1

Targets, trust and COVID-19 testing, by Christina Boswell

|

Political scrutiny of the UK’s management of COVID-19 has recently revolved around an ambitious target the government set for itself: the goal of carrying out 100,000 tests per day by the end of April. The debacle around this target exemplifies many of the challenges – and paradoxes – generated by the use of quantitative targets in government.

Let’s start by considering the purpose of setting this ambitious target. The ‘100,000 tests a day’ target is a classic case of the dual function of targets: targets being used as a tool of political communication, but also as a means of galvanising action within public administration.

The first function is all about political signalling. By setting a high profile and ambitious target, the government was attempting to reassure a sceptical public by locking itself into an ambitious pledge. This type of numerical target has a particular appeal, as it can be tracked and monitored through publicly available data, thereby establishing a particularly robust tool of accountability.

But at the same time, the target also acted as a disciplining device, designed to whip the civil service into action. Political leaders have frequently expressed their frustrated at the perceived inertia of Whitehall mandarins. Setting this type of ‘stretch’ target can place huge pressure on public officials to ramp up resources to achieve ambitious goals in a short space of time. And in this case, it clearly did have a galvanising effect on public administration.

Yet combining these two functions in one target is likely to create problems. High profile targets designed to reassure publics are rarely devised in a way that aligns with operational needs. Such targets are often set with political communication in mind – rather than a consideration of the types of actions that would be most effective in achieving a particular outcome. Thus in this case, it may have been more sensible to focus on questions such as prioritisation, quality control, logistics, and the role of these tests within a broader test, trace and isolate strategy. Too much attention on just one aspect of the strategy – the number of tests conducted – narrowed down attention in an unhelpful way.

The effects of the target were also predictable. This simple and snappy numerical goal became a lightning rod for media and political attention, the central focus for holding the government to account. In doing so, the target displaced attention from other, more pertinent questions. Thus we had several days of media headlines focused on whether or not the government had met the goal, obscuring wider issues about the relevance or importance of this numerical goal as part of the government’s overall response.

As is often the case with targets, even those who disagree with the target on principle cannot resist critiquing the government for failing to achieve it. Even those sceptical of the target have found it irresistible to use it as a tool for holding the government to account. In this way, detractors of the target have inadvertently helped shore up its validity. In this sense, targets are highly performative, recasting how we frame social problems and evaluate policy responses.

Finally, what about the political leaders who set such targets? For governments, setting this sort of ambitious, publicly monitored, goal is a big political gamble. Governments can face a severe loss of credibility when they fail to meet targets. But they also accrue very little political capital when they do meet them. Ambitious targets that end up being met tend to get very little air-time. And when they are covered, they tend to be greeted with suspicion – as we saw in sceptical media coverage at the end of April, when the government’s target appeared to be briefly met. The fact that a government meets a target it set for itself is not likely to meet criteria of newsworthiness.

So why do governments keep setting risky targets when they have so much to lose, and relatively little to gain? Despite their short-comings, targets retain a strong appeal to political leaders. They offer an especially rigorous tool for holding government to account, in an age where governments are searching for ways of shoring up credibility. First and foremost, these tools are seen as a device for grounding political trust – even though in the longer-term, they may have precisely the opposite effect.

Given these dynamics, governments are unlikely to learn the lessons of episodes such as the 100,000 tests targets. The immediate political capital gained from signalling commitment to such an ambitious goal will continue to outweigh the potential risks further down the line.

Christina Boswell is Professor in the Department of Politics and International Relations at the University of Edinburgh. Her book ‘Manufacturing Political Trust: Targets and Performance Measurement in Public Policy’ won the 2020 Political Studies Association Mackenzie Prize for best book in political science.

This piece was originally published in Cambridge University Press blog.



As countries ramp-up COVID-19 tests, Edinburgh University researchers discuss the expectations and values of diagnostics, writes Aphaluck Bhatiasevi

|

“You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected. We have a simple message for all countries: test, test, test.”

WHO director general Dr Tedros Adhanom Ghebreyesus said at the 16th March 2020 press briefing broadcasted live on social media.  He demanded governments to test every suspected case, so that they could be isolated and treated, and their contacts be quarantined.  He said WHO had shipped almost 1.5 million tests to 120 countries and are working with companies to increase the availability of tests for countries most in need.

Testing for COVID-19 has been at the centre of political debate about the pandemic response, particularly in the United Kingdom and the United States. The political messaging around testing has, however, underplayed the complexity of diagnostics, says Dr Alice Street, senior lecturer at the University of Edinburgh’s School of Social and Political Science.  She was speaking at the Edinburgh Infectious Diseases’  webinar series on COVID-19 on ‘The social life of COVID-19 testing’. Dr Street is the principal investigator of DiaDev, a partnership between the University of Edinburgh, Kings College London, Kings Health Partners and Public Health Foundation India, which is funded by the European Research Council.

Dr Street says the value of diagnostics has placed enormous expectations on the COVID-19 tests.  They are expected to provide certainty on the pandemic situation the country. They are expected to give reassurance that the measures taken by governments and health authorities are appropriate for controlling the spread of the pandemic. They are expected to provide a guarantee for people to come out of the lockdown and get back freedom of movement. Perhaps above all they are expected to set countries back into economic production and move towards the path of financial recovery.

While demand for more testing is expected in the UK, she acknowledges that it may not be possible in many low and middle income countries (LMIC), including in countries where investments have been made in laboratory and diagnostics capacities in recent years.  Drawing on experiences from DiaDev’s (Investigating the design and use of diagnostic devices in global health) research in Sierra Leone on the West Africa Ebola response in 2014-2016, and ongoing research on COVID-19 in India and the UK, she says the social value of diagnostics and the relationships between people, technology and spaces are often overlooked.  Moreover, there are multiple kinds of diagnostic technologies with varying usages and benefits, but this complexity is often underplayed in political messaging potentially generating unrealistic expectations of tests.

Dr Street says different kinds of tests are best operated in different places – triaging patients, for making decisions on clinical care of individual patients and for surveillance purposes.  The focus on getting the tests capacitated for the purpose of emergency responses has also diverted attention from development of laboratory capacities as a whole, particularly in LMIC, where resources are limited.

Reflecting on these experiences, Dr Street says it is evident that even in a country like the UK, there are weaknesses with the supply chain and the manufacturing system for diagnostics. The focus on point of care diagnostics may be distracting concerned authorities from considering the comprehensive system, from production to marketing, distribution, maintenance and waste management.

The values diagnostics have is different for different people and social groups.  Often these values are overlooked. Investigating why diagnostics matter and what benefits are expected of them are important to their development and use, says Dr Street.  Although their primary role is to inform treatment of patients, in practice this role may be least performed.  Responses to Ebola outbreak and COVID-19 has shown that they have high humanitarian value and are seen to save lives. This is evident from fast tracking of regulatory procedures for its use in humanitarian responses. They have also shown to have high economic values. In the UK, increase in testing is associated with the country’s gross domestic product (GDP) and the economic recovery from the lockdown.

Testing for COVID-19 can also give the people a reassurance that the government cares.  It shows that they are recognized by the state. Failure to adhere to increasing their confidence can impact their trust on the authorities.  DiaDev is currently involved in a project which looks at the public perception and expectations from COVID-19 testing, to inform future testing policies. The research is carried out in Lothian, Scotland, in collaboration with the Royal Infirmary, with funding Scotland’s Chief Scientist Office.

Prof Jurgen Haas, Head of the Division of Infection Medicine at the Edinburgh Medical School says there are different kinds of tests currently available, including antibody tests which can trace past infections, but we currently do not know whether they provide information about immunity and protection.  He was speaking on ‘SARS-CoV-2 in Edinburgh: Clinical situation and ongoing research’ at the Webinar.

Prof Haas is one of the six Consultant Virologists in the Royal Infirmary Edinburgh currently involved in COVID-19 response and in COVID-19 research with Scottish and international collaborators.  The current testing policy in the UK is to test for  COVID-19 infection only in patients and individuals living in carehomes as well as hospital and carehome staff who develop symptoms. However, previous results have shown that also completely asymptomatic individuals can be positive for COVID-19 and spread the disease. Scottish NHS Health Boards currently have a testing capacity of around 4,000 individuals per day, but in some Health Boards such as Lothian (Edinburgh) the testing capacity is not fully used since Government guidelines have not changed or not been communicated appropriately. Thus, increasing testing in elderly homes can possibly reduce death rates, he says, adding that in Edinburgh, approximately 50% of all care homes are affected.

 

Aphaluck Bhatiasevi is a PhD candidate in Social Anthropology at the University of Edinburgh.

 



Don’t touch your face! The triggers, isolation and social connections of body-focused repetitive behaviours during COVID-19, by Bridget Bradley

|

As an anthropologist who researches a mental health disorder that I also suffer from, I take this opportunity to reflect on the ways that COVID-19 has affected daily life with a body-focused repetitive behaviour (BFRB). In particular, this piece draws attention to the impact of lockdown in the UK including the advice on face-touching; the triggers of staying at home; the paradox of anxiety; and how isolation can lead to increased social connections.

Don’t touch your face!

Body-focused repetitive behaviours are compulsive mental health disorders including hair pulling (trichotillomania), skin picking (dermatillomania) and nail biting (onychophagia). Clear from the name, these behaviours involve a repetitive, somewhat obsessive interaction with the body. My ongoing research with people living with BFRBs in the UK and US, as well as personal experience living with these behaviours has confirmed that BFRBs are more complex than habits that can be easily overcome. The urges that accompany BFRBs are frequently described to me in terms of addiction, where pleasure and harm are entangled with satisfaction and shame. People with BFRBs usually do not understand why they have the urge to pull out the hair from their bodies or constantly pick their skin. These urges are rarely at ease, and while people attempt to conceal their behaviour from public view, the need to satisfy their bodies through pulling and picking occupies their thoughts most of the time.

In the early advice of COVID-19, media coverage highlighting the risks of face-touching took on a new meaning for my interlocutors. For many people with compulsive skin picking, the face is a site of great obsession. Urges accompany the frequent scanning for imperfections and scabs. Some hair pullers target their eyebrows and eyelashes, others frequently touch areas of the face to search for tiny hairs to pull. For nail biters, oral stimulation of fingers and nails is a daily occurrence. Importantly, many people with BFRBs carry out their behaviours subconsciously, so may not be aware that they are doing it. The reality of these behaviours means that sudden bombardment of “don’t touch your face” messages, becomes a harsh wake-up call to the frequently with which they actually touch their faces; their lack of control over it; and the very real risks in doing so. I recently asked a friend about this message, she said, “Honestly, the ‘avoid touching your face’ advice from the government and in the media was something I immediately dismissed. Not as unimportant, but as unimaginable. I read somewhere that the average person touches their face around 200 times a day – as a compulsive skin picker I reckon mine must be in excess of 2000”.

The “don’t touch your face” message has further connotations for people living with BFRBs, as they have likely heard this numerous times before from frustrated family members. I have written elsewhere about how trichotillomania affects and is affected by family relations (Bradley & Ecks 2018). A major challenge lies in the comments from loved ones who fail to comprehend the complexity of hair pulling and skin picking, saying things like, “stop at your hair!”; “stop chewing your nails!”, “leave your skin alone!”, or simply slapping hands away from hair and faces while pulling/picking. Due to the intensity of urges and the embarrassment of being caught in the act, these words and actions can greatly increase feelings of shame and anxiety.

With this context,  the “don’t touch your face” message might surface unsettling memories for people living with BFRBs, but it also acknowledges how difficult it is for some people to avoid touching their faces, even when the risk of infection is brought to their attention. Organisations like the TLC Foundation for Body-Focused Repetitive Behaviours (TLC) have issued advice to people about how to cope with face-touching, and the Picking Me Foundation suggested to “reinterpret media bytes” warning you to ‘not touch your face’ as cheerleaders rooting you on”. Therefore, some of the impact of this message may depend on how it is framed; and a focus on compassion rather than surveillance will make it more likely for people with BFRBs to reduce their face-touching during the pandemic.

Anxiety

Anxiety can be an enormous trigger for people living with BFRBs, with stress influencing the strength and frequency of urges. Of course, it is assumed that living through a global pandemic is anxiety inducing, even for those with lower levels of anxiety. Paradoxically, in a recent Guardian article, Farrah Jarral notes that people with anxiety disorders and obsessive-compulsive disorder in the UK have reported lower anxiety during lockdown. Jarral suggests this is due to the stress of normal life and the benefits of slowing down for those with comfortable living standards and safe home environments. In BFRB circles, some anxiety has also been lessening, due to reduced social pressures and more time to relax with hobbies at home. For those who normally depend on external self-care strategies to manage their BFRB (regular appointments at specialist hair salons, unrestricted exercise), anxiety can be harder to maintain. However, some people have been able to adapt their self-care routines in new ways, like a friend who finally felt able to shave an undercut on the areas of her head affected from pulling. For her, the lockdown provided an opportunity to cut her own hair without the anxiety of anyone seeing her, and the new hairstyle has boosted her self-esteem.

COVID-19 has the potential to highlight where the triggers to anxiety and BFRBs lie; within certain social interactions, working life, daily commutes etc. This tracking of environmental and social surroundings with BFRB urges is a key focus of the behavioural model used by BFRB therapists, but what happens during lockdown when the environment that triggers you is your home?

Stay at Home

During the interviews and observations of my PhD research, I realised that home can be a huge trigger for picking and pulling behaviours. Like in much of the world, COVID-19 has kept British people in their homes, for weeks and months (at the time of writing the UK has entered the eighth week of lockdown). The UK message to “stay at home” has different outcomes for people, and while the overall aim is to save lives, the various challenges and risks of being restricted to the house have been acknowledged in terms of domestic abuse and suicide.

Home can be triggering for people with BFRBs for several reasons. The first is a matter of time. BFRBs are a massive time-suck, as their compulsive and often subconscious nature can lead to hours lost each day. This loss of time was described to me as a “zoning out”, similar to what has been written on compulsive gambling (Schüll 2014). During lockdown, the change in routine and excess time can increase the chances of procrastination and makes it harder to avoid entering the zone of pulling/picking. Working from home also creates additional challenges, as people often depended on being surrounded by colleagues to limit their BFRB activity during the day, but with no one around to hide from, sitting alone at computers becomes the ultimate trigger zone. Staying home creates new ways of being seen, and remaining hidden. As one woman with dermatillomania told me, “With no social plans, other than Zoom sessions showing me from the shoulders up, I have felt free to mutilate my skin without the usual post-picking panic of how to hide the damage before I head out to meet friends.” Similarly, a woman with trichotillomania said she had lost so much hair during lockdown that she is afraid to be seen publicly once the restrictions are lifted.

Staying home also affects the way we see ourselves, and for people with BFRBs, mirrors are some of the most triggering objects. This has been acknowledged in many of the BFRB COVID-19 advice blogs, suggesting that people cover mirrors, limit time in front of mirrors, or stick motivational messages on mirrors to avoid the negative effects of obsessing in them. In a recent conversation, a woman with skin picking described this situation to me, “With all this extra time at home, I have had to cover my bathroom mirror with a square of brown paper as I quickly began spending increasing amounts of time stuck in front of it. A bored/restless/isolated individual with a BFRB and an accessible mirror is like a moth to a flame.” Finally, as mentioned earlier, the presence of family members at home can bring additional struggles for people with BFRBs, limiting privacy, and often increasing the likelihood of embarrassment and shame associated with hair pulling and skin picking.

Isolation

Isolation is a familiar experience for people with BFRBs who have often spent years thinking they were alone in their picking and pulling obsessions, keeping it a secret from those around them. My PhD thesis (Bradley 2019) followed the journey of women, men and children through this isolation, to finding out that their “weird habit” had a medical name, and connecting with other people who have it too. These social relations become incredibly powerful and can develop into essential support networks.

The physical distancing enforced by the UK lockdown has reinforced this isolation for many people living with BFRBs, who are unable to attend in-person support groups. This year, a major event in the BFRB calendar was affected by the pandemic, the annual conference run by the TLC Foundation which was meant to occur in April. This conference is a rare opportunity for hundreds of BFRB sufferers and their families to spend a weekend together among leading clinicians and researchers. During my PhD research, I attended 3 of these conferences and witnessed the transformative effects of connecting with this international community. These conferences really are a lifeline for many people who feel deeply isolated by their BFRB all year long. Being unable to attend the conference has been difficult for some of my BFRB contacts, including one woman who travels from the UK to America for the event each year. She told me, “My heart was broken when we knew that the conference would not go ahead. Everyone knows it’s for the best and safety comes first, but it is such a huge part of BFRB lives. It’s our annual second family gathering.” COVID-19 restrictions have certainly created distance among families, and in this case, the community networks that provide care in ways that mirror familial bonds.

However, we are also reminded during this time that physical distancing does not have to mean social distancing, as technology offers us ways to stay connected. TLC are now providing weekly “hang-outs” for their conference attendees, which has greatly comforted those who join them. Similarly, monthly BFRB support groups in the UK have increased to offer people weekly virtual support. Adapting these groups online has meant that they are now accessible to more people, more frequently, and people have said that they are “the highlight of their week”.

So while scholars consider the long-lasting mental health implications of COVID-19, it is important to acknowledge the unique ways that different mental disorders are affected by this pandemic, especially conditions that receive little attention like BFRBs. Finally, we should make sure to pay attention to the sustained efforts of people who are finding new ways to care, for themselves, and for one another during the isolation of lockdown.

Bridget Bradley is a lecturer in Social Anthropology, University of Edinburgh

Works Cited

Bradley, B. and Ecks, S. (2018) “Disentangling family life and hair pulling: Trichotillomania and Relatedness”. Medical Anthropology. 37(7): 568-581.

Bradley, B. (2019) Biosocial Journeys: Care and Community in Experiences of Body-Focused Repetitive Behaviours. PhD Thesis. University of Edinburgh.

Schüll, N.D. (2014) Addiction by Design: Machine Gambling in Las Vegas. Princeton: University Press.

BFRB Support Links

The TLC Foundation for Body-Focused Repetitive Behaviours: www.bfrb.org

The Picking Me Foundation: www.pickingme.org

To join online BFRB support groups during COVID-19, please contact: Bridget.Bradley@ed.ac.uk



COVID-19 and gender-based violence in conflict: new challenges and persistent problems, writes Catherine O’Rourke

|

Peace is not just the absence of war. Many women under lockdown for #COVID19 face violence where they should be safest: in their own homes. Today I appeal for peace in homes around the world. I urge all governments to put women’s safety first as they respond to the pandemic. – Antonio Guterres, April 6, 2020

This call followed swiftly on the UN Secretary General’s call for Covid-19 ceasefires.  With the exhortation to states to ensure women’s security during the COVID-19 restrictions, the UN Secretary-General not just echoed his own ceasefire call, but echoed concerns from women’s rights activists globally about the potential adverse impact of COVID-19 restrictions on women’s experiences of violence and inequality. We do not yet know the full impact of COVID-19 restrictions on victims of violence within the home and their survival strategies, for women human rights defenders, for gender rights activists and women with insecure emigration status, for women IDPs and refugees, and for women seeking inclusion in ongoing peace processes. Nevertheless, the prominence of the Secretary-General’s call is important as it indicates the ways in which the UN now sees intimate partner violence (IPV) as a matter of international and intergovernmental concern, which is itself a paradigm shift.

Political Settlements Research Programme (PSRP) research on gender-based violence and its relationship to conflict includes useful insights on the likely impacts of the COVID-19 restrictions in conflict-affected settings. The PSRP blog distils some of the most pertinent insights from PSRP research, drawing in particular on Jessica Doyle and Monica McWilliams pathbreaking longitudinal study of the impact on women’s experiences of intimate partner violence (IPV) of the formal end to conflict in Northern Ireland; Aisling Swaine’s comparative study of the evolution of conflict-related violence against women before, during and after conflict in Liberia, Northern Ireland and Timor Leste; Fidelma Ashe’s report on the qualitative impact of the end of conflict on LGB&T security in Northern Ireland; and PA-X findings on gender provisions in peace agreements.

1. In violently divided societies, alienation from police will further reduce women’s capacity and willingness to report domestic violence.

In 1993, McWilliams’ initial study on the impact of ‘The Troubles’ (as Northern Ireland’s conflict was euphemistically called) on women’s experiences of domestic violence identified a high degree of alienation from the police, in particular from women in the minority Catholic/Nationalist/Republican community. This alienation was a key factor in discouraging their reporting of domestic violence.

The updated 2018 study found a dramatic improvement in confidence in the police by domestic violence survivors. Nevertheless, the high degree of control exerted in IPV relationships continued. Indeed, the study identified a specific perpetrator strategy of ‘social isolation’ of victims. For example, 54 of the 63 study participants (86%) reported that their partner had prevented them from seeing or contacting their families and friends. Forty-eight participants (of 63; 76%) reported that their partner needed to know their whereabouts at all times. More than three quarters of participants in the 2016 study (49/63; 78%) reported that IPV had disrupted their income-generating activities such as employment and education, as well as hobbies and leisure activities. The controlling behaviour of the perpetrator and impact of abuse had serious negative effects on the physical and psychological well-being of participants.

The compounding effects of social isolation as a perpetrator strategy, aligned to alienation from the police in many conflict-affected settings, need to be factored into any response to COVID-19’s gendered impact.

2. The further empowerment of security forces in conflict settings can exacerbate gendered and sexual harassment.

The further empowerment of state actors to enforce COVID-19 restrictions can heighten the forcible regulation of gender norms. Research conducted during the Troubles in Northern Ireland found gay and lesbian young people frequently reporting gendered forms of harassment. For example, in instances of police harassment, sexuality was often focused on as a ‘vulnerability’, and in particular with regard to people from Catholic/Nationalist/Republican communities, to be used to push people to become ‘informers’. Informing was in itself a lethal activity given that informers were routinely killed by the IRA.

Fidelma Ashe’s study of LGBT security in postconflict Northern Ireland reveals a situation where LGBT communities still feel insecure.  Even new generations are affected by some of the historic distrust of institutions such as police, with respect to past actions.

3. In violently divided societies, community ‘self-policing’ heightens scrutiny of gender non-conforming behaviour. Also, additional surveillance creates new opportunities for ‘entrepreneurial’ harassers.

 Restrictions imposed by COVID-19 do not only involve formal state regulation, but also a high degree of community self-regulation. PSRP research has found that heightened community self-policing, which is common in conflict-affected settings, manifests in gendered ways. For example, gender non-conforming behaviour can be exploited by non-state armed groups to coerce individuals – fearful of disclosure – into cooperating with them. Moreover, gender non-conforming behaviour – including IPV victims leaving violent households – can be targeted for violent reproach.

Swaine’s comparative research found that conflict can present increased opportunity for state and non-state actors to enact violence on a personal motivational basis, in the absence of or alongside ordered militarised violence. For example, in Northern Ireland and Timor-Leste there is evidence of armed and civilian actors enacting sexual abuse on children and women for personal motivations, enabled by increased contact opportunities resulting from increased surveillance, such as checkpoints.

4. ‘Don’t you know there’s a war going on?’ Crises typically redirect police attention and resources from gender-based violence to ostensibly more urgent matters.

In the context of ongoing ethnic violence, McWilliams’ initial study on IPV in Northern Ireland in 1993 found several domestic violence victims and survivors reporting police disinterest and deprioritisation of their experiences. There is potential for the policing priority of COVID-19 restrictions, coupled with ongoing conflict issues, to risk the further deprioritisation of IPV, unless pro-actively addressed.

5. Crafters of peace agreements typically view issues such as IPV as outside their purview, resulting in a missed opportunity to improve institutional responses.

Despite growing reference to gender and gender-based violence in peace agreements, in line with the WPS agenda, the PA-X database reveal very few references to IPV in peace agreement texts (the only clear examples of inclusion are found in Colombia, Yemen, Zimbabwe). PSRP gender work on peace agreements identifies how the peace agreement texts establish certain path dependencies as to how the issues and institutional reforms that are prioritised in the postconflict setting.  With the UN’s COVID-19 ceasefire initiative, it would be important to both understand how forms of violence against women are included in the terms of the ceasefire, and to understand how addressing IPV can be made a priority for any post-agreement period.

6. Generalised restrictions can be used to target gender non-conforming behaviour.

Outside of conflict contexts, we see evidence of undemocratic leaders using ‘crisis’ to sharpen and toughen measures against perceived ‘deviance’ from gender norms. For example, Hungarian lawmakers have commenced an effort to end legal recognition of gender reassignment amid the COVID-19 crisis.

Such dynamics are often very much shaped by conflict divisions in conflict-affected or post-conflict contexts.  Northern Ireland witnessed efforts by some political leaders to subvert long-awaited and hard won liberalisation of abortion provision due to COVID-19 restrictions. Liberalisation of access to abortion in Northern Ireland was finally secured through Westminster legislation last year and was due to commence at the beginning of April. Some Executive members, including the Minister for Health, sought to postpone provision until the end of the COVID-19 restrictions. These efforts were only reversed by determined action by campaigners compelling health authorities in Northern Ireland to make formal provision for abortion by telemedicine in line with provision with the rest of the UK and Ireland.

7. Generalised feelings of insecurity can further fuel militarism, with gendered consequences.

PSRP research in Northern Ireland found that the increased availability of guns due to the conflict – both legally and illegally held guns – resulted in more fatal incidents of domestic violence in the jurisdiction as compared to the rest of the UK and Ireland. Similarly, the broader demilitarisation of society associated with the peace process positively correlated with a reduction in the use of firearms in domestic violence. Dramatic increase in gun sales in places like the United States, for which we have data, point to further worrying trends in responses to the insecurity engendered by the COVID-19 pandemic.  There is also evidence that organised crime is flourishing as organised criminals seek to step into COVID-19 service provision voids, in countries as diverse as Italy, and Guatemala. These moves are often closely associated with these groups exerting forms of local community control, which are underwritten by increased arms that bring threat of violence into communities and even homes.

Conclusion

Women’s rights activists are rightly calling attention to the uneven gendered consequences of the COVID-19 pandemic and efforts to halt its spread. Whilst the COVID-19 pandemic presents a new and unprecedented global challenge, the gendered effects of crises and complex emergencies are not new. We have a robust evidence base from which to anticipate gendered inequities and to be vigilant against them.

This article was originally published on the PSRP Blog

Dr Catherine O’Rourke coordinates PSRP Gender Research and is Director of the Transitional Justice Institute at Ulster University, a partner in the PSRP Consortium. PSRP Consortium is a partnership with University of Edinburgh’s Law School.

 



COVID-19, emergency legislation and sunset clauses, by Sean Molloy

|

The UK’s Coronavirus Act 2020 affords the UK government new powers in attempt to mitigate the effects of the COVID-19 pandemic, as with similar legislation enacted by governments around the world. But how important are sunset clauses as part of these measures? And what checks and balances are needed?

On 25 March, the UK passed the Coronavirus Act 2020 as part of its attempt to manage the coronavirus outbreak. The Act introduces a wave of temporary measures designed to either amend existing legislative provisions or introduce new statutory powers in order to mitigate the effects of COVID-19 (see Nicholas Clapham’s Conversation post here on the content of the Bill). As countries around the world enact similar laws, there are notable concerns regarding not only the impact of emergency provisions on human rights, but also the potential of emergency powers to become normalised. One response is to utilise sunset clauses. This piece argues that while sunset clauses are both welcome and necessary, they should nevertheless be approached with a degree of caution.

Legislation in Times of Emergency

Following agreement by both Houses of Parliament, the Coronavirus Bill received Royal Assent on 25 March transposing the Bill into primary legislation in the form of The Coronavirus Act 2020 (c. 7). The Coronavirus Bill Explanatory Notes capture the Act’s existence as emergency legislation that ‘enables the Government to respond to an emergency situation and manage the effects of a COVID-19 pandemic.’ Amongst other things, the Act attempts to increase the available health and social care workforce, ease the burden on frontline staff, and contain and slow the virus. Conversely, the Act also grants police, immigration officers and public health officials new powers to detain “potentially infectious persons” and put them in isolation facilities.  It will also enable the government to prohibit and restrict gatherings and public events for the purpose of curbing the spread of COVID-19.

Similar pieces of legislation have been passed across the globe, sometimes following a declared state of emergency and other times existing as emergency provisions (see Asanga Welikala on differences between states of emergence and emergency legislation). In Scotland, for instance, the Coronavirus (Scotland) Act 2020 passed through the full legislative process at Holyrood in a single day. In Ireland, The Health (Preservation and Protection and other Emergency Measures in the Public Interest) Act 2020 was passed by both houses of the Oireachtas (the Irish Parliament) and was signed into law by the President on 20 March 2020. On Sunday 22 March, France’s two-chamber parliament adopted a bill declaring a health emergency in the country to counter the spread of the coronavirus, a move that gives the government greater powers to fight the spread of the disease.

Through emergency legislation, special and extraordinary measures are enacted to respond to certain crises, in derogation of existing standards and rules.  The adoption of emergency provisions invokes differences of opinion regarding their appropriateness and necessity. On the one hand, emergency legislation is thought to enable the state to respond effectively to crises while keeping the exercise of emergency powers within the rule of law. It reflects that, in extraordinary times, Parliament must make some allowance for the passing of laws quickly and effectively should circumstances demand it. On the other hand, emergency provisions, in granting powers to the state that circumvent ‘normal’ legislation, can have adverse effects on the enjoyment of rights to life, a fair trial, liberty and security, and freedom of assembly and association, as examples (see Amnesty International; Joint Committee on Human Rights; Greene). Times of emergency can, therefore, produce what Oren Gross terms a tension of ‘tragic dimensions’ between democratic values and responses to emergencies.

Where one sits on the potential trade-off between government intervention and individual rights and freedoms during times of emergency is a matter of personal opinion (see different contributions from Koldo Casla and Kanstantsin Dzehtsiarous). It is, however, the longer-term implications and impacts of law adopted in response to emergences that raises additional and arguably greater concerns. There is always the risk that exceptional or emergency powers, granted for temporary purposes, can become ‘normalised’ over time. Alan Greene has noted, for instance:

History shows us that emergency powers often outlive the phenomenon that triggers the introduction of emergency powers in the first instance. While the need for exceptional powers may be obvious at the outset of the emergency, assessment of the point where these powers are no longer needed is considerably more problematic.

Elliot Bulmer also identifies that many governments have used emergency powers inappropriately — needlessly prolonging or renewing states of emergency and using emergency powers not to restore democratic normality but to bypass normal channels of democratic accountability. When examining emergency legislation, therefore, one is required to contextualise any assessment in light of the broader realities and tensions faced, accepting as part of this analysis the need for flexibility on the part of the state to respond to the unfolding events. At the same time, it is also necessary and expedient to consider the potential ramifications of any necessary restrictions on the enjoyment of rights at a later stage. Sunset clauses, in theory, exist to bridge this chasm between immediate requirements and future fall outs, ameliorating, in turn, the tension of ‘tragic dimensions’ between democratic values and responses to emergencies.

The Use of Sunset Clauses in Emergency Legislation

Sunset clauses or provisions are dispositions that determine the expiry of a law or regulation within a predetermined period. Through their use, an act or provision automatically ceases in its effect after a certain time. For instance, in the UK, The Terrorist Asset-Freezing (Temporary Provisions) Act 2010 stipulates that its provisions have effect for the period beginning when this Act comes into force and ending with 31 December 2010. Sunset clauses can also make provision for future debate in order to limit the potentially deleterious and undemocratic nature of legislation that is ‘fast-tracked’. Thus, sunset clauses can require either that parliament renew a piece of legislation or replace it with a further piece of legislation subject to the normal legislative process. Indeterminate provisions such as these blur the lines between sunset clauses and post-legislative scrutiny.

Various emergency provisions adopted in response to Covid-19 have included variations or combinations of sunset clauses. In the UK, for instance, section 89of the Coronavirus Act provides that the majority of the provisions will expire after two years. However, this period may be extended by six months or shortened in accordance with section 90. The Government also accepted an amendment, which introduced the requirement that the operation of the Act must be reviewed by Parliament every six months (see section 98). In Ireland, the powers under The Health (Preservation and Protection and other Emergency Measures in the Public Interest) Act 2020 will cease to have effect after the 9th day of November 2020, unless a resolution is passed by both houses of the Oireachtas (parliament) to approve the continuation of the measures. In Scotland, the Coronavirus (Scotland) Act includes a “sunset clause”, according to which most of it will automatically expire six months after it comes into force. MSPs will be able to vote to extend this for another six months if necessary, and then for another six months after that, but this is the absolute limit – so the measures in the Act have a maximum duration of 18 months. In France, the emergency lasts for two months from the day of its adoption, although it can be extended by lawmakers.

Sunset clauses when included in emergency legislation can be seen as a mechanism by which democracies devise ways to accommodate governmental powers within a pre-established legal framework, rather than leave it to governments to use raw power and untrammelled discretion to deal with emergencies in an unregulated way.

The Limitations of Sunset Clauses

Nevertheless, while history teaches us to approach emergency laws with a degree of scepticism, it is equally necessary to adopt a cautious approach to sunset clauses. The addition of sunset clauses notwithstanding, pieces of emergency legislation can remain in force long after the proposed sunset. In the US, for instance, the 2001 Patriot Act adopted in the aftermath of the September 11th attacks, included sixteen sections originally meant to sunset on December 31, 2005. The Act was, however, reauthorised several times in the following years following very limited evaluation. When sunset clauses provide for further debate, the efficacy of the review process is of central importance. However, the mere provision of future scrutiny is no guarantee for the effectiveness of that process. For instance, the Counter-Terrorism Review Project highlights that in the 2003 debate in the House of Lords on whether to renew the Part 4 powers of the Anti-Terrorism, Crime and Security Act 2001 – the controversial measures which allowed for the indefinite detention of non-national terrorist suspects – just four Lords spoke. This included the Minister who had introduced the renewal order. Only 13 MPs attended the first debate in 2006 on whether to renew the Prevention of Terrorism Act 2005 – the legislation which established the control order regime. In addition, the time allotted for debates on sunset clauses is also very short, often limited by parliamentary procedure to only an hour and a half. This has not always been a problem for Parliament. The House of Commons Third Delegated Legislation Committee, which was entrusted to consider whether the Terrorism Prevention and Investigation Measures Act 2011 should be renewed for a further five years, debated the measures for just 32 minutes (see here for discussion). In addition, there are questions regarding the most effective form of review. If parliamentary post-legislative review is the chosen approach, there may be problems associated with politicisation of the legislation in question. Should, then, the review be undertaken by an independent expert, Committees of the House of Commons or Lords, or independent group? If so, how democratic is this process?

Similarly, there are questions around the necessary period of time between adoption and review and between different review processes. Although the UK’s Coronavirus Act allows for review after a period of 6 months, this may still be too infrequent. During the House of Lords review of Fast Track Legislation in 2009, for instance, The Better Government Initiative argued that “post-legislative scrutiny is all the more necessary” in cases of fast-track legislation, and that “it should perhaps be more frequent.” Such is the nature of the pandemic and such is the extent and wide-ranging nature of powers afforded under the Coronavirus Act (and similar pieces of legislation adopted globally), that more review processes might be required. But how might this be achieved in light of social distancing? Of course, many of these are issues that arise in the context of any review process, but they nevertheless demonstrate that there are a range of considerations to flow from sunset clauses, which require ongoing scrutiny themselves. In short, sunset clauses, in whatever form, are important but should also be approached with a degree of caution.

Conclusion

Sunset clauses will continue to be included in emergency legislation adopted in response to the COVID-19 pandemic. They are unquestionably a useful mechanism by which to ensure that emergency provisions do not normalise, thereby entrenching powers that can adversely affect the enjoyment of individual rights and freedoms. At times, they merge with post-legislative scrutiny, conditioning the continuation of legislation on the basis of ongoing and periodic review processes. They can, as noted, ease the tension of ‘tragic dimensions’ between democratic values and responses to emergencies. However, there are limitations associated with sunset clauses. They can exist on paper but have little impact in practice. They can be renewed on an ongoing basis, often with little or insufficient scrutiny. Thus, adherence to sunset clauses must itself be scrutinised. On the whole, emergency legislation adopted in response to COVID-19, will require, as Stephen Tierney and Jeff King note, not only sunset clauses, but also ‘robust parliamentary scrutiny of the powers, and adequate provision for administrative and judicial oversight are imperative for the granting of such significant powers to ministers.’ To this one might also add the important role that the media, civil society, international community and human rights monitoring mechanisms will play in assessing the use of powers granted under emergency legislation.

This article was originally published by the UK Constitutional Law Association and the PSRP Blog

Dr Sean Molloy is a PSRP associate and researcher at Newcastle University Law School. PSRP is a consortium in partnership with the Univeristy of Edinburgh’s Law School.



COVID-19 and violent conflict: responding to predictable unpredictability, by Christine Bell

|

The World Health Organization is working on the basis that death rates rise when COVID-19 casualties exceed domestic health service capacity. The response is to require “social isolation” and shutdowns of large swathes of society and the economy. So far, media focus has been on the crisis in China, Europe, and the United States. However, the world’s poorest countries have little public health care capacity, and often also lack effective central governments with any geographic reach or legitimacy to order — let alone enforce and manage — shutdowns. Unless there are mitigating disease dynamics in other places that are not yet understood, the consequences of the ongoing pandemic on poorer countries will be grim.

At the same time, many of these same impoverished countries are also in the throes of violent conflict. We know from experience that the relationship between armed conflict and crisis is complicated and leads to unpredictable results. If this unpredictability is, however, itself predictable — a “known unknown” — can a “smart” response be put in place? Our ongoing research at the Political Settlements Research Programme suggests that the following 11 baseline understandings are likely to be key in designing the most effective responses to the COVID-19 pandemic in conflict-affected regions:

1. Implementing technical solutions is always political, and “conflict lenses” are needed to anticipate the effectiveness of any response

Violent conflict takes place in deeply divided societies, where “the State” is often seen as owned by and serving “one side” of these division(s). Any disease response needs to factor in that any “technical response” will be understood through local conflict sensibilities. Local populations will appraise and measure any response in terms of wider conflict divisions and lack of trust, which will determine how “help” is received. For example, even in relatively peaceful Northern Ireland, disagreement over when the power-sharing government should implement COVID-19 school closures, took on a conflict hue, as Irish nationalist parties pushed for similar timing to the Republic of Ireland, while Unionist parties awaited the response of the British government.

2. Mid-level peacebuilders have unique capacities to bridge and build trust between the state and local communities

Where and whenever possible, combined messaging by local and international “ethical brokers” who are trusted in local communities can be important for navigating lack of trust. During and after the Ebola crisis in Sierra Leone, networks of local “mid-level” peacebuilders played an important role in building trust for interventions in borderland communities whose experience of the conflict had left them with no trust in the State or its health interventions.

3. Flexible aid may be needed that can bypass the State in contentious areas

Donors may need to provide creative “direct-funding” for local communities, particularly where they are autonomous and oppositional to the state. However, states subject to such bypassing, will likely view this process as a threat to their sovereignty, particularly if the sub-state region has aspirations of becoming an independent state. Hence, aid modalities may themselves need forms of conflict-diplomacy.

4. Crisis management can have “peace dividends”

Moments of crisis can also provide turning points in a conflict, depending on how the parties and international actors behave. COVID-19 itself has already contributed to renewed calls for a ceasefire, and implementation of prisoner releases in Afghanistan. Both were provided for in the recent U.S.-Taliban Agreement, but until COVID-19 evolved into a full blown global pandemic, these provisions were proving difficult to implement. Similarly, President Rodrigo Duterte of the Philippines recently declared a unilateral ceasefire with the National Democratic Front (NDF) to better fight the spread of the coronavirus, although the NDF greeted the call with some suspicion rather than reciprocity. The December 2003 tsunami that devastated Indonesia reinvigorated a settlement process, which was all but dead between the Free Aceh Movement and Indonesian government, resulting in a peace agreement.

5. Conflict parties often seek to make military and political gains, under cover of crisis response

Crises can also be used as cover for military and political gains in a conflict that is continuing. For example, the same 2003 tsunami that arguably helped produce a peach agreement in Indonesia, contributed to dynamics that ultimately saw the peace process in Sri Lanka failing, producing a bloody conflict. In Nepal, the deadly 2015 earthquake pushed the main parties to agree to a permanent constitution, but at the price of narrowing the peace process’ wider promise of inclusion to a range of ethnic and socially excluded groups, including women. In Ogaden Ethiopia, famine and delivery of food aid has often been charged as being a vehicle for the Ethiopian military to gain access to opposition-held areas, and pursue destructive policies such as “de-villagization.” Local humanitarian agreements in Syria, also stand charged with swapping “bread for surrender.” Thus, how crisis response is delivered, and how it enables other agendas, can become independent conflict accelerants, as can perceptions of bias in terms of which communities’ needs are viewed as being prioritized.

6. State and non-State armed actor capacities for mobilization, and their political and military calculations, will be different

During conflict, efforts by international agencies to implement something like a “shut down” will impact very differently on State forces as opposed to non-State forces such as al-Qaeda or the Taliban. In a conflict like Afghanistan, where policing border crossings are key to inserting break points in disease spread, if these are also conflict or rebel-held hotspots, then this will pose added challenges. Local geographies will be affected differently, because crises will affect them differently and because they will have different local political settlements between State, non-State and civic actors, which affect their capacity for coordinated responses.

7. COVID-19 may pose unique logistical challenges to current peace processes

There are challenges that may be unique to COVID-19 because of its global scale, and the nature of the crisis.

8. Diplomacy and peacekeeping may become “absent”

The pandemic has impacted on all forms of diplomacy, from Brexit to regional peace processes. Peace processes depend on diplomacy and third party guarantees. In peacekeeping forces and donor country missions, States are withdrawing personnel. The COVID-19 pandemic has already seen a travel ban and ban on social gathering implemented in South Sudan, where the last transition agreement is but three weeks old, effectively bringing its process of implementation and diplomacy to a standstill. The COVID-19 pandemic differs from the Ebola crisis in that with Ebola diplomacy and internationalized responses could continue beyond shutdowns and immediately affected zones. Whereas with COVID-19, diplomats falling ill, sometimes perhaps as a result of their diplomatic contact, has been a feature of transmission this far. There are innovative ways to use technologies — the two week old Spanish-Catalan dialogue is moving online for example. But, face-to-face contact often has a distinctive trust-building role to play in conflict settings (e.g. Anwar el-Sadat’s visit to Jerusalem, which paved the way to the Camp David Accords).

9. Emergency legislation is a response with conflict-dangers

Western states such as the United Kingdom and France seem to be moving toward forms of emergency law that have little democratic or judicial oversight. Where democratic states go, more autocratic, conflicted states will quickly follow. In divided societies, states of emergency have a long history of uneven application to national minorities and political opponents. They are often “synonyms of sustained and extensive human rights violations.” There are reasons to work within the confines of human rights law, especially during health crises where use of law really matters. In any country, the risk is that while some urgent powers will be needed for health care provision, the police and executive powers will have wider application. In conflict contexts, crisis often provides a pretext for a long-term executive power-grab of dubious constitutionality or other abuses of exercises of emergency powers. A clear danger is that these emergencies do not end when the health crisis does, but continue indefinitely.

10. Elections are also peculiarly at threat, with specific conflict consequences

The social isolation element of containment also means that the holding of elections is particularly at threat in a context where democratic decay is already a global phenomenon and poses a particular risk for conflicted states. Post-conflict contexts depend on elections to resolve power tussles peacefully and avoid governmental breakdown, such is now threatened in Kosovo.

11. A lack of international legal confidence

Finally, the COVID-19 pandemic provides wider challenges because of the moment in which it arises. We are living in a period during which the currency of international norms, international organizations, and globalized responses, are less popular than even a decade ago. For a crisis that is inherently, cross-border — indeed global — in nature, such increased skepticism of multilateralism render necessary cross border global responses harder to put in place.

Conclusion

In conclusion, the COVID-19 threat is unusual in that it is imminent, and globally existential. Countries in conflict have populations who have been facing existential threat for a long time. At time of writing, the U.N. Secretary General has called for a world-wide ceasefire. If illness takes hold in conflicted states, it is possible that this call will be heeded. But even ceasefires require agreements and diplomacy. Creative thinking on how to address coronavirus and conflict together could play a game-changing role in ending unnecessary deaths by disease and warfare in of some of the world’s most troubled places.

This article was originally published in Just Security and on Political Settlements Research Programme (PSRP) blog.

Dr  Christine Bell is the director of PSRP and a professor of Constitutional Law at the University of Edinburgh .



How COVID-19 is used to stop lone child refugees from joining families in the UK, writes Nasar Meer

|

The UK and other countries are using the COVID-19 coronavirus outbreak as an excuse to prevent even the most vulnerable of refugees from crossing their borders.

In recent weeks, according to the United Nations, at least 167 countries have either fully or partially closed their borders. These travel restrictions seem an important means to help contain the pandemic, but they are also proving to be a way for some countries to forfeit their asylum responsibilities.

Presently, at least 57 states are citing COVID-19 to ignore international conventions by making no exception for refugees seeking asylum, even though the World Health Organisation (WHO) offers clear guidance on the use of quarantines and health screening measures at points of entry for those fleeing persecution.

Some politicians have openly signalled their intention to use the present uncertainty to ramp up anti-refugee sentiment. The Hungarian prime minister, Viktor Orbán, for example, has told the people of Hungary that “our experience is that primarily foreigners brought in the disease, and that it is spreading among foreigners”. In Italy meanwhile, the former interior minister Matteo Salvini has claimed that his country’s outbreak was caused by a maritime refugee rescue in Sicily.

Closer to home, the legal charity Safe Passage has issued to the UK Home Office a list of unaccompanied children and vulnerable adult refugees trapped in refugee camps on the Greek islands, but who have been legally cleared for transfer to join family in the UK. The Home Secretary has refused to accept them.

What is at risk in all of this is not just viral contagion, but the very basis of the international refugee conventions that have shaped our post-war landscape. This includes the principle of “non-refoulement” which is the cornerstone of international refugee protection.

Enshrined in Article 33 of the 1951 Refugee Convention, this principle insists that “No Contracting State shall expel or return (‘refouler’) a refugee in any manner whatsoever to the frontiers of territories where his [or her] life or freedom would be threatened on account of his [or her] race, religion, nationality, membership of a particular social group or political opinion.” This principle is in serious jeopardy and Filippo Grandi, the UN High Commissioner for Refugees, has said he fears “the core principles of refugee protection are being put to test”. It is a test we cannot fail.

Even Germany, a country that has in recent years shown the rest of Europe (if not the world) how to successfully take in refugees, has seen the suspension of its humanitarian refugee admission programmes. In the case of Germany, this is expected to be a temporary measure but there is no guarantee this will be the case for other countries.

The WHO has helped establish the International Health Regulations (IHRs) designed to form an international legal position for responding to a public health emergency of international concerns. The regulations were not conceived to undermine the 1951 Refugee Convention nor EU refugee law, where the Charter of Fundamental Rights guarantees the right to seek asylum.

Temporary travel restrictions, therefore, should not apply to people in need of international protection or for other humanitarian reasons.

Indeed, on April 2, the European Court of Justice ruled that Hungary, the Czech Republic, and Poland were not legally entitled to opt-out of EU treaties that required them to take their allotted share of asylum seekers from Greece and Italy in 2015.

There is, of course, a long history of associating diseases with migration, but COVID-19 will not be tackled in the long-term by closing borders to the most vulnerable, and the cost of doing so is profoundly undermining our post-war refugee settlement. Forced returns and refoulement are not justified by suspicion of COVID-19 transmission.

There are ways to manage border restrictions in a manner which respect international human rights and refugee protection standards. It is imperative that in all the uncertainty accompanying this virus these approaches and standards are upheld.

This article was originally published in The Scotsman

Nasar Meer is professor of race, identity and citizenship at the Univrsity of Edinburgh. He is  the principal investigator of the research project: the Governance and Local Integration of Migrants and Europe’s Refugees (Glimer)

 



What do abortion pills mean in a pandemic, asks Leah Eades

|

Like many doctoral students, my research is currently in limbo. I was meant to be moving to Ireland in September to conduct anthropological research on the politics of abortion – but now, I’m waiting to see whether that will be possible. In the meantime, I do the only thing I can: sit in my Edinburgh flat and watch my social media newsfeed fill up with stories of how COVID-19 is impacting reproductive rights and healthcare across the world.

Often, the news is not good.1

Researchers, campaigners, and journalists alike have been quick to note that the pandemic is having a devastating effect on abortion. In some places, COVID-19 has given anti-abortion politicians a thinly veiled excuse to further restrict access to legal abortion – take, for example, Poland, whose government attempted to push through an abortion ban while protestors were on lockdown, or the conservative US states that rushed to categorise abortion as a non-essential “elective” medical procedure, rendering it inaccessible for the duration of the crisis. In other places, such as Gibraltar and Argentina, progress towards legalising abortion has also ground to a halt, with referendums postponed and parliaments closed for the foreseeable future.

That said, even in countries where abortion is legal, the pandemic has shone a light on shortcomings in current abortion law and provision – and particularly the perils of assuming that abortion rights necessarily translate into abortion access. The UK is a good case in point. In England, Scotland, and Wales, legal restrictions have now (after some kerfuffle) been temporarily lifted in order to permit telemedicine abortion, allowing people to receive abortion pills in the post following a telephone consultation. In Northern Ireland, however, abortion only became legal on 31st March. The government, citing the pressures of the pandemic, refused to launch domestic services on that day as initially planned, and instead advised abortion-seekers to travel to England for procedures, in spite of the nationwide lockdown. In response to this inaction, both Alliance for Choice and the British Pregnancy Advisory Service (BPAS) publicly announced plans to provide abortion pills to residents of Northern Ireland – a move that finally prompted the government to change its position and begin allowing abortion on 9th April. Even now, telemedicine abortion remains unavailable in Northern Ireland, unlike in the rest of the UK.

I highlight the UK case as a means to exploring a question that is increasingly on my mind: what do abortion pills mean in a pandemic? In recent years, abortion pills have come to mean a lot of different things to a lot of different people. Often, they’re framed as having revolutionary potential – one that can “change everything” in terms of how abortion is conceptualised, accessed, and provided (Berer and Hoggart 2018), and can be linked to wider processes of demedicalisation and decriminalisation (Jelinska and Yanow 2018). Moreover, the rising availability of abortion pills has significantly changed the political geography of abortion – increasingly, as Sydney Calkin (2018) notes, access is determined not by state-imposed legislation and regulations but rather by fluid, dynamic, and transnational technology and information infrastructures. The COVID-19 pandemic represents, perhaps for the first time, a major reconfiguration of these infrastructures – and one that has profound implications. With borders shutting and supply chains disrupted, the revolutionary potential of abortion pills, now more than ever, is being put to the test. So: how are they faring?

As the UK case above highlights, the possibilities of abortion pills during a pandemic are significant. Through telemedicine abortion, patients are able to access safe, legal abortion without leaving lockdown and exposing themselves and health workers to unnecessary risk. In Northern Ireland, meanwhile, the informal supply of abortion pills provided people with an alternative to abortion travel at a time when such travel was, at best, inadvisable, and at worst, impossible. Moreover, pro-choice groups such as Alliance for Choice and BPAS were able to effectively use the threat of circumventing state restrictions by supplying pills as a means of forcing the government to act.

However, it is important to note that abortion pills are not a panacea – alone, they cannot ensure that abortion is always accessible when it is needed, during a pandemic or otherwise. Firstly, it’s vital to note that medication abortion is not suitable for everyone – there will always be patients who need surgical options, for example those at a more advanced stage of pregnancy or those with pre-existing health conditions or other complications. Secondly, even for those who can have medication abortions, access continues to be shaped by infrastructures that determine who can access abortion pills, as well as where and how. The pandemic has already led to concerns about disruptions to the medication supply chain. In addition, the suspension of international mail in places such as Poland means that abortion pills can no longer be reliably imported, leaving abortion-seekers with even more limited options and in even greater uncertainty.

Finally, even in contexts where abortion pills are available, it’s important to note that, for many patients, they now exist in a context where patients have few other options – it has been reported that 25% of UK clinics are currently closed due to staff shortages, while travel disruptions and restrictions are impacting people’s ability to travel for appointments both domestically and transnationally. As Cassandra Yuill (2020) has pertinently pointed out, rights to choice in reproductive and sexual health care are “evaporating in the name of public health” – and, in so doing, revealing the ideological illusions and power imbalances that underlie many contemporary healthcare systems.

Taken together, these pandemic conditions only serve to highlight the fact that abortion pills are not, and have never been, a silver bullet solution to the issue of abortion access. Certainly, the availability of telemedicine abortion, whether through formal or informal channels, provides important opportunities for safeguarding and promoting abortion access in times of crisis. Nonetheless, times of crisis also reveal the shortcomings and limitations of these pills, which remain entangled within the wider medico-legal nexus, and shaped by infrastructures that depend on global production supply chains and technology and information systems.

While the long-term implications of the pandemic on reproductive health and rights remains to be seen, the current role of abortion pills in attempts to navigate the pandemic highlight that no one technology has the power to “change everything”. If we want to ensure abortion is accessible for those who need it, then we have to address the broader political, cultural, socioeconomic, and structural factors that shape the contexts that these technologies exist within.

Leah Eades is a PhD candidate in Social Anthropology at the University of Edinburgh. Her research looks at abortion and the politics of reproduction in Ireland following the repeal of the 8th Amendment. You can follow her on Twitter at @AnthropoLeah.

References

Berer, Marge, and Lesley Hoggart. 2018. “Medical Abortion Pills Have the Potential to Change Everything about Abortion.” Contraception 97 (2): 79–81. https://doi.org/10.1016/j.contraception.2017.12.006.

Calkin, Sydney. 2018. “Towards a Political Geography of Abortion.” Political Geography 69: 22–29. https://doi.org/10.1016/j.polgeo.2018.11.006.

Jelinska, Kinga, and Susan Yanow. 2018. “Putting Abortion Pills into Women’s Hands: Realizing the Full Potential of Medical Abortion.” Contraception 97 (2): 86–89. https://doi.org/10.1016/j.contraception.2017.05.019.

Yuill, Cassandra. 2020. “Reproductive Rights in the Time of COVID-19”. Somatosphere, 29 March. http://somatosphere.net/2020/reproductive-rights-in-the-time-of-covid-19.html/.

 

 

 

  1. For up-to-date news about the impact of COVID-19 on reproductive health and rights, I recommend consulting the Centre for Reproduction Research’s COVID-19 and Reproduction Digest as well as the International Campaign for Women’s Right to Safe Abortion’s news archive.


Edinburgh based anthropologist and artist auctions her painting to raise funds for the NHS, writes Aphaluck Bhatiasevi

|

Inês-Hermione Mulford is a resident artist at the Royal College of Surgeons.  She graduated form the University of Edinburgh in Social Anthropology in 2018.  She combines the disciplines of the arts and sciences through anthropological research and uses the medium of paint to present her findings.   She wanted to do something to help raise funds for National Health Services (NHS).  Her mother is a midwife based in Oxford, while she lives in Edinburgh.

“We are in a health crisis and are told to stay home to help prevent the spread of COVID-19, and to protect our NHS. My sister Felicity and I wanted to do something, but during these times, we can’t go on long distance runs or organize a social activity to raise funds. We’ve been discussing over Facetime as she’s in Oxford,” said Ms Mulford. They decided to develop a website where they could auction one of her oil paintings to help raise funds.

She has relocated her studio to her flat and developed her website during the lockdown.  The oil painting she chose to put out for auction was recently created as part of her surgical art series from her flat during the COVID-19 pandemic.   It displays the white gowns and hands of a surgeon and a nurse performing a surgery. She has named this painting “PPE” (personal protective equipment). The auction will be closed at 5pm on Friday the 8th of May 2020. The funds from the auction will be managed by the NHS Trust, with the contributions going to  NHS Edinburgh and NHS Oxford.

To create the paintings, in normal times, she captures images of surgery in real time, while performing the surgery, through sketches and photographs. She then follows-up with discussions with surgeons and nurses. When she gets back to her studio, she reviews these materials, and then begins to work on her painting.  “I try to reflect on the complexity of the surgical artform, both in the theatre and on canvas,” said Mulford.

Ms Mulford is currently working on a set of paintings on robotic surgery where she explores relationships between the surgeon, the robot and the painting. This piece of work is part of ‘The Body Voyager’ exhibition which will feature work on the future of surgery. It was scheduled to be on display at the Surgeon’s Hall Museum in October 2020, but due to the pandemic, the exhibition has been postponed to March 2021.

Aphaluck Bhatiasevi is a PhD candidate in Social Anthropology at the University of Edinburgh

 

 



The UK COVID-19 response ignores impact of social inequalities, by Nasar Meer, Kaveri Qureshi, Ben Kasstan and Sarah Hill

|

In April 2020, National Health Service (NHS) England and Public Health England launched an inquiry into the disproportionate impact of COVID-19 on Black Asian and Minority Ethnic (BAME) communities. As we wait for the terms of reference to be announced, and with mounting disquiet over the lack of transparency and appropriateness of its membership, it is imperative that policy-makers, public agencies and researchers maintain a broad focus on the underlying determinants of susceptibility to the virus and not allow the physiological risks to be separated from their social exposures.

In our recent submission of evidence on COVID-19 and the disproportionate infection and mortality rates for BAME groups, we set out why the UK government response, including its emergency legislation in the Coronavirus Act 2020, overlooks the inequalities broadly experienced by ethnic minorities.

As of 24 April, data from the Intensive Care National Audit and Research Centre indicate that people from Mixed, Asian, Black and Other ethnic groups make up a third of patients critically ill with confirmed COVID-19, whilst only constituting 14% of the general population in England and Wales. Meanwhile, the Racial Equality Foundation calculated – from data up to 21 April – that the risk of dying in hospital from COVID-19 was twice as high for people of Mixed ethnicity, nearly three times as high for British Asians, and four times as high for Black and Other ethnic groups compared with White British people.

This disproportionate burden of COVID-19 among ethnic minorities mirrors the picture emerging elsewhere, including the United States, Sweden and Spain.

Despite long-standing evidence that increased health risk in UK ethnic minorities reflects underlying inequalities in housing, employment and income, medical ‘experts’ continue to propose various biological (and even genetic) ‘explanations’ for this pattern. A recent piece in the British Medical Journal opined that “BAME individuals… lack knowledge on the importance of a balanced and healthy diet containing all essential micronutrients that are required to boost immunity and prevent infectious diseases”.

This ignores the overwhelming weight of evidence that ethnic inequalities in health are driven by social, economic and political divisions, and reinforces harmful (and flawed) conceptions of cultural essentialism which deflect responsibility onto the victims of structural discrimination (Williams and Mohammed, 2013).

It is true that the disproportionate burden of COVID-19 among BAME undoubtedly reflects greater levels of pre-existing chronic health conditions in these groups. Yet these higher levels of chronic illness are themselves the product of socioeconomic disadvantage and other manifestations of racial discrimination (Phelan and Link 2015).

From the post-war to the present, both institutional and personally-mediated racism have channelled new migrantsinto the lowest rungs of the UK’s segmented labour market (Meer, 2020). As in most countries, institutional racism in the UK ‘unwittingly’ allows White people to gain more from the education system, the labour market, and the health system (Hill 2015), while also affording marginal attention to the racial dimensions of policy responses in health and other sectors (Salway, 2020).

It is for these reasons that COVID-19 and the UK Government response have the potential to amplify existing socio-economic disparities and racial discrimination that undergird ethnic health inequalities. The same factors that predispose people from ethnic minorities to live and work in circumstances that engender chronic ill health are those that will make it harder for these same people to protect themselves from COVID-19 by social distancing.

Ethnic minority households are more likely to be overcrowded and multi-generational, minority groups are grossly overrepresented in institutional settings where social distancing is ineffective and impracticable, and they are more likely to be in keyworker occupations where they are compelled to continue at work.

Worryingly, we anticipate extremely disproportionate economic impacts from the lockdown that will compound these social inequalities even further. As noted above, ethnic minorities have been incorporated into the UK’s segmented labour market in ways that direct them predominantly towards sectors offering few job protections, including a lack of provision for sick leave and sick pay (Qureshi et al., 2014).

It is deplorable – but sadly unsurprising – that The Independent’s BMG poll found people from BAME households are almost twice as likely as White British people to have lost income and jobs.

As such, the terms of reference for the inquiry must not be narrowly focused, but reach beyond these peak months into the long-term and disproportionate impact of COVID-19 on BAME groups. We urge NHS England and Public Health England to focus on the social determinants of health, and demand action on long-standing inequalities. In order to secure sustained public health preparedness, the UK needs a long-term commitment to improving social protection and social equity for all our communities.

This post is reproduced from Discovery Society

References
Hill, S. (2015) ‘Axes of health inequalities and intersectionality’, in: K. Smith, C. Bambra and S. Hill (eds) Health inequalities: critical perspectives. Oxford: Oxford University Press.
Meer, N. (2020) ‘Race and Social Policy: challenges and contestations’, Social Policy Review, 32, 5-23.
Phelan J. and B. (2015) ‘Is racism a fundamental cause of inequalities in health?’, Annual Review of Sociology, 41: 311-330
Qureshi, K., et al. (2014) ‘Long‐term ill health and the social embeddedness of work: a study in a post‐industrial, multi‐ethnic locality in the UK’, Sociology of Health & Illness, 36(7), 955-969.
Salway, S. et al. (2020) ‘Transforming the health system for the UK’s multiethnic population’, British Medical Journal, 368.
Williams D. and Mohammed S. (2013) ‘Racism and health I: Pathways and scientific evidence’, American Behavioral Scientist, 57(8): 1152–1173.

Nasar Meer is Professor of Race, Identity and Citizenship at the University of Edinburgh and a Commissioner on the Post-COVID-19 Futures Commission convened by the Royal Society of Edinburgh (RSE). @NasarMeer Kaveri Qureshi is a Lecturer in Global Health Equity in the School of Social and Political Science at the University of Edinburgh. @KaveriQureshi Ben Kasstan is a medical anthropologist based at the Department of Sociology & Anthropology at the Hebrew University of Jerusalem, and affiliated with the University of Sussex. Twitter: @kasstanb Sarah Hill is a Senior Lecturer in the Global Health Policy Unit at the University of Edinburgh. @sarahhilltop

 



Edinburgh based sociologists document their social transformation by the COVID-19 pandemic to create new sociological knowledge, writes Aphaluck Bhatiasevi

|

As sociologists voice out on how the COVID-19 lockdown is impacting societies across the world by transforming the social relations and interactions, a group of sociologists at the University of Edinburgh have come together to curate a blog to document and share personal experiences on how the pandemic has transformed them socially.  The objective of this virtual diary in the form of a blog, is to share experiences as a collective, and to generate new knowledge on social transformation.

I recently interviewed Prof Liz Stanley and Dr Angus Bancroft, curators of the blog Edinburgh Decameron: Lockdown Sociology at Work. They told me about how the blog emerged from conversations they had with other members of the Sociology Department through Skype, Zoom and Teams meetings under the lockdown.  Dr Bancroft is interested in maintaining the sociological community and documenting the social change which may influence the creation of new knowledge, while Prof Stanley is interested in ideas of storytelling, from the “Decameron” perspective where different people who may be in similar situations, tell different stories because of their different experiences. Both the experts wanted their blog to get away from the usual scientific discussions they have in the academia, to reflect on the COVID-19 times as sociologists and as human beings, which includes being able to express anger and upsetness with the situation.

Concerning some of the contradictory things happening, Prof Stanley spoke about one of these being the tussle between rationality and emotionality that many people, herself included, are presently experiencing. Although not a sentimental person, she commented on finding that things like the Thursday clap for care staff and reports of hundred-year birthdays touched an emotional nerve because linked to the shared sorrow or trauma of so many deaths occurring.

Dr Bancroft says the lockdown has changed their lives as academics. “How we do scholarship and teaching will be very different.  Whether our students will be based in Edinburgh or not in the coming year, we don’t know.” Inspired by renowned British sociologist Sir Patrick Geddes’ observational techniques to discover and work with relationships among place, work and folk, Dr Bancroft says this form of documentation of experiences may lead to new knowledge and theories in sociology.  For instance, Edinburgh as a place which houses the University is important to the discovery of how education may be transformed by COVID-19.  The notion of how time is perceived and during the lockdown is very different for different people, says Prof Stanely. While some people say they have a lot of free time at hand, others may feel their time has passed by quickly without being able to do what they had planned to.

As a collective, they want to document the different stories told by sociologists living in a real pandemic, a transformation from the imagination, only a month ago. These stories, told in forms of structured narratives through written texts, poems, images and voice or video recordings, carry momentum that moves forward accounts. Interpretations of these viewpoints in future dates will provide evidence and arguments, analysis and conclusions to inform development of social theory.

The blog is open to the university’s staff, students and alumni, to share their experiences from different parts of the world.

 

Prof Liz Stanley is a professor of Sociology in the School of Social and Political Science at the University of Edinburgh.

Dr Angus Bancroft is a senior lecturer of Sociology in the School of Social and Political Science at the University of Edinburgh.

 

 



Edinburgh Infectious Diseases members make COVID-19 information accessible in over twenty languages, writes Hilary Snaith

|

COVID-19 is affecting the great majority of people on the planet in one way or another and information (fact and fiction) relating to the pandemic is circulating via social media streams at an astonishing rate.

Providing factual, accessible, and unbiased interpretations of insights emerging from COVID-19 research is critical.  To help contribute to this Edinburgh Infectious Diseases  published summaries of the talks at the Edinburgh Coronavirus Workshop at the end of March.

However, as with so much of the information that is available about COVID-19, these summaries are in English.

Engaging locally and globally

To make this information much more accessible for people whose first language is not English, the Edinburgh Infectious Diseases community came together to translate these summaries into twenty one different languages from around the world.

Over 50 students, postdocs and group leaders have generously contributed their scientific and linguistic knowledge to the project, which has now published translations in Arabic, Bosnian, Chinese, Croatian, Czech, Dutch, Esperanto, French, German, Hindi, Italian, Malay, Nepali, Polish, Portuguese, Romanian, Russian and Spanish, Telugu, Thai and Turkish.

“I’m delighted that so many members of our international community in Edinburgh have contributed to this initiative allowing access for non-English speakers from around the world to learn about the cutting edge COVID-19 science being carried out in Edinburgh that is being used to inform clinical treatment and public health measures,” said Professor Ross Fitzgerald, Director of Edinburgh Infectious Diseases.

Particular thanks are due to Nat Ring at the Roslin Institute and Julie Fyffe in the School of Biological Studies, who collated and compiled the translated texts, he added.

It has been wonderful to see how many people from across Edinburgh Infectious Diseases and beyond have come together to make this project possible, and highlights the truly global diversity of our staff and students.

For the translated summaries of the talk from SARS-CoV2/COVID-19 workshop please visit Edinburgh Infectious Diseases website.

Hilary Snaith is the Manager of Edinburgh Infectious Diseases, Univeristy of Edinburgh.



The many masks of a lockdown, by Krithika Srinivasan

|

The ways in which a ‘non-discriminatory’ virus can very quickly evolve into a disease of the poor

Communicable diseases, we know, affect socio-economically disadvantaged communities disproportionately. But how do these inequalities emerge? We now have a live example in COVID-19.

Until recently, the virus has been non-selective in whom it affects: it could be people in the global North, the non-poor everywhere, people who are not used to being vulnerable to contagious diseases. These are also the people who influence state responses — scientists, policy-makers, commentators. And so lockdown and social distancing were rapidly established as the one-size-fits-all response to COVID-19 globally — despite the variations in the impact of the disease and the serious social consequences of such measures.

While these measures protect people by reducing and slowing down transmission, what has also become quickly apparent everywhere is that they benefit only a minority of the population — those who have salaried jobs, savings, fridges large enough to stock groceries, and homes spacious enough to stay indoors without confinement causing health problems.

Whom they cannot protect are those who face bigger everyday health threats — hunger, homelessness, the risks of more dangerous diseases. If anything, a lockdown adversely affects the vast majority of people for whom this novel coronavirus is a smaller risk when compared to more serious and immediate issues such as hunger, domestic violence or eviction. And when ‘home’ is a room in a slum with community toilets, or when lockdown refugees are transported in buses or housed in makeshift camps, there is clearly greater crowding than if they were outdoors: it might well be that lockdown then exacerbates the spread of the virus among them.

Even in the U.K., where social security systems are stronger, more than 2 million people are estimated to fall through the cracks: sex workers, gig economy workers, the newly self-employed, lone parents in small flats with little savings and no childcare support, women and children subject to domestic violence, and those with other physical or mental ailments.

In the dominant response to COVID-19, there is clearly a deeply uneven distribution of risks and benefits. And this includes inequalities in the impact of the disease. Indeed, there is already evidence from major cities in the U.S. and the U.K. that minority ethnic groups are disproportionately impacted by, and die of, COVID-19 — because they are more likely to be employed in essential services, or live in conditions that don’t allow for social distancing, and are less likely to have access to healthcare.

Political pathogen

And so what was initially a ‘non-discriminatory’ virus is very quickly evolving into a disease of the poor because of the response of lockdown and social distancing. Lockdown flattens the curve, but in the process skews the curve in terms of who is affected. It helps prevent situations where hospitals have to make ethically-charged decisions about whom to prioritise for beds and ventilators — but it does so by displacing ethical questions onto ‘inadequate social security systems’ and amorphous government and private sector processes.

Some argue that social distancing and lockdown have to be in place until there is a vaccine or until healthcare systems are strengthened. But both vaccine and systemic improvements will again be more readily accessible to the middle and upper classes, as is already the case with testing and hospital-based care for COVID-19. So, when the lockdown is finally lifted, COVID-19 will become firmly established as a disease of the poor, like so many other infectious diseases already are.

This is how a pathogen becomes political. This is how health inequalities are created. But this isn’t new; there’s ample research on health inequalities. Yet, as social distancing and lockdown started being replicated across the world as the only appropriate response to COVID-19, there was almost no resistance in the U.K. and the U.S.

On the contrary, there was near-total compliance and those who raised uncomfortable questions were dismissed and shamed. In India, some sections of the media, academia and the Left have actively challenged the lockdown approach from the start, but in the U.K., critical questioning began only after the third week.

The strength of science lies in its openness about uncertainty, and the ability to challenge assumptions and hypotheses. However, with COVID-19, modelling predictions that support lockdown have been presented and accepted as the singular truth. Other equally plausible interpretations querying the lockdown rationale have been condemned or ignored. Countries like South Korea, Taiwan, Sweden and Germany, which have adopted different approaches to COVID-19, have been set aside as anomalies or, in some cases, even had their data on mortality rates questioned.

In India, where transmission and mortality rates have so far been very low relative to population size and density, the dominant narrative is that this is an indicator of inadequate monitoring and reporting, or because the country is yet to experience a peak. There is a reluctance to engage with other explanations.

Some lives only

Why has the lockdown solution become so entrenched? Is it because the debate became inaccurately framed as a conflict between the economy and human lives, when in fact, as one writer pointed out, it is actually a conflict between some lives and other lives? Or does it have to do with the pathogen and disease itself? Is it because those of us in the middle and upper classes are not accustomed to the risk of catching and dying of communicable diseases?

Epidemiological transitions have meant that communicable diseases have become strongly associated with poverty. To be then suddenly faced with a contagious disease that can kill and that cannot be avoided with better nutrition and living conditions must be deeply unsettling. Money and social privilege have temporarily lost their protective function — the list of high-profile people affected by COVID-19 includes Idris Elba, Prince Charles and Boris Johnson.

This situation is further complicated because it appears that many infected people are asymptomatic but can nevertheless transmit the virus. So, suddenly, everyone is at risk and everyone poses a risk — even if being infected does not always lead to disease, and even if having the disease is unlikely to cause death. It is not really possible to develop a public health strategy that selectively protects only those who are vulnerable — because we don’t know who is likely to be vulnerable.

Perhaps this explains why COVID-19 has generated so much fear among the wealthy and the middle classes even though its impacts and death toll pale in comparison to diseases of the poor such as diarrhoeal disease and tuberculosis, each of which kills around 1.3 million people every year. Perhaps this explains the lack of resistance to the ‘There Is No Alternative’ to lockdown narrative.

Some of its strongest advocates, such as hedge fund billionaires, are from sections of society that have always spoken against state investment in public health. Lockdown has made visceral sense to those of us who by virtue of belonging to the middle or upper classes have not really known — until now — what it means to have one’s health vulnerable to factors outside one’s perceived control.

With COVID-19, we have become acutely aware that our health is tied to others, and to what the state does or does not do. We want the state to take ‘strong’ measures that protect us from the rest of society, the rest of humanity. The poor have always known this — that their health is not within their control; that the choice is between drinking no water at all and drinking contaminated water. But their lives have not mattered enough to generate the kind of state-led action that COVID-19 has.

Personal stakes

Perhaps this is why, barring some exceptions, those who have spent their lives investigating health inequalities now seem oblivious to how only one data interpretation has been favoured in the media and by thought-leaders, and others rejected as anti-science. Perhaps we have suddenly lost our capacity for critical reflection because this is an issue in which we have personal stakes. After all, lockdown benefits ‘people like us’, a minority of humankind, even as it actively harms the rest.

The irony is that those who benefit from lockdown do so only because there are others who aren’t going into lockdown and who continue to face the risk of infection. In our deeply interconnected societies, every minute aspect of our everyday lives — from food and water to electricity, phone and internet connections, sewage systems and waste management services, and medical supply chains — depends on the work of other people who, more often than not, are those in low-income occupations. We may cheer them from the safety of our homes on Thursdays or Sundays, but we lose no time in also shaming them for their ‘irresponsible behaviour’ for being out on the roads or in public spaces.

So, what is the alternative? How can we address COVID-19 in ways that don’t further marginalise and harm already vulnerable people?

The first step is to overcome the ‘There Is No Alternative’ loop. Looking beyond lockdown will enable more careful engagement with the evolving science on the disease, the experiences of countries that have considered alternative approaches, and the regional variations in the prevalence and impact of the disease.

Crucially, we must foreground fundamental ethical issues. At this juncture, it is simply not enough to call for better social security measures — all that does is to displace blame and responsibility in time and space. We must instead ask hard and immediate questions about whether it is right to expect the poor to shoulder the burden of measures that don’t really protect them, and worse, can actively harm them.

More specifically, we could examine a strategy that is based on voluntary measures: trust people to decide whether the risks of contracting COVID-19 are higher than the risks of starvation or being beaten to death or dying of some other disease; back it up with the necessary social security interventions so that they have real choices. This is crucial, because no matter how serious a threat the novel coronavirus might pose, there are people everywhere who face and have always faced far greater threats to their lives, health and well-being. We need to think beyond pathogen and infection and act for health.

Last week, I was at a grocery store in Edinburgh when a woman came in to do her shopping wearing a mask, visor and gloves. The elderly shop assistant of South Asian origin smiled kindly at her and said in broken English: “You are very afraid? We are all going to ‘go up’ one day, you know?” This to me captures the essence of the huge social divide that characterises the dominant response to COVID-19.

Krithika Srinivasan is a lecturer in Human Geography at the University of Edinburgh. This post was originally published: https://www.thehindu.com/todays-paper/tp-features/tp-sundaymagazine/many-masks-of-a-lockdown/article31379402.ece

 



Lockdowns save, lockdowns kill: valuing life after coronashock, writes Stefan Ecks

|

The scale and severity of the coronavirus pandemic is a shock to health systems. It is a shock to economies and governments. It is also a shock to the life sciences, which were meant to anticipate a pandemic of this magnitude, but failed to do so. The “life sciences” in question are virology, epidemiology, biomedicine and pharmacology. But the social, political, and economic life sciences were also unprepared for COVID-19. It will take an in-depth autopsy to see why anyone in the social sciences believed the people in medical sciences when they told us it would only be “the pandemic perhaps” (Caduff 2015) rather than the pandemic for sure—and probably soon. COVID-19 is not only a viral pandemic, it is also a pandemic of epistemic unpreparedness.

How life is valued has become an urgent question (if it hasn’t been an urgent question long before). As the social life sciences are reeling from coronashock, how can we theorize the value of life to make sense of the current moment? At its most basic, life is value, and enhancing life means to enhance value. Living means valuing, and what makes people’s lives better is valuable. But what, exactly, “improves life”? To say that life values living “still doesn’t answer the question of what it means to ‘improve people’s lives,’ and on that, of course, rests everything” (Graeber 2019: 208). What does it mean to “make life better” in coronatimes? Lockdowns have been enacted in many countries, with profound consequences. What is the value of “lockdowns,” are they worth it?

The “lockdown” has emerged as the signature biopolitical response to coronashock. The rationale of the lockdown is to delay the spread of coronavirus infections. The value of lockdowns is that they “buy time.” Without lockdowns, hospitals might be overrun by patients and too many lives might be lost before a biomedical treatment can perhaps be found. To date, no vaccine or any other pharmaceutical therapy is available. COVID-19 reduces the scope of biomedicine to acute intensive care: keeping people alive on respirators if the infection takes a bad turn. The only interventions available are about population control. Some of these techniques include contact tracing and testing for acute infections. Other measures control individual movement and behaviors. These include border checks, travel bans (both internal and cross-border), quarantine (at home or in public facilities), physical distancing, closing of workplaces and educational institutions, canceling public events, closing public transport, and wearing face masks (Hale et al. 2020). Any of these measures can be advisory or mandatory. A “lockdown” is a maximal combination of these measures, with a focus on prohibiting citizens’ physical movement outside their homes. Lockdowns are investments in population health that come at a huge cost in other areas of life. But what are these “costs,” and what are these “other areas of life”?

SARS-CoV-2 was first detected in the city of Wuhan in China’s Hubei province in December 2019. For several weeks, the Chinese authorities suppressed news reporting about the spread of the new disease. Li Wenliang, a Wuhan doctor who used social media to alert medical colleagues of the disease was forced by the police to retract everything he had said; he died on 7 February with COVID-19 (Buckley & Myers 2020). China officially notified the World Health Organization of the outbreak on 31 December 2019. In early January, WHO issued its first guidance on how to deal with the virus “based on experience with SARS and MERS and known modes of transmission of respiratory viruses” (WHO 2020). The first case outside China was confirmed in Thailand on 13 January 2020. The first WHO committee meeting on whether COVID-19 should be classified as “public health emergency of international concern” (PHEIC) took place on 22-23 January. A consensus was not formed at the time, but one week later, WHO decided that the outbreak is a PHEIC. On 23 January, the Chinese government imposed a fēng chéng (“blockade line”), first on Wuhan and soon on other Chinese cities. On 11 March, WHO classified the outbreak as a “pandemic.” On 13 March, the Chinese government partially lifted the lockdown, and ended it officially on 8 April 2020.

Most governments were initially skeptical of lockdowns. Governments asking citizens to stay indoors and avoid meeting others has been used in epidemics many centuries before. But the Wuhan lockdown was unprecedented in its scale, its length, and its administrative rigor. On 23 January, Gauden Galea, the WHO representative in China, said that the Wuhan lockdown is an extreme intervention that needs to be carefully evaluated: “The lockdown of 11 million people is unprecedented in public health history, so it is certainly not a recommendation the WHO has made” (Reuters 2020a). Nevertheless, beginning from January, many governments started to issue travel warnings and some moved to close air traffic with China. Italy, for example, suspended flights to and from China as early as 31 January (thousands of Chinese tourists then travelled to Italy via Frankfurt). The same day, the US government declared COVID-19 a “public health emergency” and mandated a 14-day quarantine for passengers who had been to Hubei. From February, country-wide lockdowns that included closure of businesses, schools, and restrictions on all but essential travel came into effect in the US on 15 March. In the UK, similar measures started on 23 March. In India, a country-wide lockdown was imposed on 24 March, stopping the movement of its entire population of 1.3 billion people. The measures in India are the strictest in the world (e.g., not even outside physical exercise is allowed). Most governments hesitated to impose lockdowns but felt pressured to act by the exponential spread of the virus. On 6 March, there were over 100,000 confirmed cases worldwide. Cases numbers doubled by 17 March, doubled again by 23 March, and doubled again by 30 March. By 15 April, more than 2 million people had confirmed infections and 140,000 people had died with the virus (Center for Systems Science & Engineering 2020). By March 2020, the Wuhan lockdown had become the “Great Lockdown” of the world (International Monetary Fund 2020).

Governments in both the US and the UK were reluctant to disrupt their national economies by imposing Wuhan-style lockdowns, but by mid-March the spread of the infection threatened to make hospitals collapse under a “tsunami” of people needing intensive care. Until early March, the US and UK declared their countries would “stay open for business,” both denied that COVID-19 was much to worry about, and both failed in preparing their health services for the massive rise of infections. Boris Johnson, referring to the Wuhan lockdown in a speech on 3 February, said that Brexit Britain values freedom: “humanity needs some government somewhere that is willing at least to make the case powerfully for freedom of exchange, some country ready to take off its Clark Kent spectacles and leap into the phone booth and emerge with its cloak flowing as the supercharged champion of the right of the populations of the Earth to buy and sell freely among each other” (cited in Helm, Graham-Harrison & McKie 2020). Dominic Cummings, the UK prime minister’s chief adviser, summarized the initial strategy: “protect the economy, and if that means some pensioners die, too bad” (cited in Walker 2020). Similar arguments were made in the US (e.g., Katz 2020). Letting the virus “run its course” while protecting the economy is a typically neoliberal policy response. Free movement and free markets are more important than saving as many lives as possible. Governments are not meant to disrupt the free market for the sake of population health. And yet even the US and the UK governments eventually followed other countries into lockdown, “deliberately inducing one of the most severe recessions ever seen” (Tooze 2020). Governmental attempts at stalling the health disaster accepted that lockdowns would do unfathomable harm to the economy. The world is staring at the worst recession in a century. Businesses are going bankrupt and people are losing their jobs at catastrophic rates. Even countries that did not impose lockdown measures are experiencing an unprecedented economic shock due to the disruption of supply chains, bans on travel, and trillions of dollars of capital flight.

In India, the socioeconomic fallout of the lockdown is even more severe than in the US and the UK. The lockdown hit India’s large population daily wage laborers particularly hard. 380 million people in India work in the informal economy. Millions of them are rural-urban migrants. After the lockdown was imposed, hundreds of thousands of migrant laborers started to walk by foot to rural areas, some of them for hundreds of miles. The government’s response strongly discriminates along entrenched social divisions, such as that the majority of casual laborers are from lower castes and ethnic minorities. The strict measures imposed in India caused extreme economic hardship, with hunger and much collateral damage to people’s health and wealth. In turn, it remains unclear if the Indian lockdown will protect many people from dying with SARS-CoV-2 in the long run. Public health experts argue fear the Indian lockdown might cost more lives than save them: “The national lockdown will delay things, but will not reduce the overall numbers greatly in the long-term … this will cause serious economic damage, increase hunger and reduce the population resilience for handling the infection peak” (Center for Disease Dynamics, Economics & Policy 2020). Another prediction is that the combined effects of the coronavirus pandemic will throw poverty levels back by 30 years. The global number of people living in poverty could increase by 580 million worldwide (Sumner, Hoy & Ortiz-Juarez 2020). The Indian governments’ emergency food relief is stymied by bureaucratic hurdles: to access food relief, people must be registered with food welfare schemes or have official documents to show that they are entitled, but the majority of people do not have the required documentation (Reuters 2020b). Put bluntly, COVID-19 kills, but poverty kills as well. Whether lockdowns will save more lives than they destroy is not clear.

In Living Worth: Value and Values in Global Pharmaceutical Markets (Duke UP, in press), I argue that the value of life is negotiated between social actants within contexts of good practice. Building on Espeland & Stevens (1998), I call these valuing processes biocommensurations. In biocommensurations, lively matters are valued toward pragmatic goals. Biocommensurations are processes that draw vitality, health, disease, and healing into comparisons and exchanges with living and non-living entities. These commensurations are done by human actants and involve different transactions, either with other humans (as individuals or groups) or with nonhuman entities. Biocommensurations put two or more entities into value comparisons toward a pragmatic decision: “Two roads diverged in a wood and I—/I took the one less traveled by/And that made all the difference” (Frost, The Road not Taken).

Biocommensurations rest on agreements about what “good practice” looks like. What is valuable and what is not depends on the criteria for value, and these criteria are based on context. In turn, what counts as good practice depends on different degrees of recognition from actants (A and B). What A sees as good practice may differ from what B recognizes as good practice. Recognition can be nuanced by direct mutual recognition between A and B, and wider social recognition of the relation between A and B and of the entities transacted. Trust is a form of recognition that the other will behave in a manner consistent with past behavior. Further, there are different degrees of transparency about what is being valued and who is doing the valuing. Each dimension differs by how routinized commensurations are. This includes different degrees of institutionalization. Each differs by levels of expertise required to perform a convincing valuation. Levels of expertise, routinization and institutionalization are tied to levels of technological elaboration. When life is biocommensurated, the work of experts in institutions, and of the accounting technologies used, varies considerably. Questioning the power of institutional experts doing health metrics is a difficult task, which requires substantial counter-expertise (Adams 2016).

Coronavirus lockdowns reveal extremely conflicted biocommensurations. To begin with, it is not obvious which interventions are being compared to each other. Countries have adopted a host of interventions in various constellations, to various degrees, for different lengths of times and at different points in time. This makes it difficult to compare their relative value. The easiest value comparison would be between comprehensive lockdowns and doing nothing, but all governments have done something, even if it was just asking people to wash their hands. Some countries were able to avoid full lockdowns by a combination of interventions. Hong Kong, for example, managed to avoid a lockdown by using border restrictions, mandatory quarantine, and physical distancing (Cowling et al. 2020). The coronavirus pandemic is a real-time experiment in biopolitical responses. The research design is extremely messy and there is no placebo control group. Nevertheless, value comparisons must be made because so many lives are at stake.

Biocommensurating coronavirus lockdowns shows vastly different levels of certainty and routinization. Value comparisons address the following questions: (1) what makes two possibilities similar? (2) What is the degree of similarity between them? (3) How are these similarities relevant? (4) Why are possibilities similar? (5) To whom are these similarities relevant? (6) What is the pragmatic operation that the value comparison makes possible? In the case of lockdowns, (1) “similarity” between different policy responses might be established by “number of human lives saved.” However, it is not clear whose lives are saved, and if these are lives saved in the short term or in the long term. (2) The degree of similarity is determined by “number of people saved from dying with SARS-CoV-2 infection.” How this number should be assessed, and whether there are not hundreds of other criteria for comparison, is uncertain. (3) The “relevance” of valuing different interventions is clear: human life and well-being is at stake at a global scale. (4) Why different policy responses might be “similiar” is not as clear as it may seem. For example, it is certain that close proximity influences how fast the virus spreads, but it is not clear by how much. Further, physical proximity is not the only factor. How infectious SARS-CoV-2 is and which routes of infection are more likely than others is still to be determined. (5) To whom the similarities are relevant is clear: anyone who lives on this planet now, or in the near future, or maybe even the distant future (we don’t know). One reason why this pandemic is so extraordinary is that no one alive today can self-isolate from either the virus or the responses to the virus. (6) The pragmatic operation that the comparison should make possible is starting or ending lockdowns and deciding on what forms of movement should be prohibited.

Biocommensurations are context-based negotiations between different actants. Governments’ lockdowns received a relatively high level of recognition from citizens. Some governments introduced lockdowns almost by popular demand. Countries with high levels of citizens’ trust in governments appear to be more successful in stemming the spread of the infection (New Zealand, South Korea, and Taiwan are cited as positive examples). Governments show various levels of transparency about how the lockdowns would be enforced and what they are meant to achieve. The US government stands out globally for its lack of transparency: government advice was muddled and President Trump often contradicts his own policies (e.g. when he urged US citizens to “liberate” themselves from his own administration’s lockdown policies). But no government can be fully transparent about the advantages and disadvantages of the lockdowns because no one knows what these measures do. No one knows how to biocommensurate lockdown effects. One of the deepest shocks of the coronacrisis is the absence of expertise, technological elaboration, and routinization among the agencies in charge of pandemic preparedness.

In hindsight, it is also stunning how unprepared the social life sciences were for this pandemic. Before coronashock, versions of Foucauldian biopolitics provided a comfortable frame to describe the work of experts (Caduff 2014; Lakoff 2017). Foucault never doubts that “power” is grounded in “knowledge.” The experts are portrayed as competent, methodical, and bureaucratically routinized. Social scientists believed that there were experts anticipating an outbreak such as this, and they believed that these experts had developed a solid grasp of “prevention, precaution, preparedness” (Keck 2020). If anything, social scientists believed that pandemic experts went too far in their quest for biosecurity. But when the COVID-19 pandemic unfolded and governments scrambled for a response, it became clear that the expertise does not exist. Epidemiologists knew nothing of economic impacts, and macroeconomists knew nothing about viruses. Guidance from the World Health Organization was entirely focused on epidemiological interventions such as contact tracing and testing but had nothing to say about lockdowns and their effects. Institutions such as the World Bank or the International Monetary Fund were also caught out cold by the economic shock of the lockdowns. No one knew how to make informed value comparisons between locking down and not locking down. The criteria do not exist, the institutions do not exist, and the technological infrastructures do not exist. The International Monetary Fund opens its 2020 Report on World Economic Outlook by admitting that “none of us had a meaningful sense of what [a pandemic] would look like on the ground and what it would mean for the economy” (2020: v). Biocommensurations are most successful when they are routinized and when everyone concerned agrees what should be done. Coronashock revealed that no one knows what a “good practice” of comparing different possible interventions even looks like. Perhaps “lockdowns” cannot even be called “measures” as long as no one knows how to measure what they do.

We still do not know the full scale and severity of COVID-19. The unintended consequences of the lockdown interventions are even less clear (Ecks 2020). The task of anthropologists is to listen to the people we work with and hear how they perceive the consequences of lockdowns. We need to discover with them what the relevant criteria for good comparisons are. The experts failed to describe the criteria for valuing different interventions. It’s now time to hear from the people most affected what these criteria should be.

 

References

Adams, Vincanne, ed. 2016. Metrics: what counts in global health. Durham: Duke University Press.

Buckley, Chris & Steven Lee Myers. 2020. As new coronavirus spread, China’s old habits delayed fight. The New York Times, February 7, 2020.

Caduff, C. 2014. On the verge of death: visions of biological vulnerability. Annual Review of Anthropology, 43: 105-121.

Caduff, C. 2015. The pandemic perhaps: dramatic events in a public culture of danger. Oakland: University of California Press.

Center for Disease Dynamics, Economics & Policy. 2020. IndiaSIM Model. https://cddep.org/covid-19/india/

Center for Systems Science & Engineering at Johns Hopkins University. 2020. COVID-19 Dashboard. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

Cowling, B. J., et al. 2020. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: An observational study. The Lancet Public Health, April 17, 2020, S2468-2667(20)30090-6. https://doi.org/10.1016/

Ecks, S. 2020. Coronashock capitalism: The unintended consequences of radical biopolitics. Medical Anthropology Quarterly blog, April 6, 2020. http://medanthroquarterly.org/2020/04/06/coronashock-capitalism-the-unintended-consequences-of-radical-biopolitics/

Espeland, W. N. And M. L. Stevens. 1998. Commensuration as a social process. Annual Review of Sociology 241: 313-343.

Graeber, D. 2019. Bullshit jobs: A theory. New York: Simon & Schuster.

Hale, Thomas, et al. 2020. Variation in government responses to COVID-19. Version 4.0. Blavatnik School of Government Working Paper. April 7, 2020. www.bsg.ox.ac.uk/covidtracker

Helm, T., Graham-Harrison, E. & McKie, R. 2020. How did Britain get its coronavirus response so wrong? The Guardian 19 April 2020.

International Monetary Fund. 2020. World economic outlook. Chapter 1, The Great Lockdown. Washington, DC: International Monetary Fund.

Katz, D. 2020. “Opinion: Is our fight against coronavirus worse than the disease?” The New York Times, March 20, 2020.

Keck, F. 2020. Avian reservoirs: virus hunters and birdwatchers in chinese sentinel posts. Durham: Duke University Press.

Lakoff, A. 2017. Unprepared: global health in a time of emergency. Oakland: University of California Press.

Reuters. 2020a. Wuhan lockdown ‘unprecedented’, shows commitment to contain virus: WHO representative in China. https://www.reuters.com/article/us-china-health-who-idUSKBN1ZM1G9.

Reuters. 2020b. India’s coronavirus relief plan could leave millions without food aid, activists say. https://www.reuters.com/article/us-health-coronavirus-india-poverty-idUSKCN21S122

Sumner, A., Hoy, C., Ortiz-Juarez, E. 2020. Estimates of the impact of COVID-19 on global poverty. WIDER Working Paper 2020/43. Helsinki: United Nations University World Institute for Development Economics Research.

Tooze, A. 2020. Coronavirus has shattered the myth that the economy must come first. The Guardian, 20 March 2020.

Walker, P. 2020. No 10 denies claim Dominic Cummings argued to ‘let old people die’. The Guardian, 22 March 2020.

World Health Organization. 2020. WHO timeline COVID-19. https://www.who.int/news-room/detail/08-04-2020-who-timeline—covid-19.

 

 

Stefan Ecks co-founded Edinburgh University’s Medical Anthropology programme. He teaches social anthropology and directs PG teaching in the School of Social & Political Sciences. He conducted ethnographic fieldwork in India, Nepal, Myanmar, and the UK. Recent work explores value in global pharmaceutical markets, changing ideas of mental health in South Asia, multimorbidity, poverty, and access to health. Publications includeEating Drugs: Psychopharmaceutical Pluralism in India(New York University Press, 2013) andLiving Worth: Value and Values in Global Pharmaceutical Markets(Duke University Press,forthcoming), as well as many journal articles on the intersections between health and economics.



Recognising childrens’ rights in responses to COVID-19, by Aphaluck Bhatiasevi

|

We are all trying our best to deal with the COVID-19 pandemic crisis, be it from governments seeking to protect public health and livelihoods, to key workers trying to ensure essential services are maintained, to many of us trying to maintain social distancing and self-isolating as individuals and for our families. But in the immediacy of responding to the crisis, adults can focus on protection and overlook the part children can and do play in the fightback to the crisis.

Why does it matter?

In emergency contexts, it is easy to concentrate solely on children’s physical protection, and overlook the importance of emotional and social protection, which is critical both during times of emergencies and in post-emergency situations. It is also easy to ignore children’s participation rights – rights to have information, to provide information, to have their views considered and enacted in decisions that affect them. The University of Edinburgh’s Childhood and Youth Studies Research Group works on a project in parthership with the International and Canadian Children’s Rights Partnership (ICCRP).  This project often works in sites of immediate and ongoing fragility. The project demonstrates that not involving children leads to poorer decision-making and thus poorer outcomes for both children and their communities.

The partnership  of the Childhood and Youth Studies Research Group and ICCRP  works with children and young people, civic society and government stakeholders and academic institutions in Brazil, Canada, China, South Africa and the UK on children’s human rights in situations of international child protection.

For further informationon the project, please visit: https://blogs.ed.ac.uk/cysrg/2020/04/09/recognise-children-rights-covid-19/



For the ‘at-risk’ or vulnerable COVID-19 group: staying or becoming active during social distancing , by Lis Neubeck, Sheona McHale, Chloe Williamson, Paul Kelly, Alice Pearsons, Steven Hanson & Carol Hanson

|

During COVID-19, the World Health Organisation has defined vulnerable groups as those aged over 60 years (regardless of health condition), and those with underlying health conditions, such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer. Additionally, the UK Government has identified pregnant women as an ‘at risk’ group. The benefits of physical activity for these groups are well known and emphasised in the 2019 UK physical activity guidelines.[1] As well as physical benefits, being active promotes emotional well-being.[2] With anxiety levels escalating, this matters more than ever. Normally, we tailor our physical activity advice around community provision, such as swimming, fitness classes and even walking with friends. These options may no longer be available and home-based activity could be your best option. Although some providers have tested home-based activity programmes for people with underlying health conditions, we need to adapt resources for those who need to stay indoors for long periods and practice social distancing. Many people might feel lonely and may not have a plan to maintain their health. More than ever, physical activity can help to reduce the effects of social isolation and prevent deconditioning caused by extended sitting. In this blog, we share some of the evidence about home-based physical activity, and provide practical advice to begin a home-based activity programme.

No equipment? No problem

If you are now having to spend more time at home than you are used to, increasing moving time and reducing sitting time are the key components to physical and emotional well-being.[3] Typically, we talk about four key components to maintaining physical wellbeing. These are endurance, strength, balance and flexibility. Here are some ideas to promote all of these:

Being active does not need to rely on fancy equipment. Recently, one man completed a marathon on his 7 metre balcony.[4] We would not suggest that you try this, but it shows that anything is possible even with very little space! We recommend making a daily commitment to do some form of activity, even walking around the room will give you some health benefits. If you have stairs, walk up and down them a few times. As we age, we tend to have less strength in our muscles. Studies recommend repeated movements of between 8- 10 repetitions to help reduce the effort of daily living activities such as stair climbing and carrying groceries. Doing muscular strengthening activities on at least two days per week has physical benefits.  You can use kitchen items, such as tins of beans or filled water bottles, instead of hand weights. We suggest counting to three during each part of the activity (e.g. in a bicep curl, to three as you raise your arms and to three as you lower them again).

Practical activities to frequently break up sitting time can really improve your mood.[4]  Try to stand up every 30 minutes if you are able, and move for two minutes. To improve general wellbeing, mood and energy levels, activities that increase breathing rate as well as muscle strength activities are important factors.[3] Dancing to music is fun, and if done regularly, is effective in improving quality of life and fitness for people with underlying conditions.[5] Other beneficial activities include walking inside and outside the home, Tai Chi and yoga.[6, 7] If you have to walk outside, remember to strictly observe the guidelines to stay at least two metres from anyone outside your household. A simple activity to improve your balance is walking heel-to-toe across the room. At first, you might find it helpful to hold on to the back of the sofa for stability. Although there is no definitive threshold to achieve benefits, for some people, small changes (e.g. increasing the number of times you stand from sitting throughout the day) can improve physical function within a few weeks.[8] Overall, the key message is it does not really matter what you do, as long as you do something!

How can I use technology to be more active?

If you have a mobile phone, computer or television with internet access, there are many online opportunities to help you be active. Mobile apps, text messaging and web-based solutions help people be physically  active and improve wellbeing.[9]  One study that brought together all the evidence for remote interventions for older adults found that booklets with goal setting, videos and telephone calls were effective in helping people to be more active.[10] Phone a friend and encourage each other to be active.

If you have a condition such as heart disease, the Heart Manual is a self-management book for people recovering from a heart attack, heart surgery, stroke and cancer.  A digital format is now available and research shows that this is as effective as face-to-face cardiac rehabilitation for people with heart disease.[11] If you have a heart problem, telephone your cardiac rehabilitation team and ask what is available.

Physical activity is safe if you are pregnant.[12] Choices should reflect activity levels pre-pregnancy and include strength activities. If you were not active before, do not suddenly take up strenuous activity. You should be able to hold a conversation as you exercise when pregnant. If you become breathless as you talk, reduce your intensity.

Overall, the good news is that many activity providers are working very hard to make sure that there is access to online resources to help you. Check what your local leisure provider is offering. We recommend this online booklet for ideas on home-based activities http://www.laterlifetraining.co.uk/wp-content/uploads/2015/08/OEP-Home-Ex-Booklet-FullS_A4.pdf

We have constructed the above infographic using evidence-based principles on how to construct and deliver messages to promote physical activity among the ‘at risk’ or vulnerable group during this global pandemic.[14]

Who is this infographic for?

The infographic is for all adults aged 70+ years, pregnant women, or those with underlying conditions, who are staying at home. This population may be facing unprecedented restrictions to travel, social, and family life.

What is the aim of the infographic?

The aim of the infographic is to give people classed as ‘at risk’ or vulnerable ideas about how to remain safely active during COVID-19 and to motivate them to do so. We hope to achieve this through increasing awareness and knowledge of physical activity benefits, and by improving confidence to be active during this pandemic.

What is the content of the infographic?

Evidence supports the use of gain-framed messages (information on the benefits of physical activity) with particular focus on the short-term social and mental health benefits.[15] We have positively framed messages on links between physical activity and mood, stress, energy levels/fatigue, depressive symptoms, and anxiety. We have given practical examples about “how to” remain active during COVID19.

How should the infographic be used?

We encourage the sharing of the infographic to friends and family through online channels (Twitter, Facebook, WhatsApp etc.). You could print out the infographic to remind you to remain active.

***

Lis Neubeck 1,2 (corresponding author), Sheona McHale 1 Chloë Williamson 3, Paul Kelly 3Alice Pearsons 1, Steven Hanson 4, Coral L Hanson 1

1 School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Edinburgh, EH11 4DN, UK. Email: c.hanson@napier.ac.uk Tel: +44 7908861666
2 Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
3 Physical Activity for Health Research Centre, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, Edinburgh, UK
 4 Floating Boat Design Solutions, Stocksfield, UK

References

  1. UK chief medical officers, UK Chief Medical Officers’ Physical Activity Guidelines. [Date accessed 25/03/2020] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf. 2019
  2. World Health Organisation, Global action plan on physical activity 2018-2030: more active people for a healthier world.
  3. Gibson‐Moore, H., UK Chief Medical Officers’ physical activity guidelines 2019: What’s new and how can we get people more active? Nutr Bull, 2019. 44(4): p. 320-328. doi:10.1111/nbu.12409
  4. The Guardian, Man runs marathon on 7-metre balcony during French lockdown avaliable at https://www.theguardian.com/world/2020/mar/21/man-runs-marathon-on-7-metre-balcony-during-french-lockdown  [Accessed 23/03/2020].
  5. Gomes Neto, M., M.A. Menezes, and V.O. Carvalho, Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis. Clin Rehabil, 2014. 28(12): p. 1172-1179. doi:10.1177/0269215514534089
  6. Chen, Y.-W., et al., The effect of Tai Chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses. Br J Sports Med, 2016. 50(7): p. 397-407. doi:10.1136/bjsports-2014-094388
  7. Thayabaranathan, T., et al., Determining the potential benefits of yoga in chronic stroke care: a systematic review and meta-analysis. Top Stroke Rehabil, 2017. 24(4): p. 279-287.
  8. Rosenberg, D.E., et al., The feasibility of reducing sitting time in overweight and obese older adults. Health Educ Behav, 2015. 42(5): p. 669-676. doi:10.1177/1090198115577378
  9. Jin, K., et al., Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis. Eur J Cardiovasc Nurs, 2019. 18(4): p. 260-271. doi:10.1177/1474515119826510
  10. Zubala, A., et al., Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews, PLoS One. 2017. doi: 1371/journal.pone.0180902
  11. Clark, M., T. Kelly, and C. Deighan, A Systematic Review of the Heart Manual Literature. Eur J Cardiovasc Nurs, 10(1): p. 3-13. doi:10.1016/j.ejcnurse.2010.03.003
  12. National Health Service. Exercise in pregnancy Your pregnancy and baby guide https://www.nhs.uk/conditions/pregnancy-and-baby/pregnancy-exercise/ [Accessed 26/03/2020] 2020.
  13. Latimer, A.E., L.R. Brawley, and R.L. Bassett, A systematic review of three approaches for constructing physical activity messages: what messages work and what improvements are needed? Int J Behav Nutr Phys Act, 2010. 7(1): p. 36. doi:10.1016/ 1186/1479-5868-7-36
  14. Williamson, C., et al., A conceptual framework for physical activity messaging. Int J Behav Nutr Phys Act, 2020 (in press)
  15. C., et al., A conceptual framework for physical activity messaging. ResearchGate, 2019 (pre-print)

Reproduced from Neubeck L, McHale S, Williamson C,  Kelly P, Pearsons A, Hanson S, Hanson C.L. (2020). For the ‘at-risk’ or vulnerable COVID-19 group: staying or becoming active during social distancing.British Journal of Sports Medicine Blog Published Online First: (08/04/2020)https://blogs.bmj.com/bjsm/2020/04/08/for-the-at-risk-or-vulnerable-covid-19-group-staying-or-becoming-active-during-social-distancing/ with permission from BMJ Publishing Group Ltd.



The science of quarantine and the social life of COVID-19, writes Aphaluck Bhatiasevi

|

So much has been happening in the last months. Since the WHO declared the coronavirus a global pandemic on 11th March, the situation has been rapidly evolving on a daily basis, in different parts of the world.

Speaking about the social life of COVID-19, we began to hear about the virus in January, on how it was spreading rapidly in Wuhan, China. Within a few weeks, the virus traveled to different parts of the world and has since been moving around on airplanes and on cruise ships. It is now reported in all countries and territories.  COVID-19 has no nationality. It did not require a boarding pass or a passport, and was able to slip through border controls without difficulty. It has been very active in the mainstream and social media and is now part of our daily lives.

This pandemic is real

The situation we are in is serious. COVID-19 is taking many lives and making more and more people sick every day. And the numbers of people infected will continue to multiply.  Governments of many countries are being demanded to take action quickly to stop the spread of the virus. The measures taken by communist China – the lockdown which began in Wuhan, a city of 11 million people, and soon extended to other parts of Hubei province, impacting more than 60 million lives – was observed with skepticism from the outside. These measures are now adopted by the most liberal and republican countries of the global north.

Since the beginning of this event, the narratives around COVID-19 has been evolving and the social media is playing a key role in shaping and reshaping these narratives. The power and influence of the social media is undeniable. This is evident from the WHO DG made the announcement of COVID-19 as the global pandemic at a press briefing streamed live on several social media platforms. This changed the public perception on WHO which is often criticized for being slow and conservative, to becoming one of the most influential information sources for COVID-19.

Narratives of COVID-19

We will all experience the lockdown and the quarantine differently in different parts of the world. Our experiences will be shaped on the basis of our social status at the macro and the micro level. At the macro level, it would depend on our experiences and the relationship we have with state authorities, our access to basic needs (such as food, water, shelter, toilets), and our access to health care. At the micro level, it depends on our relationship with our family, friends or the people we live with during this lockdown period and the personal space we have.  Relationships will foster in some households, while they could break down in others. The fear of the unknown and the uncertainty of the situation will influence our day-to-day lives.

There are so many evolving narratives around COVID-19.  How did we move so fast from hand washing to social/physical distancing to quarantine and now lockdown in many parts of the world as a protective measure against the virus?  The narrative shifted quickly from China being the epicenter of the outbreak to Europe and the United States being the epicenter of the pandemic.  There has also been a quick shift from a public health response to the political and economic response.

Since the beginning of the outbreak of COVID-19, WHO has been advocating handwashing as the most effective protection against the virus, at the individual level. While recommendations for state authorities to implement measures such as social/physical distancing, which involves closure of schools and universities, and cancellation of events with public gatherings like concerts and sports was delayed.  WHO also advised against countries imposing travel or trade restrictions. However, soon after the pandemic was declared, countries in Europe began shutting down their individual national borders. Travel restrictions were imposed against Europeans by the United States, and multiple flights were cancelled across the world.   How did this happen so quickly?

When the epicenter of the pandemic moved from China to Europe, multiple countries took immediate actions to safeguard their own territories and populations.  Unfortunately, Italy and Spain being are hit hardest, with high numbers of infections and deaths among the elderly people and health care workers.  The UK and the US governments which have been criticized for their slow actions, are being warned that they could face a similar fate as Italy and Spain.

What can we learn from the past?

Looking back at the responses to Ebola outbreaks in West Africa in 2014 and more recently in the Democratic Republic of the Congo, what they have taught us  is that the most important tool to control an infectious disease outbreak is to gain community trust build trust and to communicate frequently with the people.  “Care builds trust” says Vinh-Kim Nguyen of The Graduate Institute of Geneva. If governments want to build trust, they have to look after the people who are sick and protect them. They need to do something that is tangible and visible, to show that they care and that something is being done.

In this case, most governments are choosing to highlight quarantine, which is an ancient infectious disease control measure, dating back to the 12th Century. It was first introduced in what is today  Croatia, on a ship, in relation to a plague outbreak. It has since been used in limited geographical areas as an international health measure to control the spread of infectious diseases like cholera, smallpox, yellow fever, tuberculosis, leprosy, influenza, AIDS, SARS and more recently for Ebola.

When quarantine was imposed on the British licensed cruise ship ‘Diamond Princess’ which docked in Japan in February, experts blamed the Japanese authorities mismanaging the outbreak through the quarantine. The numbers of COVID-19 infection increased from 10 to more than 700 persons, out of  a total of 3700 passengers on board, by the end of the 14 days quarantine.  Conversely, the lockdown in Hubei province was praised by the international team of experts led by WHO to assess China’s response to COVID-19 in late February. They said the lockdown was effective in slowing down the spread of the virus. Government policies in Europe and the US on quarantines and lockdown are being influenced by projections of numbers of infections and deaths.   Neil Ferguson of Imperial College, whose mathematical modeling is informing the UK government’s policy decisions says these measures need to be in place until a vaccine is available. This means for at least 12-18 months.

The question is whether quarantine or lockdown is the best option and whether it should be the main focus of the pandemic response?  Is it diverting the attention and resources away from where the needs are most, that is in the health care sector? Are health care workers being equipped to carry out their work confidently? Do they have adequate PPE? Are the people suspected of COVID-19 who are at risk of developing severe outcomes of illness being tested and cared for?

Why don’t governments also consider projections of the consequences a lockdown would have on other health problems and on social issues?

WHO’s Mike Ryan said on 22 March that countries can’t simply lock down their societies to defeat coronavirus. What is really needed is to focus on finding the people who are infected, their contacts and to isolate them so that the virus does not further transmit to others.

Devi Sridhar of the University of Edinburgh‘s Usher Institute says lockdown is not the solution. It just buys time to do mass testing, contact tracing and isolation of virus carriers. It is something that allows health services to be prepared to deal with rising number of patients.

Carlos Caduff of King’s College questions whether quarantine or lockdown is an effective tool. He asks if countries with less restrictions on movement are witnessing faster and wider transmission of the virus.

Based on the history of quarantine, in many instances, groups that are already socially marginalized and stigmatized tend to be inappropriately quarantined.  A web-based roundtable discussion on COVID-19 carried out by Somatosphere on 28 February says evidence from the early days of the AIDS epidemic in Haiti and in the United States show that gay men suffered from worsened health conditions and access to health needs during the quarantine period.

Wendy Parmet of Northeast University says quarantine can be a useful tool when done well – when it separates the persons who are not sick from the sick, when it does not enforce laws or authority of the state in policing people.

Mark Rothstein a health policy legal expert says 4 key issues need to carefully be considered before imposing quarantine (1) necessity, effectiveness, scientific rationale (2) proportionality and least infringement (3) humane supportive services (4) public justification.

A study conducted Hawryluck et al from University of Toronto, on 15,000 persons who were quarantined during SARS in Canada in 2003 showed that 29% of those who were quarantined for an average of 10 days had symptoms of PTSD, and 31% had depression.

A rapid literature review of the psychological impact of quarantine carried out by Samantha Brooks and team from King’s College shows that most studies reported negative psychological effects which include post-traumatic stress symptoms, confusion and anger. The main stressors were associated with longer quarantine duration, the fear of infection, frustration, boredom, inadequate supplies, inadequate information, financial loss and stigma.  Some research suggest that the effects could be long lasting.

To mitigate the consequences of quarantine, Brooks et al suggests that the quarantine period be kept short, based on the duration of the incubation period of the disease, and that authorities stick to the timeframe announced. “For people already in quarantine, an extension, no matter how small, is likely to exacerbate any sense of frustration or demoralization. Imposing a cordon indefinitely on whole cities with no clear time limit might be more detrimental than strictly applied quarantine procedures limited to the period of incubation.”

This pandemic is socially exhibiting both positive and negative effects. It has definitely increased awareness on the infectious disease and the importance of handwashing. It has drawn attention to epidemiology of disease spread (e.g. many people are talking about flattening the curve). It has connected people across the world through social media and through lockdown.  It has displayed expressions of care, compassion, solidarity and creativity.

While at the same time, it has demonstrated xenophobia, fear, anxiety, paranoia, blame, limits of capacities of both rich and poor countries in dealing with a major health crisis.  I have mainly focused on the big picture issues related to the global North. I cannot imagine how the prolonged lockdown will play out in countries like India and South Africa.

This is just the beginning. We need to look into the health and social consequences of the lockdown, just as we are on the economic aspects.

Aphaluck Bhatiasevi is a PhD Candidate in Social Anthropology at the University of Edinburgh.



Interview of Agomoni Ganguli Mitra on pandemic related social inequalities by University of Oxford’s Practical Ethics channel

|

Is the Coronavirus Pandemic Worse for Women?

Dr Agomoni Ganguli Mitra of the University of Edinburgh’s Law School talks about how pandemics increase existing inequalities in societies, and how this may result in even more victims than those from the disease itself. She urges governments and others to take social justice considerations much more into account when preparing for, and tackling, pandemics.

This is an interview with Katrien Devolder as part of the Thinking Out Loud video series from Oxford University’s Practical Ethics channel

 



How the social and behavioural sciences can help us beat the pandemic, writes Gowri Iyer and Nanda Kishore Kannuri

|

The social and behavioural sciences (SBS) in public health have had an essential but relatively unacknowledged role since the beginning of the field in the early 19th century. Over the last few decades, there has been a slow and gradual paradigm shift in the field globally with growing acknowledgement of the need for SBS research to drive interventions for successful public health outcomes.

However, in India, experts argue that public health continues to be dominated by a biomedical approach to health. In public health, infectious disease management is a high-priority area due to the large number of existing and emerging infectious diseases, such as malaria, measles, diarrhoeal diseases, tuberculosis, Ebola, Zika, Nipah, etc. All of these pose numerous and complex challenges in detecting and managing them. While SBS approaches in disease outbreak investigation and management have been used in the past, the systematic inclusion of social science-based interventions (SSIs) as an integral part of operational response remains a challenge.

In India, SSIs have also been used but only in a relatively episodic manner, relegated to targeted interventions focused towards dealing with conditions like HIV/AIDS and tuberculosis. However, SBS methods, to be effective, must be developed in an integrated manner with affected populations to bring a disease outbreak or health emergency to an end. In addition, there needs to be a systematic use of methods and analyses to understand the cultural and social contexts of communities affected by health emergencies, as well as the need to detect behaviours and practices that increase the risk of death, disease or social and economic loss.

In the current COVID-19 crisis, epidemiologists and other health experts are working tirelessly to understand the scale of the problem and to help develop strategies to mitigate risks associated with it. In addition, scientists in both the public sector and private enterprises are racing to develop tests and vaccines. However, social and behavioural scientists can also play an important role in the current pandemic, especially given the current absence of any vaccines and medicines.

SBS interventions such as effective communication (improving awareness of the virus and risks) and behaviour change (physical distancing, frequent hand washing, avoiding mass gatherings, etc.) are critical at this juncture to contain the transmission of the virus and flatten the curve. In addition, established social interventions, including social mobilisation, health promotion through education enable community level adaptations to comply with the new social norms. These measures give the government a critical window to strengthen the health system and evolve strategies for testing, isolation and contact tracing of new cases.

For effective communication, we need to understand the intended audience, level of public trust in the people conveying the message, and the level of public awareness of the pandemic. The aim of good messaging should increase public awareness, reduce the anxiety and distress that arises, and also facilitate the behaviour change that might be required by the people in such situations.

So how can we use SBS to inform effective communication over COVID-19? Successful communication campaigns have incorporated accuracy, consistency, clarity and empathy as key components. In contrast, ill-informed communication strategies carry the risk of precipitating behaviours that run counter to stated public health goals. This risk is exacerbated in a people whose cultural familiarity and risk perception is low in behaviours such as physical distancing, making adherence to them difficult. Studies report that ambiguous and inconsistent messaging increases chaos, confusion and distrust, leading to non-compliance to the behaviour change that may be essential during the pandemic, ultimately making the situation worse.

We see some evidence of the public’s difficulty in grasping these concepts across the situations that have emerged since the lockdown, for example panic buying, increasing stigma, anxiety and frustration, the exodus of labourers from cities after the lockdown, and people crowding streets to bang plates, etc.

To enable behavioural change in the public, we need to understand individual (beliefs, motivations, biases, etc.) and group level factors (group dynamics, peer influence, cultural beliefs, public trust, etc.) that can influence our judgment and decision making. Understanding of these factors is achieved through systematically studying how different individuals perceive risk and what prompts them to act upon it. Some of the seminal work in this field by Daniel Kahneman, Amos Tversky and other researchers present substantial evidence of the heuristics and biases people use to make judgements and decisions. This body of research has consistently shown that people’s decisions are swayed by factors such as their beliefs and emotions, and which often ignore logic and facts, even during peaceful times. Such tendencies will be further enhanced during a pandemic.

Beyond effective communication and immediate behaviour change (such as physical distancing), there are other critical SBS aspects that need to be studied and understood for their impact on people during this unprecedented crisis. These include growing stigma associated with healthcare professionals, people exposed to the virus, the adverse mental health issues due to social and economic costs, role of communities, etc.

These adverse events are a consequence of the restrictive policies (such as quarantine, lockdown), misinformation, ineffective communication and poor health literacy, and using SBS research and evidence to inform policy and interventions can mitigate some of these effects. A review article recently published by The Lancet reports that the psychological impact of quarantine includes post-traumatic stress, anxiety, depression and public anger.

While there is evidence of successful strategies from previous public health campaigns using SSIs, such as using graphic imagery in the anti-tobacco campaign, and reducing stigma associated with HIV/AIDS patients by awareness campaigns involving celebrities. Such approaches when broad-based and integrated into public health will be most impactful. These approaches work best in tandem with social protections and policy measures that help alleviate some of the inevitable social and economic distress.

As the COVID-19 pandemic evolves and worsens without any visible respite, sustaining these social interventions is critical. It is important to engage with the community to ground our pandemic response in the social, cultural and ecological contexts to reinforce their long-term participation. We need creative ways to build community resilience, evolve models of care, social support and solidarity.

While there has been a considerable and understandable push for biomedical research to help us deal with COVID-19, it is important to invest in public health research with a particular emphasis on social and behavioural approaches and methods for a holistic response. It is critical to focus on a collaboration and real-time integration of interdisciplinary approaches involving epidemiologists, social and behavioural scientists and other disciplines in designing innovative, rapid, culturally sensitive and precise public health interventions to respond to crises and also enable us to be better prepared for such public health emergencies in future.

Gowri Iyer is a cognitive and behavioural scientist and Nanda Kishore Kannuri is a medical anthropologist, both at the Indian Institute of Public Health, Hyderabad. The views expressed here are the authors’ own.

This piece was originally published in https://science.thewire.in/health/how-the-social-and-behavioural-sciences-can-help-us-beat-the-pandemic/



Edinburgh Infectious Diseases held a workshop to highlight research carried out in the University of Edinburgh and NHS Lothian in response to the COVID-19 pandemic

|

The aim of the workshop held on 25th March 2020, was to highlight research being carried out in the University of Edinburgh and NHS Lothian in response to the COVID-19 pandemic.  The presentations were delivered by some of the top scientists and clinicians working in this field in Edinburgh.

The Director of Edinburgh Infectious Diseases, Professor Ross Fitzgerald, said that the workshop provided “an excellent forum for discussion of early data emerging from a number of projects at the University of Edinburgh, which are in receipt of substantial funding to enhance our understanding of both the virus and the patient response to the virus.”

The workshop was attended by more than 250 people, who heard from local scientists and clinicians on a range of topics, including basics of coronavirus virology, epidemiological modelling of the outbreak, how we can use rapid sequencing to track the course of the epidemic, and the sociological effects of quarantine.

The workshop, which was hosted on Blackboard Collaborate virtually, stimulated a variety of useful discussions and ideas for future research. As research progresses, it is likely a similar workshop will be held later in the year.

Videos and summaries of each talk are available at:

https://www.ed.ac.uk/edinburgh-infectious-diseases/covid-19/covid-19-events-and-activities/edinburgh-coronavirus-workshop/workshop-summaries