What is the influence of community on public health? Katherine Furman considers some of the social aspects of the pandemic.
Pandemics are stress tests on existing infrastructure. Do we have enough hospital beds? What about doctors? Can our food networks deliver groceries to people quickly enough, or will our supermarket shelves go bare? They are also stress tests on our communities.
In the time of COVID-19, we physically survive in part through our most immediate community networks. Church groups deliver food to the elderly. Neighbourhoods create social media groups to help each other out. Small local businesses keep afloat by delivering bags of stew and boxes of beer, or at least that is what is happening in my neighbourhood in Liverpool.
Many of us had already been surviving through our communities. In 2019, an estimated 1,6 million people in the UK made use of food banks. But much of this communal reliance had slipped from conscious view. Communitarian ethics – those theories that stress the moral aspects of our interconnectedness – tend to be less trendy in wealthy parts of the world, but much more fashionable in places where very many people need their communities to stay alive.
We also rely on our social circles to help us form beliefs about what is going on and how to respond. A 2019 study on vaccine hesitant mothers found that women consult with their friends and families in addition to their doctors when deciding whether or not to vaccinate their children – with occasionally terrible results. In the 2014 Ebola outbreak, this social dimension of belief substantially hindered public health interventions. Rumours spread that medics were stealing bodies to sell on international organ markets, that they were spreading the disease rather than treating it, and that they were in cahoots with untrustworthy governments to kill off marginalised political groups. All kinds of resistance resulted. The most extreme of which was the murder of eight members of a medical team in Guinea.
We are seeing information travelling through social networks in a similar way now. Some of it is obviously helpful: how to make a facemask using an old tee-shirt. Some of it less so: sesame oil cures COVID-19. And some is very troubling: COVID-19 is a bioweapon that has intentionally been released by malicious powers. Some countries, such a Russia, have criminalised spreading “misinformation” about the disease, where misinformation includes posting about sick and deceased loved ones on social media. It is too soon to tell whether information from our friends and families will help or hinder public health efforts this time around.
In South Africa, my home country, we have seen the ways that community can make or break public health efforts. In 2004, after a protracted battle and hundreds of thousands of deaths, South Africans finally got access to HIV/AIDS treatments via the public health system. But the sense of victory was short-lived. Initially it seemed that people would avoid being tested and so would be unable to access the medication. The trouble was that people lived in small communities and everyone would know if you went to be tested. Worse still, everyone would know if you stayed in the testing facility for an extended period of time, meaning that you had tested positive and had stayed on for counselling and treatment advice. Living in close knit communities, it turned out, could be deadly.
But by 2015, three million South Africans had begun ARV therapy – a huge public health success. What hadn’t been anticipated was that communities would organise support groups, who were instrumental in helping people get on and stay on treatment regimens. Communities, it turned out, could save lives. The trick was anticipating which way the community would go when developing a public health policy.
Dr Mike Ryan, the Executive Director of the WHO (World Health Organisation) Emergencies programme, has emphasised that the best health responses to COVID-19 will work together with communities. One way to do this is via community-health workers (CHWs). These are ordinary members of the public that undergo short intensive training (typically 4 – 6 weeks) in both health promoting activities and in how to spot medical issues that need to be referred. CHWs have been successful across the world and an April edition of the Lancet included a piece requesting the NHS to include CHWs as part of Britain’s Covid-19 response. Part of what makes CHWs successful is that they are already members of our communities. They take seriously the ways that we survive, form beliefs and make decisions through our immediate social circles.
If Coronavirus is a stress test on our communities, how are we doing? Despite the home-delivered stews and neighbourhood Facebook groups, we aren’t doing great.
On the one end of the spectrum is loneliness. As we continue to venture into the epidemic, many of us have been and will continue to be alone in lockdown for protracted periods of time. Loneliness is an obvious outcome of this, and one with severe consequences. The WHO has changed the language of ‘social distancing’ to that of ‘physical distancing’ in an effort to emphasise that remaining socially connected is important for both our physical and mental health. Physically, loneliness is linked to higher blood pressure and increased risk of heart disease.
But the harms of loneliness are not just physical. One of the central features of our lives as humans is that we participate in communal life. We need friends, families, those we can rely on. Kimberly Brownlee, a philosopher at the University of Warwick, has argued that we do a social injustice to those we prevent from participating in communal life. The injustice of this emphasises the extent of the harm inflicted on those who have no social contact. It might be that this is for a greater good, but it still involves a harm.
In these lonely times, it is precisely an appeal to a more all-encompassing sense of community that is used to justify the harms of physical distancing. We appeal to solidarity with the elderly and those with pre-existing conditions – those who are most at risk of dying. You might be lonely, but staying at home saves lives. When we see videos of American teenagers who insist on going on spring break, our moral outrage is based in the fact that they haven’t taken their moral obligations to the rest of us seriously. In England, we clap for the National Health Service (NHS) workers, because they are seen as taking on a disproportionate obligation to keep us all alive, although some argue that clapping for medics is just a faux sense of community; a position which has gained credibility as large groups have repeatedly gathered on Westminster Bridge in London in contravention of social-distancing rules to clap for the NHS.
If the one end of the spectrum is loneliness, then the other must be over-crowding. Community is great, loneliness is bad, but some of us cannot get any physical distance at all.
In New York, homeless shelters have reported that people who tested positive for Coronavirus were returned to shelters, spaces which are already over-crowded. By mid-April, 23 had already died. The situation is similar in shelters across the world, and the same picture is emerging in refugee camps and migrant detention centres. In Ireland, stories from direct provision centres (migrant detention centres) are that numbers of positive cases are high, but that residents are often not informed of this or given advice about what to do. The same goes for prison populations globally; notoriously, both Joe Exotic of Tiger King fame and Harvey Weinstein have tested positive in American prisons. People in these situations are trapped by too much physical proximity.
The stress test highlights already existing injustices within our own communities. It also highlights global injustice. The poorest members of our global community are also those who are the least able to access the physical distance required to keep well. How do you self-isolate in a favela in Rio de Janeiro, a Mumbai slum, or a shack settlement in Cape Town?
In South Africa the lockdown has been severe. People are not allowed to leave their homes at all, except to collect food, medical supplies or to collect government grants. Cigarettes and alcohol have been banned. There have been no opportunities for exercise outside, and this entire set of rules is enforced by the police and the army. The South African presidency has been praised for taking early and decisive action, but many do not live in situations in which they can self-isolate. At least four million South Africans live in shack settlements, where five or six people live in small self-made shacks of corrugated iron. Toilets and plumbing are communal, and require that you leave the shack to use them. Again, too much physical proximity means that people cannot keep safe.
The situation in Brazilian favelas is similar. People live in cramped quarters with no way to create distance and no place to go. The situation is Rio de Janeiro also highlights another communal aspect of the disease – how the decisions of one community can have disproportionate effects on another. In this city the disease began in its most affluent parts, presumably brought back with those who had visited the US and Europe. Then it slowly crept across the city, until it reached the poorest parts, where people are least able to protect themselves.
The global injustices highlighted by the crisis also make clear that it really matters who counts as part of a given community. Singapore acted swiftly in response to COVID-19. They had detailed response plans. They were the ‘gold-standard’ of testing and contact tracing. The crisis had been handled. But they had forgotten the migrant construction workers, who live in densely packed dormitories on the outskirts of the city. They weren’t part of the Singaporean community, as the government imagined it. Much like Cape Town and Rio de Janeiro, these people live in cramped spaces and have nowhere to go. The virus has exploded under these conditions and the country has reaped the whirlwind.
Pandemics are stress tests. Different countries will respond differently, and within countries people will be better and worst placed. One of the resources that is placed under pressure everywhere are our communities. Communities help us to survive, but from loneliness to overcrowding there are many ways that they can exacerbate suffering. Communities can also make or break public health interventions; the lesson from the South African AIDS crisis was that close-knit communities can prevent you from getting help, or they can be crucial to it.
In some moments of crisis, the community that is needed to survive can have transformative effects – one need only look at the establishment of the NHS after World War Two. It is too soon to tell whether communities will help or hinder public health interventions. It is also an open question how we will determine who will be part of the communities we are creating, and what our moral obligations to these new peers will be. If history is any guide, these communities and their norms may well become the fabric of the society we will one day leave our homes to rejoin.
Katherine is the Philosophy, Politics and Economics Lecturer at the University of Liverpool. She is a Philosopher of Public Policy and works mostly on health policy cases. She received her PhD in Philosophy from LSE in 2016.