COVID-19 and the "Stay at home" recommendation: An ethnographic study.

BACKGROUND: Facing a devastating infectious outbreak like COVID-19, the command of "stay at home" was recommended by some officials as a self-voluntary quarantine strategy for controlling the outbreak, but the people perceived and act differently. In this study, we aimed at ethnographic evaluation of public response to this command.
MATERIALS AND METHODS: This research used ethnography for observing the public response to the recommendation of "stay at home" in the COVID-19 outbreak. Data were collected via observing public behavior and documentation; then, the data were qualitatively analyzed.
RESULTS: Our findings showed 10 different ignored dimensions in this moral statement including lack of legal and administrative support, diverse perception and contradictory reactions of the people to the epidemiological forecasting and recommendations, different response to moral statements, various perceptions of the people about health and wellbeing, feeling exhausted of staying at home, not including justice and fairness in the moral statement, not clarifying the meaning of necessary matters, not considering the COVID-19 infected patients and their requirements, assigning the responsibility of government to the public, and halting other scientific activities and investigations in charge of COVID-19.
CONCLUSIONS: Taken together, the officials should take an active role in implementing this moral statement by strict regulations, public education about the disease, its control, and the importance of quarantine, considering justice and fairness in implementation. Copyright:

Introduction

The ongoing pandemic of COVID-19 infection started in December 2019 in China, and shortly it was known as a world pandemic. The disease started in Iran in February 2020 and to date, more than 97,424 confirmed cases, and more than 6203 deaths have been reported across Iran.[1] To manage the COVID-19 outbreak when there is not enough information about the virus, its transmission, prevention, and eradication, taking containment strategies plays a pivotal role in controlling the critical condition.

Different containment strategies have been taken by different countries including locking down the cities which are in the center of the infection; quarantine, isolation, and social distancing. Based on the Centers for Disease Control and Prevention (CDC) quarantine refers to restricting the movement of the exposed people to the contagious disease[2] at the aim of monitoring the symptoms and preventing possible transmission. Quarantine could be performed in two ways voluntary or mandatory. Isolation is separating the infected patient from healthy individuals to prevent disease transmission; however, these two terms are mostly used interchangeably. Voluntary self-quarantine means “staying at home and not leaving the home except for necessary matters.” This special meaning of quarantine has been transformed into an important moral statement that has been highly recommended by media, the public health officials as well as the government authorities. They use this statement to ask people to take the importance of staying at home or self-quarantine. The historical background shows that quarantine is one of the most effective measures for controlling outbreaks as it was used in the 14th, 19th, 20th, and 21st centuries for controlling bubonic plague epidemic, yellow fever, and cholera epidemic, Spanish flu, and SARS outbreak respectively.[3]

Some researchers in medical sciences and epidemiologists believe that if the people stay at home the virus transmission chain will be broken and there would be more chance for disease control and health care provision; in meantime, we could be hoping to achieve a vaccine or a drug for treatment. Although the containment strategies are applied in favor of public benefit, they may be the subject of ethical debate over the restriction of individual's autonomy and liberties which may have a major impact on their implication and effectiveness. Thus, such strategies and their following consequences should be evaluated from the ethical, political, legal, socioeconomic, and public health point of view.[4]

No doubt the message “stay at home” that has been brought up by public health officials is based on the principle of beneficence and for outbreak management; however, it may have numerous social and individual negative consequences.[5] We would like to call this message a “moral statement” because it tries to follow the utilitarian approach (more beneficence for more people) and if not performed properly the human society will be at serious risk. In this study, we aimed at the conceptual and logical analysis of this moral statement and its consequences by investigating critical design challenges.

Materials and Methods

This qualitative study was conducted by an institutional ethnographic approach. This method was developed by Dorothy Smith to find out social relations by observing real-life routines.[6] In this approach, the researcher follows his examinations, understandings, and explanations of the societies that are subject to “ruling relations.”[7] The notion of “ruling relations” is considered based on the public experiences concerning their levels of power; however, it may not be clearly expressed but it is indicated in people's debate and action.[78] In this survey, observation of the lived or common experiences is the main way of studying and finally, the researcher analyses his findings. In other words, the researcher focuses on understanding the beliefs, attitudes, and behaviors of a culture[9] and its internal factors affecting the real-life environment. This method is well fitted to take any action for improvement in health care settings.[10]

In this study, the researchers deeply observed the people's acts and listened to their dialogue and had indirect experiential interviews with them. The researchers are originally Iranian who are living in Tehran and have a well understanding of the Persian culture as well as Tehran's culture and living conditions. Since the last February and after emerging COVID-19 epidemy in Tehran the authors lived among the people who accepted and observed self-quarantine and who ignored it. The authors had a comprehensive perception of the social dimensions of the coronavirus epidemic. Finally, the obtained data were analyzed conceptually and based on ethical principles. The registration code of the study in Tehran University of Medical Sciences was 99-2-114-49432. Regarding the observational method of the study and indirect assessment of the public behaviors, there was no need to take ethical approval for the study. Furthermore, all ethical considerations especially confidentiality were observed and respected. Accordingly, all data were documented anonymously.

Results

The findings of this study organized around the implication of the moral statement of “stay at home” and its obstacles, and challenges. The findings are presented in two parts. In the first part, the current situation is described and then in the second part, the challenges of encouraging the public for staying at home are described after conceptual analysis in four different categories including governmental issues, personal issues, the essence of the moral statement and the unique characteristics of the disease [Figure 1].

Figure 1

The schematic view of the challenges of stay at home recommendation

Describing the current situation

In 2 weeks the COVID-19 spread over the country, schools, and universities got closed, the people encouraged to personal hygiene and different types of protocols for personal hygiene were released for public awareness. The health care system, as well as the health care providers, endeavored for treatment. The public health officials asked people to “stay at home” and very fast this recommendation converted to public demand. We observed two types of approaches to this recommendation. Some people took it seriously and stayed at home while others ignored it rationally or irrationally. We considered this recommendation and or command as a moral statement and present our conceptual analysis in 10 attributes.

Governmental issues

First attribute

This moral statement brings in public benefit and if ignored will negatively affect the whole society. It needs legal and administrative support and the government should guarantee its performance. Because of the lack of legal and administrative support, the health message of this statement has not properly perceived by the whole society.

Second attribute

This moral statement addresses the people and if not taken seriously the people are blameful and the government can acquit. This statement is the same as another moral statement in the condition of severe air pollution. When greenhouse gases pollute the air in winter, the officials and media blame single-passenger cars and invite them to use more public transportation. It seems that by this command the government assigns its responsibility to the people.

Personal issues

Third attribute

Paying attention to this notion “stay at home” is to emphasize the importance of people's life because in less than a month more than 2000 people died from COVID-19 infection. Based on the epidemiologists' anticipation at Imperial College London, approximately 7 billion people (90% of human beings) will get infected globally of which 40 million will die if not taking action in prevention.[11] The public sphere reacted very differently and controversially to this set of data and the negative consequences of the current pandemic. People mostly do not have a proper perception of the probabilities and do not differentiate between high, moderate, and low probability.

Some people fear becoming infected or infect others and terrified which is common in infectious diseases outbreak while others have no stress. These types of controversial reactions are not too far from our country where faced several natural and nonnatural disasters in the past several months.

Fourth attribute

Every moral statement should have some criteria for ethical acceptance. People respond to moral statements in three different ways; accept, ignore, or fight against it; however, the situation may affect the people's direction toward moral statements. This statement mainly addresses the public sphere and ask them to comply with and accept it. It is expected that they are highly responsible individuals who feel responsible for themselves and others. We observed a wide range of reactions from accepting the recommendation and voluntarily staying at home to taking a trip on vacation. Therefore, the moral statement was not applied by the whole society and as a consequence, the number of infected patients increased after the vacation period.

The essence of the moral statement

Fifth attribute

We considered this moral statement to have a health message to guarantee public health, but the message was not realized the same by the people. The public behavior showed that the message does not address the whole society in the same way, because only a part of the society value life and wellbeing while the others do not have the same sense.

Generally, from the notion of facing health messages and regulations, we could divide the people into three groups; the first group who strictly observe the regulations, the second group who relatively observe the regulations and the third group who ignore personal and social hygiene and do not care to stay at home or even to stay healthy. Also, some of them assume that they are healthy and immune enough and they get less affected.

Sixth attribute

In this moral statement, it is mentioned that “stay at home and do not leave home except for necessary matters.” Everybody has its perception of the term “necessary;” so, at first, we should clarify our meaning of necessary and answer some questions, for example, buying bread, food, working, visiting parents, participating in funeral, which one is necessary. Everybody answers these questions differently, so we cannot expect them to behave the same. Personal behavior is based on their ethical sensitivity that differs between individuals.

Seventh attribute

We considered this statement as a general ethical command. So, if we accept that justice is an ethical principle and should be included in each moral statement, it means that a moral statement should be applied by the whole society, and everybody who wants to apply it should be able to do so without violating justice and fairness. We perceived that this statement is far from justice and it could not easily get implicated. The people who are low-wage and gig workers cannot afford the economic burden of staying at home. Some others are not able to work from home or to take leave from work such as the staff of the public service organizations including the staff of health centers or the energy suppliers, police force, public transportation, etc. There is another group of people who provide basic and medical needs of the public such as butcher shops, supermarkets, bakeries, pharmacies, hospitals, etc; and their related industries and their services are necessary to meet the basic social and medical needs of the quarantined person. So, it seems that “stay at home” only addresses the ordinary people and ignores some others. In other words, it is far from fairness.

Although this statement is general, intrinsically has limitations which assign it to a special group of people and violates the principle of justice. In other words, this moral statement does not fairly consider the whole population. Therefore, some people sacrificed themselves and got exposed themselves and their families to COVID-19 infection to provide their services for the others who have enough financial ability to stay at home if they like.

Furthermore, the people who attend the supermarkets or who participate in funerals of non-corona infected patients without physical distancing could not be the subject of this command; likewise, sellers, cashiers, and customers are in close contact with each other. The funerals for non-corona infected corps are mostly performed with lots of peoples which is a common cultural and traditional ceremony, without the possibility of respecting personal hygiene and distancing while some of the close relatives of the passed away may have been spent previous days in the hospital and be a potential carrier of the coronavirus.

Financial loss is not only the concern of low wage workers. Interruption of professional activities without advanced planning and when the duration of quarantine is not verified will cause financial loss as well.

No doubt, this statement is far from justice, and if the service providers lockdown, the whole society will face chaos and anarchy.

The unique characteristics of the disease

Eighth attribute

In this study, we realized that people who obey this moral statement, soon or late will get tired and ignore the rule; especially when no one knows how this condition ends and how long they should stay at home.

Ninth attribute

The moral statement “stay at home” would like to address the whole population, but there is another problem. The COVID-19 infected and suspected patients are advised to be isolated at home because these patients could be the main source of virus transmission. However, after diagnosis, the patient should provide his medications-which are mostly in shortage-from community pharmacies and sometimes the free market, so this will transfer the virus more seriously.

Tenth attribute

To properly implement the statement of “stay at home,” so many clinical studies have been stopped while they should be maintained to be responsible for the other diseases that endanger human life. Considering this moral statement versus the necessity of maintaining researches creates a special feeling about changing the meaning of risk and benefit. The researchers stopped their projects, do not enrol new participants, or accept the risk of viral transmission during in-person visits at the expense of COVID-19 related investigations.

Discussion

Although the moral statement “stay at home and do not leave home except for necessary matters” seems to be valid, justified and rational in some occasion, the Iranian society and probably the other nations could not easily accept and implement it.

In this ethnography, we reached 10 different evidence which shows that this moral statement is invalid and inoperative; unless some important issues were considered and taken into account.

Our findings show that lack of legal and administrative support, diverse perception and contradictory reactions of the people to the epidemiological forecasting and recommendations, different response to moral statements, various perceptions of the people about health and wellbeing and health messages, feeling exhausted of staying at home, not including justice and fairness in the moral statement, not clarifying the meaning of necessary matters, not considering the COVID-19 infected patients and their requirements, assigning the responsibility of government to the public, and halting other scientific activities and investigations in charge of COVID-19 are the reasons that make this statement non-applicable. While the implication of this moral statement is complicated and challenging, its impact on the public could be fundamental, extensive, and deep-rooted.

The legal requirements of containment measures especially quarantine should be defined and applied; the responsibility of every part of the government as well as the individuals should be clarified while there should be a well-defined protocol for the punishment of the trespassing. The legal system should audit the efficacy or its way of conduct and if the statement fails to achieve its goals, the legal system should intervene. The CDC indicates “using the least restrictive measures necessary to prevent the spread of the disease” but does not necessitate adhering to the standards.[12] Based on US federal law, the government should meet basic people's needs including health care, medication, and food.[13] The quarantine laws could be updated whenever needed. There is a federal law in the United States[212] as well as in the other countries in which the quarantine was defined for special disease conditions and this law regulates quarantine enforcement. This law may define a plan for financial compensation for the people who may hurt economically and even a strategy for using the police force for the implication of quarantine if necessary.

In a real situation, the efficiency of containment measures should be determined by epidemiologic studies and the probability of achieving outbreak control. The early implementation of the containment strategies is very critical in controlling disease transmission. The less the number of infected patients the more possibility of implementing small and individual-level containment strategies. This strategy was carried out by Singapore to contain the local transmission of the disease.[14] Hellewell et al. define outbreak control as not having no new cases of the infectious disease 12–16 weeks after the initial cases, but when the outbreak reaches 5000 cumulative cases there seems to be no control in 12–16 weeks.[15]

For performing mandatory quarantine, there should be a justified balance between the potential benefits versus psychological impacts[16] because the people who undergo quarantine and separation may experience different types of psychological and dramatic effects.[17] Psychological problems especially anxiety is caused and augmented by media and alters the way the people think about and react to the outbreak. In the 21st century, we are facing the spread of lots of information about the disease in media; some of them are misleading and progressively make the public more confused and nervous. Calisher et al. recommends solidarity against the COVID-19 and combatting with misinformation to promote the spread of valid and scientific information.[18] Mian and Khan believe that misinformation made the public confused; likewise, they consider the misinformation so infectious that it may fatally influence governmental policy.[19]

The statement of “stay at home” is presented by officials as a high-rank statement while, there are so many important issues to be considered such as social distancing, informing the whole society about the ways of virus transmission, and its prevention. For example, social distancing insists on a distance of 6 feet between two persons regardless of the location at home or out of the home. Observing social distancing in some offices and banks or supermarkets, and bakeries are of utmost importance, and increasing the society's information could be of great help. Also, not having enough information about the time of the peak viral shedding, the probability of virus transmission in asymptomatic patients before and after treatment, and so many other information about the novel coronavirus makes the success very difficult.[20]

Brooks et al. indicate information as a key in the quarantine situation and recommend effective and rapid communication because it helps the people coupe better with the new condition. They emphasize on public education about the disease and the logic behind the quarantine.[21]

Studies show that not informing the public by health authorities and lack of guidelines act as a stressor and make the public confused.[22] So, the public health officials should transparently and honestly inform the public, and the psychological problems need to be answered;[23] otherwise they negatively affect our decision making and makes us irrational.[24]

Cetron and Simone proposed considering ethical principles and codes for guiding community containment strategies to protect communities health which may be potentially in conflict with human rights and self-determination;[25] however, Yoo and Hong believe that high-level quarantine and restrictions are not a violation of human rights because this outbreak is a serious health emergency in the world and probably this would be the last chance to stop virus spread.[26]

Although the moral statement should be equally fair and transparent for the whole society,[27] we found out that the statement of “stay at home” is far from justice and may not have positive consequences.

Nakazawa et al. indicate procedural justice for special situations when a strategy is not expected to have positive consequences.[28] They consider the utilitarian approach as the ideal ethical approach which brings maximum happiness for the maximum number of people. This approach could present the virtues of policymakers including justice and honesty.[28] It is suggested that public health officials and policymakers design guidance for the public using scientific evidence and emphasizing the altruistic approach of self-isolation or “staying at home.”[20] But, without providing enough information, emphasizing altruism for public encouragement may limit the effectiveness of this ethical approach; however, this manner is more similar to the compulsory approach versus altruistic approach.

We have reached that “Stay at home” does not include some special professions and jobs because they are responsible for providing the requirements of each society or because of its economic burden. Thus, the government is responsible for the financial consequences of the outbreak and should provide compensation for workdays lost, for unemployment insurance, and consider law enforcement for quarantine violence which happens frequently.[20] Financial reimbursements should be planned and provided as soon as possible.

To prevent exhaustion and breaching quarantine, it is recommended that the quarantine period be short and not be changed frequently except for extreme circumstances.[21] Some believe that voluntary quarantine causes less distress and long-term complications.[21]

The effect of the quarantine and these types of limitations on research is fundamental and now most scientists are struggling with this problem. They are spending their time using their energies for other activities like analyzing data, drafting articles, writing grant proposals to overcome the negative consequences of hibernation.[29] Instead, the research has shifted to COVID-19 investigations into finding a curative treatment are granted and facilitated by national and international research bodies, while we observe dysregulation and anarchy or probably pseudo-research in clinical studies and clinical use of drugs as off-label usage, compassionate use or clinical practice.[30]

Some considerations have been proposed for the successful implication of quarantine such as increasing the knowledge and awareness of the society about the disease and its dangers, creating mutual trust between the society and the government, and using effective and proven quarantine measures.[31]

The statement of “stay at home” is the simplest advice to be addressed to the people who are fully informed but not useful for the rest of the society and we could not oblige them to follow this ethical rule because it does not include them. The other negative effect of this command is that this moral statement undermines the other important and necessary recommendations.

Conclusions

Therefore, we assume that the moral statement of “stay at home” should be performed under strict supervision and intervention of the government and its affiliated organizations. The governments should accept their role in its implication; however, the people should have a social responsibility and act based on the health, benefit, and well-being of themselves as well as their society. In this regard, the government should be accountable and tries to solve the logistical challenges and the other unfavorable consequences and their impact on society using more constructive tools. Besides, the effectiveness of the containment measures should be investigated by different indicators.

It is recommended that a strategic plan for reimbursement for all workers, emergency guidance and regulations, newer and more novel legal tools, and public health laws get developed to reduce the challenges and there should be more emphasis on support rather than restriction.

For the sake of public adherence to moral statements like this, officials should be transparent and provide valid and honest information to the public, otherwise, the public will get mislead and untrusted. Providing appropriate management strategies including public education, answering to public concerns, providing ethical codes and guidelines could bridge the level of mistrust and increase public adherence and compliance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.