Emma Ross
Good morning and thank you for joining us today on the Living with COVID-19 webinar series with Chatham House Distinguished Fellow, Professor David Heymann. We have with us today Social Scientist, Olivia Tulloch, who is CEO of Anthrologica, and that’s a research-based organisation specialising in applied anthropology and global health. It’s a relatively neglected, but hugely important area when it comes to effective responses to public health emergencies. She’s been at the forefront of translating and using academic social science research to ensure stronger, more effective responses in epidemics, and supports WHO, UNICEF, and the International Federation of Red Cross and Red Crescent Societies on emergency response, including as part of the WHO’s Social Science Working Group. So, outbreak after outbreak, there’s usually a call for more involvement of Social Scientists in the response and the preparedness phase, come to think of it, as experience has shown that it’s all well and good having policies, but those don’t have much chance of working if people aren’t able and, crucially, willing to follow through on the public health measures they’re being asked to do. So, we’re really pleased to have her with us today to explore this critical aspect of the response to this pandemic.
But, before we get started, I just want to do the usual housekeeping stuff, which is that to say that the briefing is on the record and that questions can be submitted using the ‘Q&A’ function on Zoom. Upvoted questions are more likely to be selected, so if you have a question that’s similar to one that’s already there, please upvote it. Okay, so we’ll get started now. Welcome, Olivia, and thank you for joining us today.
Dr Olivia Tulloch
Thanks, Emma, thanks for inviting me, I’m looking forward to it very much.
Emma Ross
Great. So, while it’s really important for the government to have a plan and policies, the buy-in of the population is considered absolutely key to a successful response, and it is argued that the power to control the virus lies with the populous, and that, to a certain extent, such action can overcome shortcomings of the government response. David certainly has said many times that we all have a role to play in fighting the pandemic, in understanding how we can protect ourselves and others, and doing whatever that is. Unfortunately, many countries are seeing a waning of public compliance with public health measures, why, and how can they be brought back onboard? David, I wanted to start with you, unusually, first, and that’s to ask, which bits of a response are up to the government and which bits are up to the population, and which of those is the bigger driver of success?
Professor David Heymann CBE
I think – thanks, Emma. I think what we’d like to do is see a government which facilitates the activities at the lower level, because it’s in communities and in regions where the action really must occur, if it’s to be effective. So, the role of government in that is to set the guidelines, the technical input, the understanding of the strategies moving forward, to create the right environment so that at the local level those activities can be implemented and carried through. For example, if the government has, as a strategy, contact tracing, they should set up the norms and the standards and the guidelines at the national level, but then the implementation should be done at the local level, or at least at a level where there’s trust among people.
Emma Ross
Okay and thanks for that, David. Oliva, before we get into the specifics about what kind of anthropology-related issues we’re experiencing with the pandemic, I first wanted to explore what exactly is the role and power of the population to influence how a response goes, and what do we mean by ‘the community’? I mean, there are terms in public health, such as community mobilisation and community engagement, community level, are you targeting the population as a whole, as a collection of individuals, or is there more nuance to that that we need to differentiate?
Dr Olivia Tulloch
Thanks, Emma, yeah, a good question, I think we need to get our terminology straight from the start about what a community even is and it’s interpreted in different ways by different people. I think I would say, in its broader sense, it’s a group of individuals and that those individuals somehow have some common characteristics. So, they might share the same location, but they equally may not, that’s not the most important characteristic of a community member. But what they do is follow or share some values or perceptions of a common identity, and so we need to keep in mind what the differences might be between communities and the individuals within those communities, and there are different types. So, we could talk about a religious community, where perhaps people attend the same place of worship, or a university community, which could be a group of students enrolled in the same course of study, or workplace, residential, and so on, and those are all different types of community. And then, when we’ve identified indeed what that is, then we can look more into how specific populations, or communities within a population, might respond to COVID-19 and what power they have to respond.
So, I think a really important thing if we’re talking about the national and the local level, as David just mentioned, is that we don’t think of community as something that’s homogenous. But that they’re made up – populations are made up of multiple communities, different communities, with very different lived experiences. And so, if we think what the role and the power of a population is to contribute to controlling the spread of COVID-19, we can’t give one answer when we think about community, and we can’t think of them as one. We can say that there are certain protective health measures and actions that we hope all people understand and can do, but the way that we communicate to people, about those actions, will depend on who those people are and the context that they’re in. So, that’s where the disciplines of the social sciences and anthropology would come in.
Emma Ross
So, you really have to approach all these different communities differently, even if you want everybody to do the same thing?
Dr Olivia Tulloch
Absolutely. I mean, if you can imagine, in your own circumstances, how you would communicate to, I don’t know if you have children, but to your son before he goes to school about how he should cough, and how you would communicate to your husband or your cousin, you would think about different ways for those different individuals, even if – according to the circumstances in which they live their everyday life, be they in a workplace environment or a school environment and so on. And, likewise, across cultures and countries, you would tackle that differently.
Emma Ross
And do you think enough of that passing and tailoring is going on in this pandemic? I mean, what I’m seeing is, well, I don’t see behind the scenes, but when governments are addressing their people, I guess, it’s normally in a press conference to everybody, you seem to see one message that’s kind of broadcast out to everybody, is there much tailoring going on?
Dr Olivia Tulloch
I think it’s appropriate to have national messages, or at least a national strategy and plans, which are broadcast at a national level, there’s not something wrong with that per se, it’s that that then needs to be cascaded to other levels, to – through, let’s say, local leaders and so on, and that there really needs to be space for that to occur. And in, let’s say, in some countries in the Northern Hemisphere at the moment, we see that that isn’t occurring very effectively, but where there – where that space is given, it can be very effective.
Emma Ross
Okay, thank you. There seemed to be at least two aspects of – to a population response, I guess, and I’m sure there are more, but I kind of divided into compliance with government strategy or interventions, and the community’s own agency in driving response from the grassroots. When we had Mike Ryan, who’s co-ordinating the global response for WHO, on with us a few weeks ago, he mentioned that the population/community is seen sometimes as a barrier to success rather than an asset or the driver of success and how that’s very wrong and short-sighted. I first – Olivia, can we first talk about compliance? We’ve all seen that in some countries the population is pretty much onboard enough with the government’s interventions and compliant enough, and in others, there is at best a mix of compliance and defiance and a general waning of compliance, compared with earlier in the pandemic, and in Europe at least most of the spread is happening in homes, indoor spaces and in communities, not complying with protection measures. What are you seeing when it comes to compliance and defiance globally at the moment, and what’s the explanation for those differences? I mean, what are the factors that influence a community’s willingness to participate and why are there such levels of non-compliance in some places?
Dr Olivia Tulloch
That’s a really big question. I shall – I’ll try and break it down a little bit. For a start, it very much depends on the part of the world in which you’re looking and, within those regions and I’d say within those communities, how people perceive risk, because people’s risk perception affects their behaviours. So, if we were to look at, let’s say, many parts of Africa at the moment where, demographically, the population is quite a young population and, environmentally, there is a – the way in which people live in warmer climates, for example, means that there is a lot to suggest that the risks of COVID-19 transmission and infection, in some of those places, is lower than it would be in the Northern Hemisphere, as we go into winter. So, if you are asking for real stringent lockdown measures in an African setting at the moment, I think a lot of people would say that, or would feel that, that was disproportionate to the risk that they face, when in fact they have many other crises and issues that take priority over protecting themselves from COVID-19.
Whereas, if you look at, let’s say, the Northern Hemisphere, you might say, well, defiance, if we call it that, is being driven by other things. We’ve, in many nations, had strict restrictive measures for very many months and we don’t see them ending, and when we know now that we are going to have to start living with this virus in a more chronic way, really in the long-term, and so people feel fatigue and confusion and frustration to do with the measures that are being directed at them, and people look at the measures that are designed to protect them and they can see that they start to undermine other parts of their existence, wherever you might be. So, in the short-term, there might have been real willingness to follow the advice and the guidance that we had in the earlier days of the pandemic, but that’s waning because there are other things, like access to other social welfare and health services, or access to friends and families, or the ability to earn a living, all of these things are affected by the measures that we are supposed to be following. You know, and that goes across to whether or not your child can go to school or public transport can be taken, you know, these are all things that are now very familiar to all of us. And so, it’s not surprising that, in some circumstances, there’ll be a sense of hopelessness or just a kind of loss of agency, and this is especially so for most vulnerable people, those that, let’s say, the poorest within a society, people who are living in precarious situations, and we see then, that the kind of public state relation becomes, in some ways, destabilised and we see these issues that you might call defiance rather than compliance.
Emma Ross
Thanks. Just a follow-up on that, that experience and restriction is being seen all over the world, we’re all sacrificing, so why is it that in some societies they’ll suck up the sacrifice and comply, and in others they won’t? If we’re all being asked to make similar sacrifices, what makes the difference between, “Okay, I’m sacrificing, but, you know, I’ll do it,” or “No way, I’m not doing that”?
Dr Olivia Tulloch
I think there’s a few factors there. Part of it might be to do with the level of knowledge or information that people receive, and how that knowledge is, or how the information is relayed and the extent to which people trust the information that they give. So, there might be an element of relationship between the individual or the community and the state, and the way in which they absorb information and are likely to follow guidance. But also, that if the evidence itself is changing, then the way that that is presented is happening very differently in different places, and if you are in a place where the messages are changing and are not consistent or it’s being very heavily politicised, I think we do see that trust and willingness to comply can be undermined and sometimes, we’ll experience a real, sort of, overfocus on data and statistics, which very often just confuses people. And if that is a strategy that a government is taking, I mean, we can use the example that in some cases we’ve become very familiar with this term the ‘R number’, as if this is a concept that everybody should be able to absorb and understand, and we hear it all of the time and governments that are using those sorts of terms, are not necessarily going about things in the best way, in terms of making sure that understanding is really getting down, so that people know how to interpret the guidance that they’re given. And so, if you get that wrong, if you get the relaying of the information wrong, you lose people and you lose communities and you lose trust, and so I think that would be one part of it.
Emma Ross
Okay. David, in your experience, what influences population buy-in to a national response to an epidemic?
Professor David Heymann CBE
Thanks, Emma, and thanks, Olivia. I would just like to build a little bit on what Olivia said with some personal experiences, if that would be okay? And I’d like to first talk about the importance of messaging that people can understand, and this is – this goes back to experience with the Ebola outbreaks in West Africa, and even before that in DRC, and I’d like to talk about Jean-Jacques Muyembe, who was the first Western-trained Virologist and Doctor to really see Ebola in 1976. He saw Ebola, he understood what was going on, and by the time of the second outbreak in DRC, and the third, he understood that the most important thing to do, when he arrived at the site of an outbreak, was not to go to the hospital, but to go to the District Commissioner and ask him to call together all the traditional Chiefs and he wanted to see them as soon as possible.
When he met with them, he talked about two different things. He said, “There’s a terrible disease that’s occurring and it’s occurring because people are filled with evil spirits who are sick, and those evil spirits are trying to get out and by so doing, they’re making that person sick, and if you touch that person, you yourself will become sick, because evil spirits will come from that person to you, or that person’s dead body.” And then he says, “Go back to your communities, pass the word, and help the teams that are coming to stop the outbreak,” which is quite effective now, in over ten outbreaks in DRC that have been stopped very rapidly, or in certain instances, taking longer because of civil disturbance.
And then I’d like to go to not only the messaging, but the tradition of a society, which is also very important, as Olivia said as well, in what they will do, and I’d like to go to Asia where mask wearing has not been a major difficulty, for people to wear masks to protect others and to understand that physical distancing and handwashing protects themselves. And they do this, and I talked recently with a colleague whose wife is Japanese, and he said he had been speaking with his wife and that he understood from her why it was so easy for the Asians to accept the mask wearing situation, because they always do it. They wear a mask if they’re sick because if they enter a disease into their community, or the population with which they’re with, they have a sense of guilt. They have a sense that they weren’t protecting others, whereas, to protect themselves, they also try to protect themselves by distancing. So, I think what Olivia has said and what I’ve tried to build on is that messaging in the language that people that understand is very important, not the reproductive number, but something much, much accessible by populations, and at the same time, tradition is important to build upon, as you develop ways of dealing with this outbreak, that’s why community is so important.
Emma Ross
Okay. Could I ask Olivia, what is this whole concept of the social contract? What does that mean and what role does that have to play in all of this?
Dr Olivia Tulloch
Thanks, Emma, and can I – before I get onto that, can I just add a layer onto what David was just saying about wearing masks and particularly in the case of Korea that he mentioned?
Emma Ross
Sure, sure.
Dr Olivia Tulloch
Which was that I have heard exactly the same sort of stories, that it’s a very normal thing, not only in Korea, but all over Southeast Asia, that mask wearing is not something that people would feel concerned about. But in terms of the messaging and how this can be done, I think there are some quite interesting and innovative things that we can learn, and so while it might be normal across Asia, we – I read a story recently about the – a famous boyband in South Korea, which had, a few years ago, taken selfies and publicised them on social media of themselves, all in face masks. And, as a result, face masks in the young population became a kind of huge fashion item, a certain type of face mask, and everybody wanted to wear one, and they wore them not just as a fashion item, but to hide their bad skin problems or to protect themselves against pollution or whatever. And it’s just a way of thinking, well, if we want to encourage different sorts of people to adopt certain behaviours, let’s think about what people respond to, and that how you get the youth to buy into the idea of wearing a face mask, would be very different from the way you might try to encourage somebody who’s elderly, who might have problems breathing themselves. And so, the messaging for those sorts of things needs to be adapted, let’s say.
Now, you asked me about the social contract. So, I’ll – yeah, this is something that Mike Ryan had brought up a few weeks ago, wasn’t it, and it’s a really interesting idea, when we think about COVID-19 and what that means to different, sort of, communities, and it’s really being debated a bit more now, with regard to the COVID-19 measures that are being considered increasingly punitive. A social contract, in itself, is a – it’s essentially a philosophical idea, and it’s really about the relationship between the individual and the government or other authority, and specifically about the legitimacy of that authority over the individual. So, that’s the concept of it and, philosophically, it means individuals within a system agree, that’s the contract, to hand over some of their freedoms and submit to the authority, to use a, sort of, academic language, in exchange for some kind of protection. And that might be the maintenance of social order, or it might be the maintenance of public health. And the contract itself varies tremendously according to where you are, the culture, the political system and that kind of thing. And then, a social contract, because it’s a contract, means that those people who are – that it has to be agreed to by all members within the contract, you know, it’s a voluntary contract, it’s not an enforced contract. So, I think there are some quite interesting ways that this idea that Mike put forward could be used, when we discuss measures for this pandemic.
Emma Ross
Yeah. David, you’re nodding a lot and smiling, so I’m sure you have lots to say about this, but when you do that, could you include how you see the different types of social contracts playing out in this pandemic and what influence that has on the effectiveness of responses?
Professor David Heymann CBE
Well, you know, I think I would go back to what you said earlier, Emma, about compliance and defiance, because, you know, the natural tendency of humans is to defy when there’s something that they feel is infringing on their personal space or their rights, and so, it’s a very difficult activity for a government to help make the social contract, if they’re going to be too authoritarian. They have to be – they have to come across as being a government, which understands the people, which is giving them the possibility of a contract, which they voluntarily will adhere to. And at the same time, people have to feel that they do have, as Olivia said, they have to give up a little bit of their rights, in order to comply with that for the benefit of the public good.
It goes all the way from vaccinations, you know, should a child be vaccinated to protect himself or herself, or should they be vaccinated to protect others? And it’s the same with this, should someone wear a mask, or should someone do what the government is saying to protect themselves and to protect others, or should they only be looking to protect themselves? The social contract would be, I want to protect myself and protect others and the government should facilitate that as best they can, with the proper messaging, with the proper framework in which those people live and work every day.
And that’s why it’s so important in these responses to look at behaviour at the workplace, as well as in the community and home, because the workplaces, and I’ve said this before, are very important in the final solution to this. They will be able to help with the social contract within their own companies, or their own business places, as to what their people who are working for them will do and what the company or the business will do for them. So, social contracts are not just between a government and the people, they’re everywhere that people go. Olivia may want to challenge that a bit.
Dr Olivia Tulloch
I wouldn’t – I don’t think I would challenge it. I think if we were to say that there – that the government should facilitate in – within this contract, that there are some important areas in which we should acknowledge how the government facilitates. So, if we imagine that there needs to be a level of protection, that that’s the government’s side of the contract, what does that really mean? You know, if the government says, “Okay, we’ll – you have to behave this, and that will protect health services.” But then, they also need to kind of encourage that and facilitate it by making sure that people have the support that they need and the information and the knowledge that they need, in order to go through with their side of the contract too. And so, that might be making sure that people know how to self-direct and how to protect themselves and that there should not just be, let’s say, state-ordered actions, you know, the point you make about authoritarianism is really valid, but there needs to be a level of individual and collective action within that. And we see that the lockdowns are causing really a great hardship and that when people are in lockdowns for prolonged periods, or following restrictive measures for prolonged periods, they’re really suffering. They’re going through immense hardship and I don’t think that we can really recommend that in the long-term in a strong social contract.
Compelling people to act in a certain way in this contract is not really working, and we just need to, well, not just, but we need to use better ways to communicate effectively to people that they, as individuals, have some control and some agency in this pandemic and can have a degree of responsibility themselves. And so, this is perhaps the idea that the nanny state approach is not really going to work in this pandemic in the long-term.
Emma Ross
Then actually, I wanted to talk about the agency part of community participation, so when it comes to agency, can a population beat the virus, even if its government isn’t doing a great job? Olivia, what’s your opinion first?
Dr Olivia Tulloch
And even if its government isn’t doing a great job?
Emma Ross
Can the community take control and get it done?
Dr Olivia Tulloch
Yes, I understand the question, and it’s quite an interesting one, great job. Okay, the government needs to be doing an adequate job, in certain ways. There are, I think, some minimum things that we need government to be doing, in order for communities to look after themselves as well. And so, yes, agency is something that is at the individual level, but if governments are doing, let’s say, really not a great job, then it’s going to be very difficult for communities to take that agency. So, you want to give people space, in order that they can take, let’s say, take their responsibilities seriously. Things – so we need to understand how communities work at the local level and some – and propose things that make sense to them, and then let them be the ones who orchestrate what that looks like within their lives. We see really great examples of community action, collective community action, and individual action that shows that, given the space, people really do take initiative. But without accurate information, without knowing what works and what doesn’t work, without this being communicated effectively, and when there is, let’s say, a sort of political infighting or messiness, those are the sorts of things which are going to intervene with, or reduce that agency.
Emma Ross
Great. David, have you seen examples, I mean, can a community kind of take over to fill the shortcomings of government and turn it around themselves?
Professor David Heymann CBE
Yeah, I’ve seen some very good examples in the past. I haven’t seen any quite recently, but going back to the 1980s, the early 1980s, at that time I was working with the Center for Disease Control from the US, and when AIDS was first identified, when HIV was first identified, the US Government was ignoring it completely. In fact, it was saying that this was a disease of men who had sex with men and didn’t really matter. And there were a community of men who had sex with men who began to develop NGOs and all kinds of groups, which really were able to take charge and convince the government, at least the rational parts of the government, that this really was an infectious disease that could be controlled and the transmission could be stopped, with the right government policies. So, that was a group that really did take charge, and then later on, when I went to a couple of outbreaks of Ebola in DRC, I saw the same thing happening in a country where the government was not able to really manage what was going on. Getting to the communities where Ebola was occurring, it was the merchants in that community and the Red Cross volunteers in that community who were actually dealing with the outbreak in the absence of a government presence. The hospitals were overwhelmed, but there were groups of volunteers who stood up and took charge because they knew that if they did, they could make an impact. So, yes, there are ways that NGOs especially can do this by advocacy and actually by action, such as is done many times by Red Cross or other NGO groups. Olivia?
Emma Ross
Yeah, did you want to come back in?
Dr Olivia Tulloch
Only I think the point about in – the role of NGOs and other organisations in being a good facilitator for this. You know, there’s a great deal of expertise about how this can be done, in international NGOs, as well as grassroot level NGOs, so I would just wholeheartedly agree with that.
Emma Ross
Okay. So, we’ve heard a lot about how the population, or the community action is so powerful fundamental in epidemic control, and we’re seeing spiralling infections, in many parts of the world, mostly Europe and North America, does that mean that it’s the community’s fault that this is in a bad state, because if they’re the major driver of success and it’s not looking like a success, doesn’t that indicate that the community is not doing their thing? David?
Professor David Heymann CBE
Well, it’s not the time to blame, that’s for sure. We have – we’re in the middle of a pandemic and we have to move forward with what our governments are doing. But we have to also, at the same time, make sure that those people who feel strongly about an issue are heard, that they make themselves heard, because it’s only through dialogue, between a government and its people, that things can become better. The difficulty right now is that in many countries, they’re looking forward to a vaccine which may or may not come, which may or may not be effective in the short or long-term, and they’re looking at a possible therapeutic, which could come along, which could solve many of the problems, but that’s not a good way to proceed at present.
Today, we have to, as the title of this series, learn to live with the pandemic. We need to do what we can today with the diagnostic testing, with the outbreak containment activities, and with all the different factors that we can be doing to really deal with this outbreak today, and that means that communities should inform themselves, and they do understand how they can participate, and if they don’t, they should band together with groups that do. So that even if they’re not in concert with what the government is recommending, they can contribute in their own way by following the government, but also following other methods that they feel might be equally or more effective.
That’s not a complete answer, but it’s an answer to say that everybody is building this ship as it sails, and it’s not the time to really blame anyone. It’s a time to pull together and work as one community to stop the pandemic from overwhelming our hospitals and making sure that people don’t become infected, who are at risk of dying. Olivia?
Dr Olivia Tulloch
Yeah, it’s now or not. Absolutely, like, finding fault at this stage is counterproductive, and blaming, it’s not the time to blame. And what we know, from recent research that’s going on, and there’s really excellent social science research happening, is that people do often have high rates of intention to actually follow through with what it is that they are being asked to do. But sometimes it’s simply not feasible or appropriate for them to do so, and the reasons why people fail, if we’re going to use the word ‘fail’, to comply is sometimes there are really important personal reasons or financial reasons or because compliance is just really hard. It’s not necessarily deliberate that people do not comply with the public health measures that they’re expected to go through, and we need to consider how, if you have a low income or if you have commitments to fulfil, or just how damaging isolation can be to one’s mental health, that these are all things that are going to make it difficult for people to comply and that when national or local leaders require populations to comply with a certain measure, they really need to keep those things in mind. And, yes, we all have a job to contribute and to protect others, as well as protecting ourselves, as we were already saying, but there is this growing, let’s say, defiance. You know, there’s some extraordinary expressions being circulated at the moment, like Refusenik, I don’t know if you’ve heard this, but I’ve seen it a bit in the media recently, it’s a somewhat inappropriate term, I feel, but these are people who are refusing to comply with the measures that they’re expected to. And in some places we see really very dramatic reactions from governments to try to make people refuse, you know, for example, people who had refused to wear masks then being made to dig the graves of people who had died from COVID-19, you know, like really just stuff that I don’t think is probably a very sensible way to try and encourage people to take social responsibility. And so, this idea that we need to work together and be collaborative, across lots of different levels, is really important.
Emma Ross
Okay, thank you. I’m going to move to questions now. The most upvoted question by far is – comes from Dina Mufti and it is, either of you could answer this, “What is the most effective change, behaviour change technique that can be used to convince people to wear masks and socially distance?” I would appreciate that – yes, that’s directed at me. So, what’s the best behaviour change technique to get people to wear masks and socially distance?
Dr Olivia Tulloch
I can start and, David, if you want to pick up from there? I think I would say, first off, that there is not one most effective technique. I think that would be my number one response to that, is that we need to have a range of ways in which we engage and communicate with people that is appropriate to them, in order that the behaviour change technique that we want is – can be followed through with. And so, if it’s about masks, it’s thinking, well, what are the reasons why people don’t wear masks now and what can we do to make it easier for them to wear the masks? And, likewise, for social distancing, let’s really think about what the, and I’m going to say physical distancing rather than social distancing, but no disrespect to the questioner, that when we expect people to keep physical distance from each other and to stay apart from each other, what does that mean for the individual? Does it – is it going to stop them from being able to earn an income and, if so, what can we do to make sure that we can support them in the best way possible? So, I really think that all the ways – the thread that goes through this debate today is that there might be one action that needs, or a collection of actions that are being promoted at national level, but when it comes to individuals, we need to have local level support to make sure that people can follow through with those actions. And that it’s local organisations and local leaders, who know their communities best, that will be able to come up with the ideas that can support them to do so.
Emma Ross
Okay, David, the next question’s for you and it’s from Sam Meredith at CNBC, “The UK’s Chief Scientific Advisor warned earlier this week that COVID-19 would likely become endemic, suggesting the virus could eventually circulate much like other coronaviruses. Do you share this assessment and what alternatives are there if eradicating COVID-19 is not possible?”
Professor David Heymann CBE
Yes, well, thanks, Emma. I think what I said earlier was that one of the scenarios for this virus is that it does become endemic and it looks at present as if that’s going to happen, just like it happened for previous times when there was an emergence of a coronavirus into human populations that became endemic. So, yes, I think the answer is that, yes, this will become endemic and that’s why the group that I chair at WHO, the STAG-IH, put out an article last week in The Lancet, which talks about living with the COVID pandemic, using the tools we have today.
We shouldn’t just be trying to suppress this virus out of existence, and we’re trying to suppress it to a level that it protects – suppress it to a level that’s unrealistic. We have to be able to suppress it to a level where it causes minimum damage, while at the same time entering a country and becoming endemic. Think of a country like New Zealand right now, and this morning I was on a – earlier I was on a webinar with a national university in Singapore, where the New Zealand Government was talking about their response, which has been to keep the virus out. They’re now trying to understand how they can open up, and it will be a difficult decision, what they do going forward, because they have not permitted the virus to enter at present, but tourism is one of their major sources of revenue. So, it’ll be very difficult moving forward. They’re talking about testing, they’re talking about other strategies, but in the long-term, I think living with the virus is probably the best way because of the fact that this scenario today is that it will become endemic.
I’d just like also, Emma, to say one more word about what Olivia was talking about. You know, what it’s important, and she said this earlier, is that there will be champions who are promoting good practices in public health, and she talked about the boy’s band, or the boy’s group in South Korea, which was wearing masks and everybody followed them. Well, that’s important today as well, and we can see what happens when a Head of State denies that masks are important, what happens to the population? There’s confusion, there’s partisanship, there’s a whole series of things that happen because the champion of the people has not done what would have been a message – has not given a message that would have been useful in helping them to understand that mask wearing is important, no matter who you are or where you are resident.
Emma Ross
Okay, thank you. Another upvoted question comes from Charles Clift, and I’d like to hear from both of you on this, “What do you think of the effect of potentially large fines for breaking rules in influencing behaviour? Are they a good idea, do they work?” Yeah, go ahead, Olivia.
Dr Olivia Tulloch
It’s – I would not – or measures or a [audio cuts out – 46:06] way in which to prevent people from acting in the way that an authority doesn’t want them to do. In something like a COVID-19 pandemic, the most important thing, I would say, is to carry people with you. Find out what it is that makes – encourages people to comply, rather than stamp on them if they don’t, and we’ve seen countless examples of what happens when you force people to comply and things go underground and that might be if you ban a wet market that you might think is a potential source of transmission for a new disease, or it might be if you fine people for not wearing their masks, or – these – they’re simply not effective approaches. And if we’re thinking about something which is as chronic and long-term as COVID-19, then we really need to think of ways where people are going to be encouraged to follow the guidance and supported to do so.
Emma Ross
David?
Professor David Heymann CBE
Emma, could you repeat the question again?
Emma Ross
Yeah, Charles Clift and cracking down, better enforcement, fining people for disobeying the rules, is it effective and, if it isn’t, you know, why – if they’re not doing what they’re asked to do, why not make them? This whole idea of, you know, trying to make people do it and fining them, is it a good idea, does it work?
Professor David Heymann CBE
Well, you know, in the past, there’s evidence that when you do fine or you do suppress an activity, and can’t force it – enforce it 100%, then you’re driving things into a different realm. For example, if you ban food – wild animal purchases from a market in China, and there’s regulation that says it’s banned, but it’s not enforced, then you drive it underground and people know how to get the animals underground. So, I think that you can’t just have the stick, you have to have the carrot also and you have to have understanding. You have to understand – have understanding among the people why this is important, rather than using a stick and in many instances, a fine. So, my answer would be, I think that evidence shows that, in the long-term, the most important strategies are those that the people understand and accept without having to be fined or other – or have other sanctions against them. But it’s very difficult for governments to do that at the start because they understand the importance of rapid reaction and the impulses to fine and forget about it and say we’ve done our job.
Emma Ross
Okay, thank you. I’m going to move to a question from Jillian Deutsch, POLITICO, and it’s also an upvoted question, “We’ve seen some Politicians blame ethnic minorities or religious groups for spreading the virus, for example, Orthodox Jewish communities in New York City and Israel, how can Politicians ensure these groups adhere to the measures correctly, without shame, blame, stigmatising these groups?” Olivia, have you got some experience with this?
Dr Olivia Tulloch
Yeah, I think we’ve already assessed that blame is probably not the best answer. So, one way of tackling this would be to think about what it is about a specific group, whether it’s an ethnic group, or any other group, it doesn’t matter, what is the part of the behaviour that they’re being asked to do that is causing them difficulties, or that they don’t want to comply with? And if it is something that is very ingrained in their culture or their belief system or their social way of life, then, first, you need to understand why and what it is, but then make sure that you are using the right, I’m going to say interlocutors, to have the conversation with them about the importance of changing a behaviour and finding a behaviour which is appropriate. And David will know this very well from the Ebola outbreaks in West Africa that if you, for example, tell a community or tell a population that they are not allowed to wash the bodies of their dead, or to touch them or to go through their normal rites at someone’s passing, then, like we mentioned before, the – that will go underground. People will react against it and that behaviour will be hidden. So, the – I would suggest that, by working – if it’s a, let’s say, a religious group, then find those trusted voices that people from a certain group are likely to listen to, engage with those people, have dialogue with those people, so that they can be a really strong part of working with that community to tackle the risky behaviour. David?
Emma Ross
Okay, thank you. I’m going to – the most upvoted question at the moment now is from Eleanor Bennett and, David, why don’t you tackle this one, “What are the best mechanisms available to policymakers to effectively combat the spread of misinformation and conspiracy theories?” And also if you could comment on the role that that plays in influencing behaviour and compliance and willing participation.
Professor David Heymann CBE
That’s a tough question, Emma, but, you know, I learned early on in my training in epidemiology, and maybe I’ve said this before, every outbreak needs a face and it’s very true that there needs to be a constant person, such as Tony Fauci in the US, who people listen to, who people admire, who they respect, and who can convey the message in a way that they understand it. And so, my reply to that would be, there need to be credible and trusted sources of information and that needs to begin early in the outbreak and be consistently that person or that face, providing those messages. While at the same time, there needs to be credible information coming from all the different agencies as well, through their social media contacts, that provide the right evidence. It’s not easy. It’s not easy, but if people know who to turn to, who they trust, and who to turn to for the right information, that will go a long way to making sure that false information is counteracted.
Emma Ross
And so, it sounds like you’re saying the kind of a campaign of drowning out the misinformation, what about cracking down and trying to get rid of it? Olivia, do you want to come in on that, or do you agree with David?
Dr Olivia Tulloch
I strongly agree with David and that consistency is essential. I think I would also suggest that there’s a lot of really good information available and so, making sure that that good information is sent through the channels that people listen to and trust, and that we know what those channels are, and if we have specific vulnerable groups or specific populations who we know are at risk, that we try to understand who it is that they listen to and where they get their information from. Because when there’s a lot of conflicting information or confusion, that is when you get things like conspiracy theories, people jump into the vacuum, as it were, and peddle some of the more negative stuff. So, I think that one thing is really to make sure that as soon as we are aware of misinformation or disinformation, that that’s tackled and tackled fast. But also, that we really build on where we know there is good information and of which there is a central supply.
Emma Ross
Okay, thank you. We’re running short on time, so I wanted to circle back to the learning to live with the virus discussion. So, David, first from you, in learning to live with the virus, what do you think will be most important, in terms of the community aspect going forward?
Professor David Heymann CBE
What will be most important, Emma, I believe, is if the community understands if this disease is becoming endemic, that nothing will prevent that, even a vaccine will not prevent it from becoming endemic, if it’s on the way to becoming endemic. And so, populations, as Olivia said earlier, must know how to do – individuals in fact, must know how to do their own risk assessment, as they do for sexually transmitted infections, as they do for tuberculosis, as they do for other infections, they must do their own risk assessment and understand what measures they can take to prevent themselves from becoming infected and to prevent others from becoming infected. So, it’s all about the community, all about people understanding that this virus, if it is destined to become endemic, will become endemic no matter what we do, but we can slow that to a certain level that causes less disruption in our societies and lesser death.
Emma Ross
Olivia, throwing it forward to living with the virus, all the social science aspects, what are going to be really key things going forward?
Dr Olivia Tulloch
Okay, I think part of it is the levels of responsibility and we’ve talked today a bit about individual responsibility and government responsibility, but really that we recognise that responsibility goes – sorry, there’s a lot of tings going on in the background – that there is – that the collective responsibility and the collaborative responsibility. And then I think that involves a consultation and inclusion with local leadership and because those are the people who understand the needs and the norms of the communities – I’m sorry about the very long tinging of the clock – and then, I think, finally, adequate information and David was just mentioning vaccines and how, when – like, we’re putting a lot of resource into the science of vaccines, but in terms of social science, we’ve got a huge amount of work to do to make sure that when vaccines have been developed and they’re available, that we know what are the mechanisms, which are going to make these acceptable to those people who currently we know have a high degree of hesitancy.
Emma Ross
Okay, thank you. I’ve time to squeeze in one more question, for David, and this is from Bishop Richard Odoch, “If the virus is here to stay with us for a very long time, how will two weeks or three months lockdown make much difference?”
Professor David Heymann CBE
Well, as I said, we’re building the ship as we’re sailing, and we don’t know. What a lockdown does is it suppresses transmission. It keeps people physically distanced and it stops transmission from person-to-person. That’s a temporary measure. Asia has been using it for many, many months now, but they use it in a different way. The Asian populations identify where transmission is occurring and then they lockdown those segments in a precision activity and they try to rectify the situation, so that they can open up again. So, they’re doing it with an epidemiological approach, understanding, from their outbreak investigations, where disease is being transmitted and they lock that down and then they open it up again. They don’t use blunt measures, as many other countries are using, and they are in fact doing less damage to their economies because other sections of the economy remain open.
Emma Ross
Okay, thank you, and one minute to go, so I’m going to wrap up now and sorry I couldn’t get to all questions, but that’s all we have time for today. Olivia, thank you so much for discussing this really important aspect of the response with us today, and thank you all for tuning in. Please join us in two weeks’ time for the next session, when we’ll be talking with Iceland’s Chief Epidemiologist about how Iceland has approached the pandemic and what we can learn from its experience, as Iceland is pretty widely considered to have been quite successful and has some lessons for us all. So, Olivia, thank you so much.
Professor David Heymann CBE
Thank you, Olivia.
Dr Olivia Tulloch
Thank you very much.
Emma Ross
And to all of you, thank you, and have a great day.
