coronavirus, cheap world travel for its rapid spread, rampant capitalism for the pandemic’s obscenely unequal impacts, the food industry for making us fat and vulnerable to the virus’s complications, social media for spreading mischief and mis-information, unchecked globalisation for hollowing out nations who can’t produce their own paracetamol or PPE, profiteering pharma for not making enough affordable vaccines for everyone, and geopolitics for ineffective multilateral co-operation. Into this, and based on particulars agenda, can be injected other narratives such as Black Lives Matter, whether or not the Olympics should be happening, and “culture wars” of many types.
The seventh theme is prospective. There is prolific punditry around the post-pandemic world. Most projections envisage digital take-over of life, even as large elements of distancing continue in minds and hearts. The emerging world may be a somewhat colder, more robotic place. It may also be much more fearful and cautious as we await the next pandemic or climate disaster. Thus, one enduring legacy of the coronavirus may be our permanently altered perception of risk. Public policies and private practices will default to more risk averse attitudes. Could the precautionary principle take all the joy out of living?
Damaged health values
Clouded by so many perspectives, it is difficult to tell if the Covid glass is half full or half empty. Meanwhile, the pandemic casts a dark shadow on the core values around health itself.
Since millennia and across all cultures, health has been seen as an inherent good i.e. its pursuit was seen as desirable in of itself. This got codified as the ‘right to health’ in the 1948 Universal Declaration of Human Rights and subsequent international laws and covenants.
We also came to realise that diseases don’t stop at the front door or national frontiers. To ensure our own safety requires securing the safety of others. This stimulated the noble notion of “health for all” – whether our neighbour or a distant stranger. It has become the holy grail, over the course of repeated tellings. Not least because it appeals to our own self-image of decency. Such apparent benevolence is done no harm by the happy thought that while we do good to others, we also do good to ourselves.
Therefore, the specialty of global public health – projected as a moral mission to do the greatest good for the greatest number of people – is in constant tension between the impulses of selflessness and self-interestedness. The balance struck depends on seriousness of impact of the health risk tackled. That is why solidarity messaging around Covid-19 – already much hyped as an existentialist threat – often falls in a semi-deaf no man’s land.
In olden days, when health was a matter of individual chance or, at best, an uncertain partnership with one’s healer or god, selflessness pre-dominated (to earn some heavenly points akin, therefore, to a ‘spiritual vaccine’). But “health for all” required institutionalisation with bureaucrats, plans, strategies, objectives, budgets, and metrics.
Thus emerged the modern organisational set-up, whether under health ministries in the public sector or as corporate business. In either case, an institution is rationally incentivised to serve its own set mission i.e. it’s bureaucracy is geared towards self-interest even if it is composed of selfless individuals. Perhaps that is why we see so much Covid-19 nationalism in relation to border restrictions and vaccine hoarding: national health missions must do what they are obliged to do: look after their own first.
Meanwhile, as health became an institutionalised business, nations were encouraged by the global multilateral enterprise to compete on the Millennium Development Goals and now, Sustainable Development Goals. These paradigms see health as an outcome, but even more, as input towards creating stronger nations. That necessitates the further instrumentalisation of health. For example, health expenditure is required to demonstrate a return in terms of more productive societies.
Therefore, health is no longer just an intrinsic good – to be enjoyed for its own sake – but an input to a process that generates wider economic benefits. For example, better maternal and child health services mean healthier babies (intrinsic good) who grow up to be strong workers (instrumentalised good).
Ultimately, healthy and strong workers make strong nations. It is then but a short step for policy makers to postulate health as a strategic security concern that is legitimate fodder for geo-political rivalry. Obviously, when a disease breaks out and spreads widely, the country that recovers faster gets an advantage over others.
It explains why the global Covid-19 response has been marked by so much contention and acrimony. The coronavirus has driven us apart and not brought us together because the underlying health moral base has been instrumentalised and securitised. Covid-19 did not cause this. It has simply accentuated the trajectory we were already embarked upon.
On this analysis, what does the post-COVID future hold for global health? The positive aspect of a securitised health field is more investment in medical science, discovery and invention, including via the fields of artificial intelligence, health surveillance, and big data collection and analytics.
The negative aspect is that these are the same security-related technologies that can infringe basic human rights and liberties, make wars more effective and efficient, hollow-out democracies, and keep autocrats permanently entrenched.
Whether good or bad, our health is now a matter of national security and all are conscripted as soldiers. We are duty-bound to be healthy so as to be strong. Just in case we are required to compete more fiercely – even fight – others.
So, there is indeed a “Long Covid” syndrome. It is not just the many months of persistent viral symptoms that millions suffer from. It is a permanent shift in our previous benign notions around health.
Adapted from a lecture given on 19 July 2021 at the 9th International Festival of Public Health, Manchester.