An Anthropologist’s Perspective on COVID-19: Q&A with Dr. Adia Benton
Everywhere you turn, there’s talk of the coronavirus, much of it from the perspective of politicians, public health experts, economists, and scientists. Last week, I had the chance to discuss a refreshingly different point of view on the pandemic with Dr. Adia Benton, Associate Professor of Cultural Anthropology at Northwestern University, and a member of Variant’s Ethics Advisory Board (for more information on our Ethics Advisory Board, see the article I wrote about it here). Dr. Benton has expertise in global health, biomedicine, and development and humanitarianism, and in sub-Saharan Africa and Southeast Asia in particular. She is the author of numerous articles on the political, economic, and historical dimensions of healthcare, as well as of the book HIV Exceptionalism: Development through Disease in Sierra Leone (University of Minnesota, 2015). Here’s her unique take on the COVID-19 crisis, both in our own backyard in the United States, and further afield.
This interview has been lightly edited and condensed for clarity.
Sarah: To begin with, I was thinking about your work on the West African Ebola virus outbreak of recent years. Do you see any parallels between that and the current coronavirus pandemic?
Adia: I’ve been thinking about it a lot since I’m trying to finish a book on Ebola. The features that seem similar across the two are actually similar across epidemics in general. A lot of people like to cite Camus’s The Plague and how he sketches out a paradigmatic response to the outbreak from the perspective of the people experiencing it.
Early in the outbreak, there are all of these signs, and if you’re paying attention they represent something much more important than initially imagined — for example, dead rats. But people don’t really know how to make sense of this; it’s only when people start to die that a range of responses kick in. First: it’s the alarm among the first affected among the population, and then it’s an official response. So what do the politicians do? What do the political leaders do? How are resources mobilized and what kinds of interventions develop? The plot of The Plague is the plot that we see reproduced time and again. To that extent, we see it with COVID-19.
The main difference, though, would be the pathogen itself. Even though we knew less about Ebola than we thought we did when that epidemic happened — we had forty years to get up to speed and somehow that didn’t happen — what we did know made it possible to implement a set of strategies that should have worked. There were a lot of mixed messages and a lot of miscommunication and misinformation early in that outbreak, and I think it’s the same thing here, but this is a much newer virus. And so that sort of misinformation is amplified or intensified because of the lack of general knowledge among experts. Highly specialized experts have a sense because of their work with other coronaviruses. But we are all still learning just the basic stuff — what the symptoms are, the degree of infectiousness, immunity — and we don’t have any effective or possible vaccines or treatment beyond the normal treatment that you normally have under the circumstances.
What I’m seeing right now is how deep the problem of information is. We’re getting a lot of confusing messages and I don’t think it’s helpful. Of all the really bad messaging around the epidemic in the States there’s the fact that we have too much of it, and it is not correct. Under those circumstances we end up creating our own information overload situation. I wouldn’t say that that didn’t happen with Ebola as well, but there was a lot that was actually known that could be communicated. One of the challenges, though, is when there’s no effective treatment, or when that treatment is not the standard of care, there’s still a lot of room for speculation. That’s what we’re dealing with now, the extent to which our systems of care are being pushed to their limits, and therefore we are left trying to make sense of a range of things that we’re not used to having to make sense of, such as, “How do I not get this?” and “If I do get this, what is going to happen if I’m moderately ill? If I’m really, really sick?” and “How do the interventions laid down by the State impact the day to day?” That last one is the question that is rarely asked and we’re being forced to deal with it, that is, the extent to which public health interventions also fundamentally alter and are a part of the social fabric. They don’t exist outside of social life; they both reflect and affect how we are able to deal with each other.
Sarah: Are you tracking COVID-19 “from afar” in places you have worked before, like Sierra Leone, which, when I looked it up on the Johns Hopkins coronavirus online tracker, as of April 21 had just 43 confirmed cases and 0 deaths?
Adia: I am looking but it’s sort of hard to know… I’ve seen numbers for Sierra Leone and I don’t even remember what they are because I was like, how can they be useful? I bet those initial cases were elites who traveled or have connections to those who travel internationally. But one thing I also know is that there are mechanisms in place, and experience with “the last one.” Whereas many of us in the US struggle with schools being out because people expect us to go on about business as usual, while also ensuring the development of our kids, the impulse for West African governments to say, “Hey, we’re just going to shut down schools” is strong, for whatever reason. They shut down schools and immediately started radio lessons, which is what they did under Ebola. Those are the kinds of institutions that are the quickest and easiest to close during epidemics because they cost money and they’re not operating, for the majority of people, as the stable source of caregiving for kids. It’s not to say that people don’t value education, but one can always continue to be educated outside of the classroom, or it can be deferred. We shut down our schools [in the U.S] and we probably could have used them for screening because they happen to be the only stable community presence for most places. We did not, and it still bugs me to this day.
One thing that I did notice [in Sierra Leone] is that there was an official whose wife was COVID-positive, and so what they did was they tested her family, all of whom were negative, oddly, except for one family member who got sick. And they tested the driver, the maids, everybody who works in the house and the people that she regularly comes into contact with. So what ends up happening is that non-elites end up benefiting from having contact with elites because they get tested. I don’t know if that’s necessarily true in the States, but it’s certainly true in this context. As long as a person is known to be infected that allows for anyone in their circle to be suspected and tested. But if her family isn’t infected yet that means that there’s probably some other kind of community spread that’s acknowledged but not being properly counted.
What ends up happening is that non-elites end up benefiting from having contact with elites because they get tested.
Most people that I know, if they have a fever in Sierra Leone, they go, “Oh, it’s probably just malaria.” And then they go and pick up the artesunate or whatever and take it, maybe take some pills for the headache, and then if it doesn’t resolve in a few days, they go, “Oh, maybe it wasn’t.” If they have a runny stomach, they go, “Oh you know, it’s probably typhoid.” They’re not going to the doctor and getting diagnostic tests. How would people go, “Ah, I wonder if this is COVID-19”? So I wonder the extent to which people would immediately jump to that and then try to go get tested. It’s not like [in the U.S.], where we’re like, “Why can’t I get a test?!” That’s not what’s happening in Sierra Leone — at least not yet.
Sarah: Is part of it, too, what you were saying in the New York Times article that quoted you recently, about people in Sierra Leone, at least in the contexts you’ve worked in, how they see hospitals as a place you go to die, but otherwise you stay home?
Adia: For Ebola it really did feel like you were going to die because that’s essentially what happened to everyone, or half the people who went in at first. All of my friends who ended up going to the hospital either died or were on the verge of death. It’s costly to be in the hospital. You’re not always going to be treated very well, and people get sick in the hospital if they weren’t already very sick. It’s kind of your last resort. It means that you have exhausted all other resources. To some extent I would say that’s probably also true in the States, you don’t really want to be in the hospital. It’s usually because you have something serious happen. You generally want to do out-patient care for everything (with the exception of pregnancy, maybe). In general, the hospital is not a place you want to be. It may even be a last resort for some people to see a doctor or a clinician, because you usually have a long wait, and then once you do get your diagnosis you’re on a wild goose chase for your medication. So that’s kind of my experience and my take — yes, you’re going to the hospital to die. And that’s what’s going to happen if you find yourself in need of oxygen or a ventilator. I’m thinking about what the whole “going home with oxygen” would look like in the circumstances that I lived in [in Sierra Leone].
Sarah: How about the Africa CDC — what role do you see it playing now with the pandemic?
Adia: The Africa CDC is pretty new, about three or four years old. It comes out of the Ebola situation, though I think there had been a discussion and a plan for this organization for much longer than that. The Africa CDC was the first and earliest to have a statement or message about what would happen in Africa, because I think there was a sense that somehow Africa was going to be immune from or escape COVID-19, which makes no sense fundamentally. They have an emergency team of clinicians and public health professionals ready to go; they are working on diagnostics and supply chains — all those things that will help to ease the burden on countries that may have trouble mounting a robust response. But in their earliest statements they lacked a robust analysis of the global political economy that would shape early transmission dynamics; they were like, “Well, obviously there will be a problem because there are Chinese people here.”
I wrote a piece about how actually those early cases were European because a similar relationship exists between Europe and Africa as it does between China and Africa — those circuits of mobility are very much linked to the circulation of capital. Even if all of those French travelers had Senegalese parents or grandparents, or were Senegalese themselves, the circuits of capital are between France and Senegal, irrespective of the nationalities of the bodies carrying them. You can’t even get to most places in Africa without also going through Europe. Understanding those kinds of relationships are central to helping us understand possible epidemic dynamics. So of course those early cases were Egypt, Libya, Morocco, and then Nigeria, South Africa, Ethiopia — because it’s a hub for a lot of African transcontinental flights. All of these places fit into the global narrative of migration and mobility, especially among elites traveling those circuits. So the first case in Mozambique was the mayor of Maputo who had been at the Commonwealth meeting in England with Prince Charles and Prince Albert who were sick and basically resumed life as usual among his coworkers and family members in Mozambique. So he gets back and goes to a wedding and the next thing you know, cousins and grandmothers are sequestered at home.
Sarah: Has the Africa CDC’s focus on epidemic threats been at the expense of other areas of public health?
Adia: I don’t know if it’s really a question of what’s being lost as much as the intensity of focus, because there’s a tendency in many of these regional health organizations — especially those focused on outbreak investigation and preparedness — to frame things in terms of security. There’s something a little unsettling about that, where health is imagined only in terms of national or regional or even continental security. What is an epidemic a threat to? What is it threatening? Even the WHO’s international health regulations think of the threat in terms of trade, travel, and death. The balancing act they are trying to achieve is how to minimize or mitigate the impact effect of this disease on bodies while also optimizing or maintaining trade relationships. We see that played out or embodied in the policies of the U.S. government, and in China as well, but it plays out quite differently because the scales tip more in the favor of “It’s OK if people get sick, we just don’t want them to get sick at the same time” — that’s what flattening the curve is. It’s not “Let’s stop this from spreading,” it’s “Let’s slow it down a little bit.” When that’s your concern, how do you ever get to the point where you’re actively addressing the bigger questions of its existence?
Sarah: Moving back to the US context now, your research illustrates how medical crises need to be understood in their political and social contexts. How do you see what coronavirus might be telling us about American society, particularly when it comes to legacies of inequality here?
Adia: The first thing that I noticed was our relationship to work. So a question that I had was, what constitutes essential work in the kind of capitalist system that we are living under? At first it looked like it was just going to be public transportation, grocery stores, etc. And at first people were very resistant to closing down places where they socialize or have some kind of relief, like the gym, or the brands like SoulCycle whose business model is premised on the social and “intimate” elements of the brand experience, certain kinds of pubs, restaurants, bars, celebrations, etc.
What constitutes essential work in the kind of capitalist system that we are living under?
In Wuhan one of the reasons they shut down when they shut down was because they knew there was a festival coming, and that festival would mean much more mobility and social gathering. Our mass gathering-cum-superspreading event equivalent was St. Patrick’s Day or Mardi Gras. Even under those conditions, what work is necessary and essential? It seems that those areas that we’ve been fighting about, what the feminists and the Left have been struggling to bring to the forefront of politics, were revealed to be essential work — childcare, education, all of these things that we depend on to keep our society running but that get under-compensated, undervalued, under acknowledged and recognized as essential labor. And then those things that actually aren’t essential but help to reproduce certain kinds of inequalities, like gig economy food delivery and gig economy taxi driving, and all of that stuff that’s upholding the fabric of our society but is exploitative and extractive. So that’s the first thing, what constitutes essential work, and how is that work valued?
The second thing is the inadequacies of our health system, if we can call it that. I think Bernie Sanders articulated very clearly how our health system is actually not a system but a bunch of cobbled together pieces that enrich certain polities and entities — the insurance industry, hospital corporations — and also how that doesn’t really fully align with public health and public health systems. So there’s a bifurcation between clinical medicine and public health, and the gap there needs to be bridged to be able to provide care under these circumstances. What I mean by that is, population health is seen as something that sits at the level of the population but does not intervene in the body in the same way that the clinical does. The clinical is individualized and patient-centered.
There’s a bifurcation between clinical medicine and public health, and the gap there needs to be bridged to be able to provide care under these circumstances.
The essential thing is that this bifurcation is untenable in a pandemic. It shouldn’t have been tenable in normal times. And that is only visible when you look at the health of poor people, marginalized people, minoritized people. You know that the billionaire will never have to address these questions. But the rest of us, even if we’re very well off, are having to confront these questions.
Sarah: As an anthropologist, what do you make of the term “social distancing”?
Adia: The debate is that we’re not really talking about social distancing, we’re talking about physical distancing. But for some people I think physical distancing is social distancing. There’s no way you can tell me that my inability to have actual face-to-face meetings with people is not social. I find it much more draining to have a Zoom conversation with 20 students than I do to be in the room with them. There is something about that face-to-face interaction that is energizing and inspiring and different. So I don’t think that the distinction is helpful or anything like that. I believe that if we were to take it seriously, we would think about what the social costs are of the interventions employed to keep hospitals from reaching peak capacity. That might be the point of using the term social distancing, to actually take seriously the social part and the extension of the intervention into everyday life experience. Because it’s coloring and shaping nearly everything that we’re doing.
Sarah: A final question for you. From your perspective, is it possible that this protracted crisis could lead to meaningful or lasting social change?
Adia: I wish, I hope. I worry about what this could normalize too, though. I would love it if it meant that we take seriously a lot of questions about labor and work and health and care. I would love it if that could mean some kind of political shift and change in how we go about our business in the world. But I also worry that there are certain things that powerful institutions are trying to normalize, for instance scaling back certain kinds of protection. Is it a chance to take more people off of the payroll, to offer them less in the way of benefits? Less jobs, and less security in their work? A lot of us are just expected to go on doing what we’ve been doing, just remotely. And many of us have been using our own household infrastructure and resources to continue to do the work of the places that employ us. So I could see that also becoming a thing, where a lot of [employers], in an effort to save money and to save themselves, will distribute risk more to [employees].
I also worry about the distribution of surveillance as well. Like us going, “I just saw all these people not distancing” and reporting on people. I’ve heard people say they’re going to call the police on someone because they’re not properly distancing. Or the police picking people up because they don’t have a mask on. There’s that, but there’s also people who want to open their business and put in infrared temperature monitors so that if anyone comes in with a fever they’ll be kicked out. The dystopian version of all of this is that there’s a tendency or a possibility of distributing and privatizing risk and surveillance in ways that might not have been imaginable or imagined before this outbreak. Not to end it on a downer, but it’s hard to imagine that this equals medicare for all, social solidarity, unionizing, and adequately valuing caring labor and public services of various kinds.
The dystopian version of all of this is that there’s a tendency or a possibility of distributing and privatizing risk and surveillance in ways that might not have been imaginable or imagined before this outbreak.
It’s hard to imagine the progressive utopia that could emerge from this. But I am hopeful. We can do this.
