Geof Rayner
Covid-19 has been described as a ‘once in a century event’, a pointer to the 1918 influenza outbreak, with its 50-100 million dead. While this metaphor is used to expose its significance and the lack of public health preparedness, it also comfortingly hints that once the outbreak is over worries about recurrence become negligible.
Covid-19 is just one of many infectious diseases and much remains to be learnt about it. While the world, at present, is focused on viral disease and its health, economic and social consequences, other worries may have receded but remain real threats. Concerns over climate change, biodiversity loss, the increasing burden of non-communicable diseases (NCDs), novel biological organisms or antimicrobial resistance (AMR), and more, persist.
The arrival of Covid-19 might also mark the end of what was prophesied as ‘golden era’ of health, ie, the progressive improvement of global health trends (Lang and Rayner 2015), to be replaced, in the gloomiest perspective, by a new dark age. Even if Covid-19 only has a temporary impact, and thereafter preparedness and response are given far more attention by government, there is no guarantee that new outbreaks won’t recur. This being so, a renewed focus should be placed not just on national preparedness but towards primary prevention, and how far ‘upstream’ interventions should go. This is an approach consistent with the thinking of the late ecological epidemiologist, Tony McMichael (1993) who extensively documented the unruliness and potential bite-back of threatened nature.
Much has been written about how the UK, in contrast to elsewhere in Europe, has had a limited commitment to testing for Covid-19 (as the New York Times observed, its belated attempts to correct this failing have hinted of desperation), combined with loose border controls and limited quarantine rules. At the intergovernmental level, dispute and inconsistency between nations are frustrating international co-operation which, in the case of a pandemic, is absolutely required. The World Health Organization (WHO), the UN body charged with preventing and mitigating pandemic disease, lost its largest single donor, the USA, in April, interpreted by critics as an effort of ‘blame shift’ for the US government’s bungled response at home.
While pandemic preparedness rose up public health agendas internationally, the global financial crisis of 2007/8 resulted in reductions in public spending. The WHO’s budget was reduced by US$1 billion in 2011. The WHO programme budget in 2018 was $4.45 billion. To put this in context, the Coca Cola company, in the same year, spent $5.8 billion on global advertising and marketing. But if governments have been poorly prepared, globalisation and the advocacy of growth-fixated neoliberal capitalism have been entirely upended. The world economy is now in a downward spiral of ‘involuntary degrowth’, to use the language of ecological economics. In September 2019, the WHO highlighted a series of commissioned reports examining global preparedness and response. Summary: threat level, high; preparedness, low (see, here; here; here; here; and here). In the same month the Trump administration finally closed its ‘Predict’ programme which had identified more than 160 different coronaviruses that had the potential to develop into pandemics, including a virus that is considered the closest known relative to Covid-19.
Improvements in domestic preparedness alone cannot themselves halt infectious diseases arriving from abroad, particularly if there are no border health controls or visitor quarantine and testing, as at present. And to be realistic, Covid-19 is in any case just one of many potential pandemic diseases originating thousands of miles away, over which the NHS, and its public health arm, can do little. Although profoundly different in cause and impact, such powerlessness is shared with non-communicable diseases, where the shaping factors are largely domestic in origin. In the case of obesity or diabetes, and for political and economic reasons, there’s limited leverage over the causative factors, whether food and drink marketing, processed foods, or the determinants of physical activity.
Resurgent infectious diseases have a more obscure causation – more natural ecology than social ecology. Most infectious diseases are zoonotic in origin, where pathogens jump from animal to human or from animal to intermediary animal before attaching to humans. Some 60% of emerging infectious diseases reported globally are zoonoses. Over 30 new human pathogens have been detected in the last three decades, 75% of which have originated in animals (Jones, et al 2008).
Zoonotic diseases are as old as settled human civilisation, that is to say since larger human groups began living cheek by jowl with domesticated animals. The scientific understanding of zoonotic disease is relatively recent, beginning with bovine tuberculosis and human tuberculosis, an association first made in the 1880s by Robert Koch. Since then, according to Delia Grace, an epidemiologist and veterinarian at the International Livestock Research Institute in Kenya, researchers have worked hard to discover the route taken by pathogens from animal to human in order to prevent or control pandemics.
Diseases that originated in wildlife, she says, ‘led to a rush of work to find diseases in wild animals: In deltas and in jungles, in swamps and in forests… Not surprisingly, they confirmed that people, wildlife, and domestic animals are (metaphorically speaking) swimming together in an invisible sea of viruses, bacteria, and parasites. Many of the microbes they’re finding were previously unknown; most are mobile and potential species hoppers, but probably harmless. A few, however, are catastrophic, even civilization-altering, in their potential to hurt us. We need an approach for identifying those that could cause global pandemics from others that are just harmless hitchhikers.’
Such ‘harmless hitchhikers’ are unknown in number – likely into the billions – and largely unclassified.
Human diseases linked to wild animals typically occur in remote regions where healthcare provision is minimal and they therefore remain undiagnosed. The expansion of humans into formerly wild, biodiversity-rich habitats is increasing and the health consequence parallel the decline in wild animal populations and extinction risk, with over 20% of mammalian species threatened. Subsistence agriculture and expanding human habitation in wild areas occurs as people escape the consequences of extreme weather events or depleted farmlands. But commercial farming may have an even bigger impact, as areas of forest are removed for planting of soy, palm oil or for the raising of cattle on rich, virgin land.
As the liminal zone of forests come under greater stress, they become more efficient sources and spreaders of animal pathogens. While there is much individual research, as Grace says, there is no ongoing systematic global effort to monitor for pathogens emerging from animals to humans (Wolfe et al 2007). In any case, in some states, eg Brazil and Indonesia, farming intrusions are supported by government. Diplomacy – undergirded by timidity – means that such socio-political drivers of disease receive at most passing mention in official accounts of UN agencies.
This bigger picture of causation requires much broader understanding of both prevention and the strengths and weaknesses of models and approaches to public health. Elsewhere I’ve characterised traditions of public health through the lens of five different, somewhat overlapping, conceptual models (Rayner and Lang 2012). These include the bio-medical model, the approach best recognised by the public and top in the institutional pecking order, the social-behavioural model, the old health education approach, now with the addition of behavioural science and social marketing, the sanitary-environmental model, the most successful approach during industrialisation and particularly applicable to low-income countries lacking sanitation and clean water, the techno-economic model, which links economic and technological growth to human physiological development, and finally the ecological public health model, with its focus on interactions between the biological world and the social and material worlds. Ecological public health, in answer to the techno-economic approach – once promoted by the World Bank – proposes that, on the contrary, unregulated economic development may expose populations to new risks. Covid-19 may be one of the consequences.
The missing elements of preparedness are a fully funded international programme of research into zoonoses and, more politically problematic, halting of incursions into wild areas, indeed the extension of wild areas. It also implies ecological economics supplanting conventional economics. Efforts to limit the environmentally-destructive logic of consumerism must feature as part of this overall picture. Sustainable economic thinking requires stable populations and sustainable consumption, which means greater efforts to empower women to control their own fertility, better public education, broader employment opportunities and a massive switch to renewable energy.
None of this is new thinking. Ecological thought draws, in part, on the earliest social science, and from figures like Adam Smith, RL Malthus, JS Mill, and K Marx. It was Smith, a moral philosopher, and not, as often claimed, an economist (indeed, closer to sociology), who embedded his economic understanding in the natural economy, Malthus who recognised the limits on human development imposed by nature, while Mill’s 1848 call for a ‘stationary state’ economy became the starting place for modern considerations of the ‘circular economy’. And Marx’s concept of the ‘metabolic rift’ drew attention to linked depletion of humans and nature through unregulated economic development. Much of modern social science, and especially modern economics, has abandoned these earlier insights, presuming a social world that is above, indeed separate, from nature; in effect, a dualistic, disembodied perspective on the human species. This global pandemic shows not just that humans are reliant on the health of nature, but are part of nature, not divorced from it.
The preparedness and response reports released in 2019 by the WHO give an explicit role to social science, particularly in the area of public involvement and trust-building. But the aim of social science must also be that of critique. Public health measures exist within the political-economic parameters of the present, with its embedded reflexes, lines of power and inequalities. While we can expect many post-pandemic trends to be bleak, many positive things too could emerge from the current crisis, but these circumstances also offer new opportunities in an altogether negative direction: authoritarian policies, the alignment of public health controls with social control, and therefore the potential demise of the classical idea of human progress.
References:
Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, et al. (2008) ‘Global trends in emerging infectious diseases’. Nature. 2008; 451:990-3.
Lang T, Rayner G. (2015) ‘Beyond the Golden Era of public health: charting a path from sanitarianism to ecological public health’, Public Health, 129:1369-82.
McMichael A. (1993) Planetary Overload: Global Environmental Change and the Health of the Human Species. Cambridge: Cambridge University Press.
Rayner G, Lang T. (2012) Ecological Public Health: reshaping the conditions for good health. Abingdon: Routledge / Earthscan; 2012.
Wolfe ND, Dunavan CP, Diamond J. (2007) ‘Origins of major human infectious diseases’, Nature, 447:279-83.
Geof Rayner PhD is a public health sociologist who has worked in local government environmental services, NHS joint planning, and for the European Commission, WHO and European and national NGOs.
Image: Iván Tamás Pixabay