TS Eliot’s chilling start to The Waste Land has deep resonance in the time of COVID-19. We seem to be exactly in that instant when ‘the dead tree gives no shelter’, when ‘I was neither living nor dead’, and when ‘He who was living is now dead’[i]. The mere 30 days of April have felt like a lifetime, stretched out in a moment-by-moment barrage of suffering, loss and death, overlaid in turn with interpretations, facts, opinions, theories, and commentaries of every stripe.
So where to begin writing about this ‘cruellest month’?
After much prevarication I decided to reflect on what has caught my attention and what I think I’ve learned. It’s not comprehensive. There is much more that could be included, but as a medical sociology colleague remarked on Twitter recently, the array of material emanating from COVID-19 at the moment is absolutely dizzying.
One pandemic, many epidemics
Pandemic is by definition global and in some ways has a unifying quality. We frequently hear of the ‘The Pandemic’, but my perception is really of many epidemics. These work themselves out in more restricted geographies, they insinuate into care systems, local communities, organisations, friendship groups and the countless social networks of modern life. They play out behind closed doors, in private spaces, and on public platforms.
This makes for multiple narratives. We all have a story to tell. Sometimes several. So navigating the pandemic requires effort, energy and fleetness of foot. Things change quickly. Today’s confidence is tomorrow’s doubt – one of many reasons why in the UK ministerial statements from government seem relentlessly bland and equivocal.
Yet we are all experts now. Quick to judge the ‘evidence’, eagerly passing on our latest shard of knowledge, casually garnered from tweet, soundbite or image, then lightly dusted in personal ownership for added authenticity. We seek out new facts and insights at every opportunity.
If our workplaces, and places of learning, and the shops, cafes, churches, temples, mosques and clubs are closed, the information highway is endlessly open, and mostly toll free. It becomes easier to consume than produce.
But produce we do. From haunting stories by bereaved people[ii], harrowing accounts written by care workers[iii] [iv] and COVID-19 survivors[v], to more abstracted framings and new theorisations[vi] of what is going on. The ‘pandemic’ has become endemic in our communications with one another.
Talk about death is pervasive.
During April our health care systems sought to gear up for death on an unprecedented scale from COVID-19. The perspective of palliative care became more apparent than ever before. How could a dignified death, attention to ‘total pain’ and the needs of the whole person be achieved in the context of PPE, isolation and a raft of unpredictable and difficult to control symptoms? Specialists looked to Italy then Spain, for insights into the problems of delivering mass end of life care in hastily arranged wards, in the absence of relatives, and when death seemed sometimes to come so quickly.
Work got underway to formalize guidelines and advice for the practice of palliative care in these pandemic conditions. The research on which this was based was woefully thin, as few studies had emerged from SARS, Ebola or recent influenza that would shed light on the value of palliative care in such testing times. On 11th April however, the cover of the Lancet proclaimed ‘Palliative care ought to be an explicit part of national and international response plans for COVID-19’. Yet palliative care had not even been mentioned in the World Health Organization operational guidance for maintaining essential health services during a COVID-19 outbreak, published a few weeks earlier, on 25th March[vii].
One dimension of the many epidemics is the massive variation of COVID-19 incidence, prevalence and the claimed effects of particular measures taken by individual nation states at specific junctures.
Why have some jurisdictions such as New Zealand, Denmark and Vietnam, apparently contained the pandemic? What factors explain the huge number of cases in Britain, Italy, Spain and the United States? Why is it that on 21 March no less a figure than Atul Gawande, writing in the New Yorker, could describe Singapore as having ‘a handle on the epidemic’[viii] with daily cases[ix] on that date at 47, when by 20 April, daily cases had reached 1,426? Similarly, Japan’s low COVID-19 infection numbers were seen as a success story but seem to have led to a lapse in public vigilance, followed by a subsequent state of emergency.[x]
In most of the discussions about trends and rates of COVID-19 we see little reference to the social construction of official statistics – the nuanced social processes in which the people involved act to produce specific readings of external phenomena for bureaucratic and political purposes.[xi] The figures with which we are presented daily – whether mournfully, cautiously, optimistically, even defensively – serve to obscure the underlying and contingent processes involved in their compilation.
For example, what is a COVID-19 related death?
Death certification procedures are notoriously different between countries. In Scotland, legislation introduced in 2011 requires documentation of the underlying cause of death, as the disease or injury which initiated the train of morbid events leading directly to death. It also has a requirement to state any other diseases, injuries, conditions, or events contributing to the death. That means factors not part of the direct sequence, but which made the person more vulnerable to the fatal condition, so that death occurred sooner than expected.
People may thus die from COVID-19, or die with it. Both are COVID-19 related deaths.
On Saturday 25 April, the United Kingdom reached the solemn milestone of 20,000 people whose death was COVID-related. Yet on 17 March the government’s chief scientific adviser, Sir Patrick Vallance, had said keeping such deaths below 20,000 would be a ‘good outcome’. Meanwhile until 29th April, the UK mortality figures presented each day were restricted to those who die in hospital. Taking into account deaths in the community, the 20,000 milestone was probably reached much earlier.
Little wonder that during the month there was a growing critique from academics, journalists and public health activists, raising important questions about what kind of ‘science’ is being invoked by the government (much it would seem, is a toxic mixture of mathematical modelling and ‘nudge’ theory) and how it is being applied to strategy. On 17 April, the New Scientist set out the various issues concerning the Scientific Advisory Group for Emergencies (SAGE): in particular a lack of clarity about membership and process and the decision to postpone publication of its minutes until after the emergency is over. On 25 April, Anthony Costello on Twitter had listed the absences from the government’s Scientific Advisory Group for Emergencies (SAGE): molecular virologist, ICU expert, nurse, epidemic control expert, social scientist, public health scientist, information technology scientist, citizen scientist, digital app innovator, logistician, adviser from Hong Kong, China or Korea, adviser from WHO. On 29 April the UK government belatedly appealed to the universities for wider expertise to bolster SAGE.
Bio-power
There has been much talk of public health. We are expected to know what this means and many affect to do so. The World Health Organization is often cited as the arbiter of good practice[xii], not least in stressing a mix of social distancing, testing, contact tracing and isolation.[xiii] But much of the public health perspective we have seen so far is narrowly epidemiological in character. It makes little reference to structured inequalities, community perspectives, assets based approaches, or to political and cultural dimensions. Instead we see a strengthening nexus between power and knowledge – and also data – as an agent of control, in a way first articulated by Michel Foucault in his famous concept of bio-power.
‘Flattening the curve’ is something we all now feign to understand. The reproduction number R, defined as the number of secondary infections generated by an infected individual, is invoked by news interviewers without even the need for explanation. Social distancing, we ‘know’ will drive down R. Just as testing capacity is everywhere being ‘ramped up’ and the UK government battled its way to a target of 100,000 a day by the end of April.
An enormous space has opened up for bio-medical reasoning. The sense of Foucauldian bio-power is everywhere. It has become the protecting shield of our politicians. The nation state is pulling out every tool in the locker to exercise control over human populations. Foucault’s words in 1976 are more than ever apparent today, as we see ‘an explosion of numerous and diverse techniques for achieving the subjugation of bodies and the control of populations’[xiv]. In the time of COVID-19 colonizing this ground comes by following the scientific advice and taking on board the medical guidance.
Yet this in itself has caused concern, and the editor of The Lancet is on record as saying that the medical and political establishment has been co-opted into supporting the UK government line on COVID-19 and that the failure to identify and take seriously the threat of the pandemic exposes a huge weakness in science policy.
During April, other counter-logics to bio-medicine began to emerge. The contortions around lockdown and the economy demonstrate this vividly, not least in the idea of a trade-off between the number of deaths from COVID-19 that is acceptable, if business and commerce are to get going again. Stefan Ecks has described coronavirus lockdowns as ‘conflicted biocommensurations’[xv]. They have taken a myriad forms, making comparisons of their relative value highly problematic. They also have many consequences – for health, but also for the economy. They bring benefits – preventing the surge, protecting the health services. But they have their own sequelae – in mental illness, isolation, poverty and economic hardship.
There are signs too that even within the health care system itself, the exercise of bio-power is meeting resistance. Throughout April the military has been on view in UK hospitals. Local NHS managers locked in emergency meeting rooms have stratified their ‘command structures’ into ‘bronze’, ‘silver’ and ‘gold’. Some clinicians are growing sceptical of all this. In addition to flattening the curve, there are calls around the NHS for a flattening of the hierarchy and the abandonment of militaristic language. And there is concern too for the growing numbers of patients who are not getting treatment, and the possibility of very poor outcomes next year and beyond, especially for those who develop cancer during the time of COVID.
Flashpoints of the social
In my memory I have always attributed the phrase ‘flashpoints of the social’ to Jeffrey Weeks and his work on HIV/AIDS. When I looked it up, I was reminded that Weeks drew the idea from Jacqueline Rose, who observed in 1988 that ‘flashpoints of the social’ are ‘the very point where reason itself is at its least secure’. It has felt like that during April, as we listened to apparently reasonable claims and counter-claims, and even more starkly in the improbable and deeply problematic utterances of the President of the United States.
The social reverberations of COVID-19 are going far, far beyond bio-medical discourse. During April, commentary on the social dimensions of COVID-19 got fully into its stride.
This has taken many forms. We see how the pandemic is exposing pre-existing fissures and inequalities in society. COVID-19 creates greater vulnerabilities for the old, for the poor, for migrants and homeless people. It shines a light on the contradictions of globalisation, world travel, tourism and patterns of conducting business. We see moral entrepreneurs, priests, environmentalists, writers and critics who prophesize with their pens – all urging us not to yearn to get ‘back to normal’. COVID-19 has introduced ‘the new normal’, and questioned the old one. For these harbingers of change, a future normality may be blessed with many virtues, as we somehow connect with ‘what is really important’. There is a widespread sense of ‘reculer pour mieux sauter’.
The British NHS has been embraced by the nation, and is applauded each Thursday. At 7pm every night, health workers are similarly thanked in New York. Random acts of kindness, everyday heroism, and community spirit pervade our daily discourse. Musicians play from their living rooms and gardens. Virtual choirs are everywhere singing. We seem to be living at least an octave above our usual emotional pitch.
But there are also stories of increased domestic abuse (‘the shadow pandemic’), more calls to helplines, families isolated and in poverty, exacerbations to mental health problems, loneliness and despair. Over 100 care workers in Britain have died from COVID-19 and in New York, emergency department doctor, Lorna Breen, committed suicide in the face of pressures in her work, and whilst in the process herself of recovering from the virus. [xvi] There are also reports from Mexico, India and the Philippines of nurses attacked in public places and whilst making their way to work, by those fearful of contagion[xvii]. Health care workers have been ostracized by neighbours or evicted from their homes.
During April new characterisations of civic responsibility and irresponsibility emerged around the rapidly conceived norms of social distancing.
The newspapers fomented moral outrage with photographs of people gathering in parks, sunbathing in public, or otherwise flaunting the lockdown. Italian mayors were seen in fits of video rage over the numbers of ‘dedicated runners’ that had suddenly emerged in their towns or the rise in home visiting hairdressers. A trip to the supermarket has become loaded with introspection about timings, aisle etiquette, and the rituals of decontamination that accompany the return home.
To act according to the rules of lockdown has become a measure of one’s personal worth. To contravene them is to invite opprobrium. And of course the debate about masks itself unmasks bio-political assumptions, cultural transgression lines and imputations of motive: are we protecting ourselves or those we encounter?
There have been unlikely casualties of this emergent moral order.
Dr Catherine Calderwood was apparently doing a good job as Scotland’s Chief Medical Officer, but her resignation on Sunday 5th April became inevitable when she was ‘outed’ by the media and then wickedly satirized for visiting her second home, some 40 miles from Edinburgh. My namesake, David Clark, New Zealand’s health minister was likewise stripped of his associate portfolio and demoted to the bottom of the cabinet rankings over an indiscrete cycle ride and a car trip to the beach.
The late Phil Strong picked up much of this in 1990, in what was a first attempt at a general sociological statement on:
‘… the striking problems that large, fatal epidemics seem to present to social order, the waves of fear, panic, stigma, moralising and calls to action that seem to characterise the immediate reaction … since this strange state presents such an immediate threat, actual or potential, to public order, it can also powerfully influence the size, timing and shape of the social and political response in many other areas affected by the epidemic’. [xviii].
Perhaps even Strong would not have imagined the scale of the social impact of COVID-19, which almost daily takes on new ramifications far beyond the epidemiological and the medical, and becomes like the ghost in Hamlet, a deus ex machina for civilisation’s many discontents.
Bone-breaking April
I buried my father in April, many years ago.
This April all manner of restrictions and constraints on funerary and mourning customs have set limits on how and in what ways we can assemble to honour and say farewell to our dead[xix]. Grief and memorialisation are being put on hold, with who knows what psychological and existential consequences?
I am still conscious, as Dylan Thomas once observed, that April is a ‘bone breaking’ month[xx] – full of contradictions, false hopes, and deceptions. Day by day, this April has layered grief upon hope, confusion upon clarity, strength upon weakness, power upon vulnerability. It has fostered neologisms of distress (corona-shock, corona-stress, corona-shaming) and brought forth new demonisations and novel sanctifications, generating fear and optimism in oscillating measure.
April 2020 is the month in which the world pivoted, but didn’t know which way to turn. Following an April like this, can we even bear to think what the next month will hold – as Eliot puts it:
After the frosty silence in the gardens
After the agony in stony places
The shouting and the crying.
[i] TS Eliot (1922) The Waste Land. New York: Boni and Liveright.
[ii] https://eu.usatoday.com/story/news/nation/2020/04/19/coronavirus-deaths-daughter-listens-hours-father-dies-alone/2986665001/
[iii] https://www.nytimes.com/2020/04/20/opinion/sunday/coronavirus-testing-pneumonia.html
[iv] https://www.bbc.co.uk/news/world-52297156
[v] https://www.bbc.co.uk/news/health-52124554
[vi] For just one of many excellent sources of this kind of material, see Discover Society: https://discoversociety.org/category/quickfire/covid-19/ Yasmin Gunaratnam’s inter-weaving of personal narrative, the stories about the first doctors in the UK to die of coronavirus and the exposure of deep fissures and under-resourcing in the care system is a brilliant example – https://discoversociety.org/2020/03/30/when-doctors-die/
[vii] https://www.who.int/publications-detail/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak
[viii] https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers
[ix] https://www.worldometers.info/coronavirus/country/singapore/
[x] https://www.bmj.com/content/369/bmj.m1625
[xi] https://link.springer.com/article/10.1007/s11205-018-1989-x
[xii] https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance
[xiii] https://news.un.org/en/story/2020/04/1061642
[xiv] Foucault, M (1976) The History of Sexuality Vol. 1 An Introduction, p140. London: Allen Lane.
[xv] I am grateful to my colleague Dr Marian Krawcyzk for introducing me to this work – http://somatosphere.net/2020/lockdowns-save-lockdowns-kill-valuing-life-after-coronashock.html/
[xvi] https://www.bbc.co.uk/news/world-us-canada-52451094
[xvii] https://www.nytimes.com/2020/04/27/world/americas/coronavirus-health-workers-attacked.html
[xviii] Strong, P (1990) Epidemic psychology: a model. Sociology of Health and Illness. 12(3), p249
[xix] https://www.bmj.com/content/369/bmj.m1649
[xx] Dylan Thomas (1936) Hold hard these ancient minutes in the cuckoo’s month. In: Twenty-Five Poems. London: J M Dent and Sons.