Contrary to public consciousness, pandemics are a routine feature of human society. I say this not to trivialise the suffering inflicted on humanity by these pandemics, but because even a cursory glance of human history (or a microbiology textbook) reveals this to be true. Pandemics have been ravaging human populations since times immemorial, and they seem to be doing so at a greater frequency. Yet even to those of us who know this – let alone those who do not – they always comes as a shocking surprise.
Patterns of a pandemic
Pandemics are a partial affirmation of the age-old adage that history repeats itself, but never in the same way. While the causative organism, nature of the disease, place of origin, infectivity, mortality, duration, measures taken, government response and setting are vastly different, there are several patterns that almost always emerge.
As historian Charles Rosenburg illustrates using excerpts from The Plague by Albert Camus and several historical epidemics, a pandemic comprises four overlapping stages – “progressive revelation”, “managing randomness”, “negotiating public response” and “subsidence and retrospection”.
This has been echoed in pandemics throughout history, and we can see this progression in the timeline of COVID-19 as well.
“Progressive revelation” refers to the time period between when the index case is reported to when knowledge of the pandemic reaches the wider public consciousness (when it can no longer be denied that a pandemic is afoot). In the global timeline of COVID-19, that would be between December 2019 and January-March 2020 (when World Health Organisation declared COVID-19 a global health emergency and travel started being banned).
The next stage is “managing randomness”. This is the time between the acknowledgment that a pandemic is ongoing and the institution of meaningful public measures. In India, that would be between January-February 2020 (when the first few cases started being reported) and March 2020 (when India progressively banned travel, and eventually imposed the first lockdown).
Following that is the stage of “negotiating public response”, which in our timeline occurred between March 2020 and is still ongoing (the various lock and unlock phases). It is the period when public measures are decided upon and instituted.
The last stage is “subsidence and retrospection”, which refers to the end of the pandemic when cases start to come down. This is occurring in some places in the world and perhaps in some parts of India.
In his paper, Rosenburg emphasises how the prevailing ideologies and culture at the time further defines how these stages pan out. For example, he describes how in the stage of “managing randomness”, the scientific community reacted by trying to find out which people are more susceptible. The public reaction is often to use these findings to assign blame to certain groups based on moral, cultural, and religious notions. He also described how very often, the name of God and punishment of humanity was brought into the causation of the pandemic in public consciousness. Another very striking feature he noted was how pandemics start with a bang, but end in silence – often leading to a sort of public amnesia. I am sure many people would agree that they have seen these elements in the way COVID-19 has panned out.
Analyses of past pandemics also brings out certain common patterns and narratives.
For example, the sacrifice and susceptibility of healthcare workers. It was the death of four Belgian sisters from hemorrhagic fever in the Democratic Republic of Congo that brought the Ebola virus to light. Very often, the doctors and officials who first report or investigate the pandemic die – like Dr Li Wenliang in the case of COVID-19. Another example would be alleged attempts at concealment of the pandemic by national governments, which was seen at the start of the COVID-19 pandemic at Wuhan, but also during several previous epidemics like cholera in Germany and the avian flu in Indonesia.
A third example would be the effect on economy and commerce, ranging from falling GDPs and the economic crises seen in India to bans and bias against beef exported by Britain following the outbreak of Bovine Spongiform Encephalopathy. There is always a tug of war between the immediate safety of the population and the long-term economic security of the country. For example, countries like Pakistan did not go into lockdown as it was felt that the people of Pakistan wouldn’t be able to survive without an income, whereas India went ahead with the lockdown and faced the migrant labourer crisis (among several others). This also illustrates the fact that pandemics such as COVID-19 affect the poor and marginalised much more acutely, as several pandemics have in the past.
A fourth example would be the role of transport in the spread of pandemics. This was recognised as early as the 14th century, during the bubonic plague, when the city of Venice made incoming ships dock in the port for 40 days, as a sort of quarantine. Increased global travel is a major factor behind the lightning fast spread of COVID-19. Another common thread between pandemics is the bias and marginalisation of certain ethnic, religious, and cultural groups, along with assigning blame to these groups. During COVID 19, this was seen with the global rise of anti-Chinese sentiment seen, as well as in India where certain sections of society have been blamed by individuals and groups. This was seen previously in the US during several epidemics and also during the HIV epidemic.
Another debate that arises with most pandemics is that of individual liberty and rights versus the interest of the public. This is playing out in the US, where wearing a mask is seen as an obstruction of personal liberty in some circles.
The rise of misinformation
Lastly, a common pattern is seen in the dissemination of information and misinformation during the pandemic. Though information has evolved a great deal over time, dissemination of reliable information seems to be an even bigger hurdle during the ongoing pandemic. For the first time ever, information is at our fingertips, yet there is an equal amount of misinformation floating around. This prompted the WHO to state that “we face an overabundance of information related to the virus” and to set up helplines and websites to curb the rise of misinformation.
I am sure we have all had to correct a relative who claimed the “eating onions and drinking bleach cures COVID-19” or Bill Gates made COVID-19”, the source of which was surely ‘WhatsApp university’, as misinformation about COVID-19 is widespread in India. Health Analytics Asia published an article on the trends in misinformation related to COVID-19, which closely mirrors the four stages of an epidemic. The first wave of misinformation was during the “progressive revelation” phase and pertained to the origin of the virus. The conspiracy theories ranged from 5G internet to the Bill Gates Foundation to China trying to conquer and destroy the world. The next wave of information (during the “managing randomness phase”) was an exercise in fear mongering. It involved the circulation of false footage, which led to suicides in India and the consumption of methanol leading to 700 deaths in Iran.
The next wave of fake news is ongoing, as we are currently in the “negotiating public response” phase. It involves the circulation and marketing of random cures, ranging from onions and ginger to salt and bleach.
Another study performed a thematic analysis on the misinformation in India during the COVID 19 pandemic, and it observed a disturbing trend of communal news, castigating blame on various religious and cultural groups.
However, what is equally disturbing is the rise of transmission of false news by world leaders and the rise of false or substandard scientific studies that are being published. An example of the former in today’s context would be downplaying of the pandemic by the leaders of Brazil and the US. An example of the latter would be the retraction of the hydroxychloroquine study from The Lancet. Studies show that the rise of all this misinformation is in part due to the internet, and sheds light on how important fact checking is currently. Another debate arises as to the role of scientists in dispelling misinformation.
The crux of the debate is that amidst the pace of work the scientific community has to keep up with during a pandemic, correcting misinformation is something they may not be able to devote time to. In my opinion, this is where medical students can be of use. Not being occupied during a pandemic, medical student publications and other members of the scientific community could help dispel myths by writing and conveying reliable information. However, if done incorrectly, this could also worsen the situation.
As illustrated, pandemics do follow social patterns to some extent, with the same issues seen to varying degrees, no matter the nature of the pandemic. In recent years, pandemics and epidemics seem to have increased in frequency, in part due to better reporting and surveillance, but also since they are occurring more often. The latter is due to a growing and ageing population, more cross-country travel, more human animal encounters (due to human encroachment), industrial farming and rising global temperatures. Following the 2002-2003 break out of SARS, the WHO created the International Health Regulations in order to ensure member countries perform active surveillance and promptly detect and report epidemics, so that global pandemics can be swiftly managed.
Hence it is important to ensure pandemic preparedness both in terms of detection and surveillance, but also in terms of population preparedness. As we are seeing, a great deal of pandemic control revolves around hand washing and social distancing – in short, non-pharmacological measures. Hence in addition to surveillance measures, year-round education, education in school curriculums, and awareness campaigns about the history and future risk of pandemics, as well as on the importance of hygiene measures could prove to be effective measures in the future.
Another advantage of population-wide holistic education regarding pandemics is that individuals are less likely to get swayed by misinformation about false cures, dangerous cures, propaganda against certain groups and conspiracy theories. In addition to this national protocols and allocated funds for the same might improve the response to future pandemics.
Furthermore, building up of public infrastructure for healthcare and sanitation, in addition to average earning capacity of the population, is of utmost importance as COVID-19 has shown us. For example, tuberculosis, which ravages India, is not as common in western countries where measures to reduce overcrowding, and improve sanitation were taken.
As we have seen, pandemics are inevitable, on the rise and cause similar social problems. As a global community, we should not be surprised but equipped when the next pandemic comes along. We must not slip into an amnesic state as we have in the past.
Anna Mathew is a fifth year MBBS student at Christian Medical College, Vellore.