Recent years have witnessed an upsurge in global health emergencies – from SARS to Ebola to Zika, and today the new Covid-19. Each of these occurrences has sparked calls for improved health systems and forecasting performances. It also involved adjustments in their governance policies and techniques. Despite health authorities, government officials and vaccine manufacturers have been concerned with the possibility of a pandemic since decades, the project of global health security continues to be unsettled by the prospect of surprise.
In this interview Irene Falconieri and Lorenzo D'Orsi talk to Andrew Lakoff, one of the guests of the online speakers' corner series "Listen to the pandemic" organized during the first lookdown by the Italian Society of Applied Anthropology (SIAA). His researches on alert systems and preparedness devices used by health authorities, government officials, and vaccine manufacturers, and his careful look at the "devices" that structure the field of global public health security offer useful tools to understand the critical issues that have characterized the management of the current pandemic.
Andrew Lakoff is Professor of Sociology at the University of Southern California, where he also directs the Center on Science, Technology, and Public Life. Trained as an anthropologist of science and medicine, his research investigates the historical and social contexts in which authorized knowledge about individual and collective human life is produced. His first book, Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (Cambridge University Press, 2006) analyses the impact of recent developments in neuroscience and genomics on clinicians' understanding of the sources of mental illness. His second book, Unprepared: Global Health in a Time of Emergency (University of California Press, 2017), examines how experts in public health and security approach the perceived threat of emerging infectious disease. His most recent book, co-authored with Stephen J. Collier, is entitled The Government of Emergency: Vital Systems, Expertise, and the Politics of Security (Princeton University Press, 2021).
Irene Falconieri: Your book sheds light on the spatial and temporal limits of the ‘rationality of preparedness’ that is driving the management of global health emergencies. The spatial limit can be identified as the difficulty in elaborating an apparatus of responsibility that binds regional, national, international and transnational governance together. For example, it manifested itself in the failure of European institutions and national states to coordinate their responses to COVID-19. The temporal limit is reflected in the tendency to take action only within an immediate and restricted temporality, as shown by your analysis of the Zika virus outbreak. In that case, research funding was cut when the outbreak was no longer classified as an “emergency”. Our question is about these temporal limits: in your opinion, after the global experience of COVID-19, can the rationality of preparedness be freed from the restricted temporal logics of emergency? If so, how?
Andrew Lakoff: At one level, the very concept of “emergency” would seem to define a circumscribed temporal horizon, an event that has a definite beginning and end. But in principle, a regime of preparedness could be instituted in manner that has a more indefinite timespan. In a sense, this is what the WHO revision of the International Health Regulations in 2005 sought to achieve: a permanent system for anticipating, detecting, and responding to a range of potential disease emergencies. One of the shortcomings of this system, widely pointed out after the 2014 Ebola epidemic in West Africa, is its dependence on member states to invest resources in preparedness capacities such as disease surveillance systems. But the coronavirus pandemic has pointed to something else, perhaps even more worrisome, about this preparedness regime: it is not clear that the technical capacities the revised IHR sought to implement are actually those that are most needed in addressing actual disease emergencies. After all, the United States was ranked at the top of a 2019 index that compared national “global health security” capabilities across all 195 WHO member states, and yet it has clearly not been an example of successful response to the coronavirus pandemic. This points to the need for serious reflection on what “pandemic preparedness” entails, and even whether it is the right technical and political framework for dealing with future epidemics and pandemics. In other words, if one is going to try to extend the tools for managing emerging infectious diseases beyond the temporal confines of “emergency”, then we should also be asking: what in fact are the right tools?
Lorenzo D'Orsi: From our point of view, the preparedness system planned by health organisations, governments, medical researchers and academics does not take into enough consideration the spread of “irrational” tendencies, such as conspiracy theories and generic distrust of the medical establishment. It seems to us that these elements of “irrationality” are no longer restricted to marginal groups but are part of the rhetorical devices of prominent political figures (for example, Donald Trump), thus becoming crucial in contemporary global health scenarios. Do you think that those who contribute to building the “rationality of preparedness” are considering these elements? In this respect, we wonder if this field of analysis and governance is where cultural anthropology can offer a specific contribution.
Andrew Lakoff: It is the case, as you suggest, that much of pandemic preparedness as it developed over the last two or three decades has focused on technical and bureaucratic questions: disease surveillance systems, testing capabilities, medical counter-measure development, plans for coordination among disparate public health agencies, and so on. On the other hand, some of the simulation exercises that were run – for example, “Dark Winter” in 2001 – did anticipate the problem of whether members of the public would follow the directives made by experts and government officials. And there is already a fairly well-developed field of expertise in this area, at least in the US, called “risk communication.” Risk communication specialists seek to provide guidance to officials in how to foster public trust: the need for transparency, the communication of uncertainty, and so on. I would imagine that these specialists were not very pleased with the way that the Trump administration addressed key questions early in the pandemic, for instance how to deal with ever-evolving scientific understandings of the virus. As for your question: the narrow field of risk communication may not be capable of handling what we are now seeing with the rise of populism, the propagation of conflicting knowledge claims on social media, and a widespread skepticism of elites that is based around political and social identity. Here cultural anthropology can potentially provide a different register of insight – I am thinking, for instance, of Sharon Kaufman’s research into vaccine hesitancy (predating COVID-19) which situates it in relation to questions around the status of authorized knowledge within specific communities. Her point, though, is that vaccine hesitancy is not best understood as “irrationality” but rather that it operates according to a distinctive cultural logic.
Lorenzo D'Orsi: You seem to suggest that the preparedness system does not account for the way ordinary people perceive the pandemic and its risks. Since the pioneering work of Mary Douglas, cultural anthropologists have been paying attention to the moral construction of risk and danger. We wonder if, while working on your historical reconstruction of “preparedness” in relation to global health emergency, you could observe frictions between people’s moral perception of risk and the politics carried out by technical and scientific experts.
Andrew Lakoff: I think one can detect this kind of dynamic even in looking at discussions among different expert communities. Take, for example, anxiety among US national security experts in the early 2000s about the possibility of a smallpox attack. This was not long after the anthrax letters (and before it was known that these had been sent by a US biodefense specialist). They had been hearing about large stockpiles of Soviet era bioweapons whose whereabouts were unknown. A high-level scenario exercise (“Dark Winter,” mentioned above) enacted the catastrophic health consequences, as well as social disorder and conflict, that a smallpox attack would generate. To prepare for such an attack, the Bush administration rolled out a smallpox vaccination program targeted at “first responders” – public health workers, paramedics, etc. But the target population did not share the administration’s perception of the risk of a bioterrorist attack – they were more concerned about the possible side effects of the smallpox vaccine, especially for those with compromised immune systems, and they were suspicious of what they saw as the administration’s “securitization” of public health. Very few first responders accepted the vaccine, and the program was a failure. I see this as a Douglas & Wildavsky kind of example in that – in a situation of uncertainty – the perception of where the key risk lay varied according to one’s moral and epistemic commitments.
Irene Falconieri: The COVID-19 pandemic has strengthened international relations among experts and scientists committed to studying the virus and searching for treatments. However, especially in the early stages, conflicting interpretations emerged, even among scientists within the same disciplinary and research fields. This incongruity have influenced government policies (and public discourse) as well as ordinary people’s perceptions and behaviours. Can this conflict scenario help us understand the current relationship among experts, as well as between them and public opinion around the world? What do these conflicts tell us, specifically?
Andrew Lakoff: I will limit myself to discussing the case of the United States, though there may be similar patterns in other countries. In the US, there have been a number of significant changes or reversals in experts’ characterization of the disease, and in their recommendations to the public. For instance, initially officials focused on droplets rather than aerosol-spread as the key vehicle for disease transmission, and in turn they emphasized handwashing and wiping surfaces rather than wearing masks in order to interrupt transmission. Another early shift concerned the question of whether asymptomatic transmission was possible – which had huge implications for preventive measures such as quarantine. More recently there have been controversies among experts and officials over whether to recommend booster shots for the general population. There has also been uncertainty around the extent to which children are at risk, and controversy around school closure as a public health intervention. From the perspective of scientific knowledge production, these various shifts and uncertainties are understandable given the novelty of the disease. But in the context of a fragmented media landscape, the politicization of expertise, and long-standing libertarian and anti-intellectual strands in US culture, these shifts in expert understanding have accentuated public skepticism of and resistance to public health directives. Thus we now find ourselves in a strange and dangerous situation in which one’s political identity may well shape whether or not one will accept a scientific and regulatory claim about the efficacy and safety of a vaccine.
Lorenzo D'Orsi: Criticism of the World Health Organization for its management of pandemics is not new (see Ebola and swine flu). Over the years, many have accused the WHO of providing unclear, conflicting and contradictory information about diseases. Based on your work on global health governance, would you say that the circulation of information among experts, international organizations and citizens has not yet achieved an adequate level? If so, why and to what extent?
Andrew Lakoff: Speaking again from the perspective of the US, it is striking the extent to which the WHO has been marginalized as an authoritative voice in shaping response to the pandemic at the nation-state level. This may be in part the result of the “America First” position of the Trump administration, which withdrew the US from WHO early in the pandemic. It may also have to do with the ambiguous relationship between the WHO and China, and the sense – fair or not – that the WHO was overly solicitous to China and did not do a good job of warning the rest of the world about the danger posed by the coronavirus at the very early stages of the outbreak. In any case, one perhaps surprising outcome of the pandemic has been the realization that despite decades of work on global health governance, the nation-state remains the key unit in shaping collective response to a pandemic emergency. It will be interesting to see whether, in the aftermath of COVID-19, there are serious efforts to put more teeth into international agreements on issues such as sovereignty over outbreak investigations or funding for equitable access to vaccines.
Irene Falconieri: Many scholars claim that in the near future pandemics could become recurring in our everyday life. Do you think social sciences, particularly anthropology, could play a public role in future scenarios? If so, what kind of public role?
Andrew Lakoff: I would suggest a distinctive role for anthropologists as various others actors – virologists, NGOs, disaster management officials, sociologists of health, and so on – position themselves in relation to the prospect of “the next pandemic.” As interpretive social scientists, we should be attentive to the idea of “the next one” as an opportunity structure, a space of competition in which experts of various stripes see the prospect of increased funding and institutional stability. Meanwhile, we should also ask whether the category of “pandemic” collapses important distinctions among different kinds of events. For instance: are the interventions that were needed to address HIV / AIDS the same as those that were needed for H1N1 and then for COVID-19, just to mention the last three examples of “pandemics”? And, even if we accept the likelihood of continued “emerging viruses” given ongoing and perhaps intensifying forms of human-wildlife interaction, should we assume that this means there will be future events similar to the current coronavirus pandemic? After all, we still do not know whether this particular event was the result of a zoonotic spillover akin to SARS (2003), or whether, alternatively, it was the result of an accident in a laboratory where scientists were investigating SARS-like viruses precisely in order to prevent “the next pandemic.” Anthropologists, then, can take a critical and reflexive stance that insists on posing questions about what is being taken for granted, rather than offering to instrumentalize their knowledge as part of an expansive pandemic response apparatus.