Towards a comprehensive narrative and response to COVID-19 in Southeast Asia.

The dominant narrative of the COVID-19 pandemic in Southeast Asia barely gives attention to the many social and cultural dimensions of the crisis, and humanities and social science experts remain at the margins of containment decisions. This short commentary highlight our potential contribution based on our disciplinary core principles and what has been learned from other epidemics, foremost HIV. It argues that we can help broaden the current epidemiological approach to understand and impact on the social drivers of vulnerability and risk for diverse populations in specific contexts, while promoting transformative change. We can achieve this through paradigmatic adjustments as well as a more daring and engaged role on our part.

Filling a gap

Three months into the COVID-19 pandemic, a dominant narrative has developed, which is focused on tallying numbers of cases and deaths, forecasting economic impacts and hoping for better treatment and a vaccine. In the region where we live, Southeast Asia, the many social and cultural dimensions of the crisis have become obfuscated and the voices of humanities and social science experts and even public health specialists seems subdued. Measures have been implemented top-down without much discussion on their contextual suitability, implications and impacts. Yet, as stated by Jürgen Renn explaining Germany’s unique choice to form a multidisciplinary advisory working groups on COVID-19 of which he is a member, this crisis is complex and systemic, and needs to be dissected from every angle (Matthews, 2020).

Clearly this pandemic is caused by a virus, but understanding it, controlling it and reducing its human costs depends also on social knowledge and interventions. The fact that in the current global COVID-19 discourse such interventions are often called ‘non-pharmaceutical’ (Ferguson et al., 2020) shows once more the very limited space that our disciplines have been able to gain (or claim) in the health domain in the past and now. This compels us to more openly articulate the urgency of a comprehensive narrative and response to this pandemic.

Our short commentary aims to highlight the contributions that social scientists and practitioners can make to responses to COVID-19. Based on our disciplinary core principles and what has been learned from other epidemics, foremost HIV, we can help shift a purely epidemiological approach to addressing the social drivers of vulnerability and risk for diverse populations in specific social contexts, and build agency of these groups while promoting social transformative change. We can achieve this through paradigmatic adjustments as well as a more daring and engaged role on our part. To make our case, we will move from knowledge to intervention-related issues and mostly refer to countries in Southeast Asia, but some of the statements and comparisons may have a global resonance.

Transdisciplinary collaboration a must for zoonotic diseases

For about two decades, East and Southeast Asia have seen the emergence of new zoonotic infectious diseases starting in Southern China, spreading to its surroundings, until eventually self-exhausting. In particular, the SARS outbreak in the late 2002 and the avian influenza (H5N1) outbreak in 2003 have had significant transnational health and economic impacts, disproportionately affecting the region and its most vulnerable populations.

Since then, it has been recognized that this geo-economic space is a hotspot for major zoonotic outbreaks because of the rapid market integration and the increasing density and mobility of the human and animal populations. The latter, because of environmental encroachment, wildlife trade and expansion and commercialization of livestock production. Past studies of pathogens’ transmission pathways from animals to humans showed how people’s behavior and the way they interact with the animals and their habitats is conducive to health threats and biodiversity decline. In the case of SARS, the horseshow bat and the civets were identified as the virus reservoir and intermediate host respectively, with the spillover made possible by the hunting, farming, sale, consumption and export of wild animals across Southern China and mainland Southeast Asia. Cultural habits, economic profit and livelihoods’ necessities drive these practices with wild animals being used for food but also for traditional medicine, clothing, decorations or to be raised as pets (Westcott & Shawn, 2020).

To understand and tackle the complexity of intersecting health, biodiversity and socio-economic factors, in the past decade transdisciplinary initiatives were launched that promoted a new holistic approach, such as the EcoHealth and the One Health paradigms. The first, draws from the humanities and the natural, social and health sciences to examine the dependence of human well-being on the interplay of ecological and socio-economic systems. The second brought together veterinary and human medicine to study human-animal disease transmission, and later broadened its scope to include varied agricultural and environmental challenges (Harrison, Kivuti-Bitok, Macmillan, & Priest, 2019; Mallee, 2017).

These promising initiatives were still evolving and being operationalized when the SARS-CoV-2 virus that caused COVID-19 hit. Although research is ongoing to establish the exact origin of this virus and its transmission to humans, there appears to be consensus of its being zoonotic and its spread presumably related to the farming and trading of wildlife in Southern China (Spinney, 2020). These contextual similarities with previous outbreaks raise questions about the lack of preparedness for a virus that, in spite of the many conspiracy theories, could have been expected (Docea, 2020). At the same time, they do encourage us to persevere in the path undertaken and strive harder to improve and systematically implement and institutionalize the nascent transdisciplinary paradigms in the recognition that COVID-19 like previous crises “[does not] lie comfortably within the domain of a single discipline” (Squazzoni et al., 2020).

Increased humanistic and social insights in Ecohealth and One Health – or an integrated version of the two – would broaden the collaborative inquiry and the derived interventions emphasizing the systemic socio-cultural, economic and political dynamics of emerging infectious diseases. These insights are critical to address the root causes of this pandemic and its cascading systemic effects by questioning current development models. They can also contribute to shorter-term decisions such as whether and how to ban wildlife trade and markets in a culturally sensitive and eco-socially responsible manner, and enhance disease-risk prediction for successive outbreaks.

If the transdisciplinary approach has to function, however, there needs to be new integrated research models that benefit from disciplinary strengths, but deconstruct the disciplinary silos. Going beyond the rhetorical level is arduous and greater investments ought to be made to change sectoral institutional structures and specialisms, hierarchical value systems and resource allocation as well as to establish clear mechanisms for knowledge-sharing and collaboration (Degeling et al., 2015).

The paradigms should also be improved by embedding transformative processes and actors. As we learned from HIV, this is necessary not only to successfully address health threats, but to ensure that COVID-19 is an opportunity to revisit current structures and, paraphrasing writer Arudhati Roy, ‘the portal’ to a more just and sustainable society (Roy, 2020), as we argue in the last section.

COVID response ignores social context at its peril1

Outside of epistemological initiatives, social scientists and practitioners ought to engage more in ensuring that the specific contextual drivers and risk factors of any epidemic are taken into account in the development and tailoring of a package of available interventions – both at policy and programmatic levels – especially when these entail changes to established social expectations, norms, and practices and affect different groups in different ways.

In the case of COVID-19, we have a number of tools at our disposal ranging from testing and identification of carriers and their contacts to washing hands and social distancing, isolation and quarantine –just to name a few. Except for disagreement on when (and what types, and for which populations) masks are needed –by some media not too convincingly explained in terms of cultural attitudes (Leung, 2020)– these measures are meant for the entire global community. However, there is no universal guideline on their right mix and no consensus on the degree of enforcement required to ensure people’s adherence. This is where understanding of what is feasible and effective (or not) in a specific context becomes of strategic importance.

Achieving a successful mix of interventions both in the midst of the COVID19 pandemic and for exit strategies is contextually defined. What can be recommended for a slum or overcrowded area where social distancing is difficult, if not impossible, and hand washing with clean water is a challenge? Or for areas, such as most provinces in Thailand, which have already been declared as drought-affected areas with national dams and reservoirs only at an average of 49% capacity of which only 26% is useable water (Anukul, 2020)? What is the alternative to ‘work from home’ for the many who have low-wage jobs or work in the informal economy? How can prevention and risk reduction campaigns be framed to be meaningful to various population segments who have diverse cultural idioms and differential access to resources and capacities?

Similarly, recognizing that lockdown can never be 100 percent and that at some point even the stricter ones will have to open up in a “second phase”, socio-cultural insights should feed into the discussion of what is essential and should be left functioning to provide people comfort and keep society going amid the necessary disruption – and all this weighted against epidemiological risks. Policy formulation would benefit from a more inclusive debate and from the realization that ‘essential’ is not only medically or economically defined and that a top-down cookie cutter approach may not fit diverse realities even within the boundaries of one country.

The definition of epidemiological risk itself is not immune from socio-cultural biases. In Singapore, national spatial modeling exercises (Koo et al., 2020) and containment measures missed to include the large migrant population. The government was taken aghast by the growing spread of the infection to migrants’ dormitories and finally recognized migrants’ substandard living conditions, although the ‘stay-at-home’ order forces them to remain at risk. Other Southeast Asia countries have still to learn from this experience and are overlooking the vulnerability of migrant and refugee populations in their regional and national health security plans or even persecuting them like in Malaysia (Nortajuddin, 2020). Here is where ethical discussion and human-rights-based approaches could raise key questions on our collective responsibility to protect the most ill-protected in our midst and address their marginalization.

Making sense of numbers

Contextual knowledge is also crucial to comprehend the many global and regional graphics filling the infosphere and print media. Looking like a grim competition on which country has the highest number of cases and deaths, they leave the readers with fear rather than compassion for those hardest-hit. What do these numbers really mean? Does it make sense for Southeast Asia to compare in absolute instead of relative terms the number of cases in the large populations of Indonesia and the Philippines with those of tiny countries such as Brunei or even the somewhat larger Singapore? Similarly, does it make sense to compare fatality rates without taking into account the number of swabs and the procedures applied in collecting them?

In explaining differences in prevalence, incidence and fatality rates within and across countries, we should be weary of simplistic discussions and engage on social media to encourage the public to be statistically literate “i.e. to think critically about the information being presented; to understand the context; and to be able to tell the story in the data” (Australian Bureau of Statistics (ABS), 2020). Among the explanations to be given, we ought to stress that geographical differences in outcomes can only be partially explained bio-medically as they are the product of the interplay of epidemiological and social, political, cultural and historical factors. As global health expert and anthropologist Paul Farmer puts it “any kind of essentialism about the host or the pathogen” nor specific preventives or therapies would be sufficient to explain the wide variation observed in this pandemic (Miller, 2020). Unless we understand in more detail the contextual determinants of COVID-19, statistics will not tell us what has led to the numbers and comparative differences we are seeing.

Innovative research is needed that combines disciplines and methodologies and provides disaggregated data and analysis, with risk broken down according to age, gender, class, occupation and other social variables This evidence serves to identify and characterize the (combination of) factors that accelerate or slow down transmission in different populations and settings. It would also allow us to find out which groups may be more vulnerable and, for example, to check how far diverse groups have access to information, testing or care – all elements that are essential to determine if any intervention is effective (PAHO, 2020). Among others, we know that age matters and elderly people are at greater risk, especially if they have co-existing medical conditions, but we still have to investigate more their living and family arrangements from live-in care facilities to habiting in extended families to autonomous housing. We know that gender has an impact: men fall to the coronavirus much more than women; but we do not know whether this is because of genetic or social factors or both. We also do not fully appreciate yet the role of population density, socio-economic conditions, quality of health care, pollution and environmental degradation. Thailand official data are detailing transmission settings (Department of Disease Control et al. Thailand), but for other countries in the region, more advocacy is needed to ensure focus is not only on the basic clinical characteristics.

There is also much left to be known about human to human transmission and behavior that facilitate spreading more extensively. Large COVID-19 infection clusters or super-spreading events (SSEs) have barely been studied. Besides transmission within households, hospitals are proving spawning ground for transmission also among health workers in countries like Indonesia and the Philippines. From news reporting, massive religious gathering of various faiths in Indonesia and Malaysia and cultural and entertainment events (like Thai boxing and discotheque hopping in Thailand) have resulted in significant infection clusters and spreading of the disease, in some cases even to neighboring countries in the region. We are also seeing a shift from infections in socio-economically privileged communities connected through global travel towards people in more disadvantaged settings, such as Singapore’s migrants living in dormitories and workers in a tobacco factory in Indonesia. But besides these general trends we lack elements to carefully map and analyze transmission to help policy decisions concerning, for instance, which venues to reopen after lockdown (Kay, 2020). As of now, those seem more dictated by interests of different forces in society than by evidence.

Shifting from fear to resilience

The humanities have a major role to play in helping people come to term with the existential aspects of this crisis. The visual imaginary in the media, mostly consisting of death and intensive care scenes, and the escalating numbers of cases and fatalities, have augmented our fear, sensationalizing fatality rates and dehumanizing human sufferings. Whether this narrative has been fostered, intentionally or not, to imprint the urgency of our taking protective measures and “stay at home”, it remains one-sided and may have unwanted consequences, including on mental health. It is well established that “scaring the already scared” only changes behavior in the short term, is ineffective especially with high levels of anxiety (Mathusamy, Levine) and it may cause traumas and prejudices that make more difficult to learn to live with the virus. In Yoong’s words “It makes us myopic, it helps us focus only on the short term. It reduces our ability to empathize with each other. And it leads us to behavior like panic-buying, which we know when we are our better selves is not the right thing to do” (Cotiner, 2020).

Out of fear, people scapegoat the ‘other’ as the ‘transmitter’, triggering unnecessary stigma and discrimination that hampers the efforts to control the epidemic and build solidarity. We seem to have forgotten that it is the virus, and not the carriers that should be battled, and that epidemics are not only a matter of individual responsibility, but also of political and economic accountability. All over the region, health workers have been ousted by their landlords, people fingered for their perceived not complying with containment measures, patients accused of lying to avoid quarantine or hospital admission. The dread for ‘silent carriers’ is stopping the public from appreciating that their gaining some level of immunity to the virus eventually, as it is expected, will become the barrier to the spread (Global-is-Asian, 2020). Yet, fear can be overcome by better understanding and taking preventing measures so that one reduces risk for oneself and others, irrespective of what others do.

Besides more accurate reporting of the clinical realities of COVID19, a new narrative needs to be formulated that show that the pandemic is also a tale of survival, resilience and solidarity. This begins with the recognition that human perception of risk and related behavior are embedded in specific socio-cultural structures and therefore rather than blaming individuals, efforts should be directed at intervening on the environments that put them at risk. When, during the AIDS epidemic, the low bargaining power of sex workers with their customers was understood adequately, Thailand successfully introduced the ‘100 percent condom policy’, making responsible the owners of the entertainment establishments for enforcing condom use, lessening the blame on the sex workers (Rojanapithayakorn, 2003). For those who seem not to comply with isolation measures, assessments should be made on whether they have internalized (not only understood) why measures are necessary and whether they are in a position to practice those measures. If not, our responsibility is to devise strategies to change their behavior, beyond financial disincentives and even “shooting” at them as recently ordered by the leader of the Philippines (Greeley, 2020).

Polio eradication programs have also highlighted the importance of building communitywide social support for behavior change, using a whole-community approach, and building community capacity and cohesion for long-term ownership and sustainability (McArthur-Lloyd, McKenzie, Findley, & GreenAdamu, 2016) This should include strategies to enable and empower people to adopt and maintain prevention and risk-reduction practices, especially when these have to be in place for the foreseeable future and may disrupt relationships and networks. Cultural and artistic practices can contribute to enhancing communities’ resilience in facing the crises, coping with the disruption and recovering. Across the region, grassroots groups and community organizations are harnessing their cultural idioms and social capital to come to terms with the unprecedented limits COVID-19 has placed on their daily lives and rituals and to foster a collective safety culture in often constrained settings with little, if none, government attention.

How to strengthen such organic efforts without falling in the trap of seeing communities as homogenous or reducing culture to a tool for “enabling negative aspects to be managed and controlled, and positive ones to be harnessed in instrumental solutions to reduce risk and dispel ‘ignorant’ beliefs” (Leach & MacGregor, 2020)? Also, how to avert misuse of cultural resilience to justify inaction in tackling structural dynamics that place communities in conditions of marginalization and vulnerability in the first place?

Action for an alternative future

Moving forward, it is fundamental to produce engaged work and strategize on how to compel governments, media, academia and other key stakeholders to acknowledge, integrate, and act upon socio-cultural concerns in the current response to the pandemic, recovery plans and in mitigating its long-term consequences.

As many have pointed out, COVID 19 is much more than a health crisis. It has amplified the inability of most systems around the world to socially, economically, and medically protect the most vulnerable in societies (UNESCO, 2020). COVID19 has shaken the global order and exposed the fragility of a model based on the cannibalization of the planet and the reduction of people to consumers. It has shown the limits of private health care and commercialization of public goods and exposed the entrenched wealth and welfare inequities in the ways people have been differentially affected by the pandemic. This precarious architecture of unbalanced systems - unconcerned with sustainable development, resilience, and equity - appears to be tumbling down in a cascade that researchers call “synchronous failure” (Lent, 2020).

It is urgent to challenge the current response to COVID19 that ignores these complex implications and remains largely informed by the politics of security–or securitization–that justifies extraordinary measures in the face of an existential threat. In a region already prone to authoritarianism, fear of the pandemic is being manipulated to further concentrate power, curtail freedom of assembly and speech, and justify inaction on structural changes (Abuza, 2020). Surveillance measures are being implemented with scant public discussion on the use of intrusive technologies and personal information and data, and no guarantee of their being rolled back once the epidemic is over. What happened in the aftermath of the attacks of September 11, 2001 showed us that surveillance measures introduced at times of emergencies may easily become a permanent fixture especially in countries where democratic guarantees are not in place or are already weak (Amnesty International, 2020), like in Southeast Asia.

The growing use of criminal law and repressive measures to enforce compliance needs to be opposed. As stated by the HIV Justice Worldwide Steering Committee “communicable diseases are public health issues, not criminal issues” and their generally biased application persecute the most vulnerable in society, including homeless and poor people and members of already stigmatized groups, while failing to provide them the economic and social support to enable them to protect themselves and others (HIV Justice Worldwide, 2020). The failure to provide a comprehensive response is causing great suffering and desperation. In Thailand, this has led to a growing number of suicides. Civil society organizations have mobilized to provide Personal Protective Equipments (PPEs) and food aid, but they are overwhelmed by so many people queuing and standing (at a distance) for hours under the sun. Moreover, relief cannot substitute the much-needed strengthening of social protection mechanisms– e.g. through paid sick leave and investments in health (Gosh, 2020) and for redistribution measures to reduce the income and wealth inequities that the COVID-19 outbreak will only deepen (Rojanaphruk, 2020).

This bring us to take responsibility for contributing to the imagining and pursuing of alternative futures (Casciano, 2020). As social scientists and practitioners, let us reject the ideological platform of the so-called ‘new normal’ that predicates change only in terms of continued exertion of control and induced epidemiological mores after lockdowns. Instead, we should inform and design transformative reforms for equitable and sustainable development. The time is now to tackle the inequities that this pandemic has exposed, and restructure our relations in society and with the environment (Ryder, 2020).

CRediT authorship contribution statement

Rosalia Sciortino: Conceptualization, Writing - original draft. Fabio Saini: Writing - original draft, Conceptualization.

Declaration of competing interest

On behalf of the authors, I declare that we have no conflict of interest in relation to the article here submitted for publication.