Utsa Bose (Faculty of History, University of Oxford);
Alberto Giubilini (Uehiro Oxford Institute, University of Oxford)
Tolulope Osayomi (Department of Geography, University of Ibadan; AfOx-TORCH Visiting Fellow, University of Oxford)
Crossposted from TORCH Medical Humanities Blog. This post is also the basis of a workshop on 21 November 2024, to be held at the University of Oxford.
Introduction
On the 14th of August, 2024, the World Health Organization (WHO) declared MPox a Public Health Emergency of International Concern – just a day after the Africa CDC had issued a Public Health Emergency of Continental Security, following a noticeable increase in infections and deaths on the continent. Several countries around the world began monitoring the spread of the disease. While some countries raised the alarm and started asking questions about their preparedness, others considered it a less significant threat – with some commentators noticing how the talk and concern about MPox is skewed towards the wealthy countries (Adetifa et al 2023).
Soon after, there arose a perhaps natural proclivity towards comparison between COVID-19 and MPox. Headlines such as “could MPox be the new COVID-19?” started to appear on mainstream media. The WHO and many news outlets soon assured that MPox was “not the new COVID-19”. The initial alarm has been supplanted by less provocative headlines, which stress the danger of the disease, but also its low-risk (for instance here, here, and here). This “alarm-but-no-cause-for-alarm” attitude upholds the very tension between willingness to take action and a degree of restraint to preserve fundamental freedoms and avoid public backlash. This tension, of course, characterized the recent COVID-19 experience. It is only natural, therefore, to ask whether that experience can teach us anything about how to handle this tension.
The shadow of history often operates centrally during any narrative of outbreaks. We are told that we have to learn from history, so as not to repeat its mistakes. But learning lessons is very difficult, for several reasons.
- Many pasts, intersecting pasts
First, one must complicate the rather simplistic notion of ‘learning from history’ and recognise, at the outset, that histories remain plural. What one learns–if at all–depends on which past is being invoked and studied. With MPox, history seems to be deployed in two diverging strains. The first strain of history is a history of negligence and a consequent call for pro-action. This history highlights how MPox sporadically appeared in different parts of the world but never really assumed devastating proportions. However, it remained endemic to certain parts of Africa, where it became highly infectious and a persistent threat, with the last outbreak in 2022. This persistence has been largely attributed to the historical neglect of the disease (Adetifa et al 2023). It is precisely building on this history that the WHO mentions the need for a co-ordinated response for MPox globally, to prevent this history of negligence in Africa “from repeating itself” at a global level. Ifefayo Adetifa and colleagues have framed it as “a problem for Africa, a problem for the world” (Adetifa et al 2023), suggesting that an event in any part of the world and our (in-)action as a response will likely have consequences on the rest of us. The call, therefore, is for collective cooperation. The lesson from this history is caution; its guiding principle is the need to tackle an issue before it becomes worse.
The other strain is the history of public backlash as a result of COVID-19 policies. This is a history of public ire, of conflict, dissonance, polarisation, and of the consequent undermining of trust in public health officials. What does this history teach us? The ‘lesson learnt’ here is, perhaps, the need for a different kind of caution, a more guarded approach, a degree of restraint before declaring or deploying mass measures against outbreaks.
Thus, in invoking the need for ‘learning from history’, one is faced with the fact that the ‘learning’ from both these histories seems to be the exercise of caution. However, these two histories seem to intersect and work counterproductively against one another.
- A too recent past?
A second reason why learning lessons is difficult is that the past being wrestled in this context is very close to public memory. In comparing MPox with COVID-19, there is an underlying assumption of periodisation: COVID-19 was the crisis of the recent past, MPox can become the crisis of the near future. This assumes a move from one period of crisis to another. However, it is too soon to say whether MPox has succeeded COVID-19 as a global threat, since COVID-19’s ends are difficult to define (Charters and Heitman 2021). The panic and illness of the COVID-19 pandemic and of the response measures continues to exist today not only as traces and memories, but very tangibly. For example, COVID-19 still exists for many in the form of chronic illnesses, ongoing impact on healthcare systems, and the collateral damage of pandemic restrictions. Therefore, COVID-19 is both history and the present, depending on the geographical context. In some parts, MPox is a threat that is supplanting an older anxiety, while in others it compounds its current existence.
- Is disagreement a lesson?
A third reason why learning any lesson from the COVID-19 experience is difficult is that there is little agreement on what such lessons might be. Mistakes were made, no doubt, but if we were to ask different people what they were, we would likely get different answers. Some would say that measures were too harsh and some that they were not robust enough; some that policy makers deferred excessively to science experts and some that policies were anti-science; some that trust in science led us out of the crisis and some that the scientific community made itself untrustworthy.
What counts as an appropriate response to infectious disease outbreaks depends on contested tradeoffs between different values – for instance, civil liberties vs public safety or lives vs livelihoods.
Thus, it is unclear what exactly we can learn from COVID-19, except for the fact that an infectious disease outbreak is likely to bring to light underlying disagreement about the proper place of health, of science, of trust in authorities in our system of values. Inevitably, then, there will be disagreement about the lessons to be learnt.
But perhaps therein lies the main lesson: health crises generate disagreement that, in normal times, doesn’t express itself to such an extent. In “normal” times, a background of shared values – toleration, pluralism, respect for social norms – guarantees a certain stability in the way differences of values and opinions play out in the public arena. Societies can thus tolerate some internal tensions. Arguably, one factor that defines a situation as one of ‘crisis’ or ‘emergency’ is precisely the fact that such stability in managing internal tensions is threatened, as circumstances create the demand for different moral and political obligations. The crisis becomes not only a medical one, but a societal one.
- Medical geography and the ‘global’
We can see an example of such disagreement if we consider the geographical perspective on the infectious diseases under consideration. The COVID-19 pandemic brought to light the interconnectedness and interdependence of our human society. This was in itself, if not a lesson, at least a good reminder of the human condition. As indicated elsewhere (Osayomi et al 2021), our human existence was reconsidered and reorganised in the light of the complexities presented by the virus. Given its human-to-human transmission, its diffusion at the community level was largely dependent on physical proximity to origin of infection or carrier.
However, some countries were initially bypassed in the diffusion process by the virus on account of international air travel. Many of the index cases were “the internationally mobile elites”. Similarly, in 2014, Ebola moved via air from Liberia, bypassing intervening countries along the West African coast, and arrived in Nigeria. The implication is that infectious diseases do not, in every circumstance, spread to its nearest neighbour, but could diffuse to seemingly geographically distant locations of similar settlement and social hierarchies. These hierarchies are reinforced by the connection that long exists between them. Human interconnectedness at the international level, and its own dynamics, can determine the spread of a virus. Besides, the increased regional cooperation across the continental blocs of the world in terms of free movement of people, goods and services, with its significant economic benefits, has its public health risks. The 2003 SARS and 2014 Ebola outbreak showed the world the influence of international air travel in the diffusion of the viruses in Canada and West Africa respectively. Everyone is at some degree of risk. MPox’s status as an “international concern”, in the light of all this, is truly a concern for all regardless of location and prevalence. As just the rain falls on the trees, so it does on the leaves. A humanized global response to MPox would require collective action with emphasis on moral responsibility, solidarity and empathy.
However, disagreement manifests itself also when we ask what it means to consider MPox of “international concern” or to consider it a matter of “global health”. Should people living in some parts of the world be concerned about MPox because it might threaten their own health if not promptly addressed, for instance through vaccination of populations in other parts of the world? Or should they be concerned as a matter of altruism and solidarity towards the populations that are more severely affected? Or both? And should we be concerned at all? How these issues are addressed depends precisely on values that are the source of much disagreement. For example, disagreement about what we take to be our obligations to our community versus the ones to the communities in other parts of the world, and the relative tradeoffs. While this tension is present also in normal times, it typically is not so salient in public discourse and policy decisions as when a significant infectious disease threat emerges.
- Putting the humanities at the centre
If this is all true, then at least some lessons from COVID-19 can be better analysed, understood, and applied from a humanities, rather than a scientific, perspective. For disagreement springs from ethics, politics, and culture. It is difficult to see how we can be prepared for managing future pandemics – whether MPox or something else – without placing the humanities at the centre of the discussion. A recent article has argued that humanities disciplines “offer insights, expertise and tools that contribute to understanding responses to disease and uptake of interventions for prevention and treatment”.(Frampton et al 2024). For the reasons we have expounded in this article, MPox might offer the chance to take this recommendation seriously.
References:
Adetifa, I. et al. (2023), MPox neglect and the smallpox niche: a problem for Africa, a problem for the world, The Lancet; 40: 1822 – 1824
Charters E, Heitman K. (2021) How epidemics end. Centaurus; 63: 210–224
Frampton, S. et al (2024). Pandemic preparedness: why humanities and social sciences matter. Frontiers in Public Health; 12: 1394569
Osayomi, Tet al. (2021). A Geographical Analysis of the African COVID-19 Paradox: Putting the Poverty-as-a-Vaccine Hypothesis to the Test. Earth Systems and Environment 5, 799–810