There are still many unknowns about the virus and its diffusion. No matter how developed the scientific knowledge base is, there is a political imperative to take decisions. While science provides knowledge about facts, experts make judgements about what to do. They do this in the face of scientific uncertainty. Unlike scientists who strive to reduce uncertainty, experts try to answer the question of what we should do, given the knowns and unknowns.
In the UK, and many other countries, governments have set up advisory bodies to address the pandemic. Their advice was sought as the virus was new and little was known. The advice has been used to justify policy interventions designed to steer the country out of the crisis. These bodies are usually composed of scientists from a relatively narrow disciplinary range. Epidemiology is the leading discipline. It provides the epistemic core, the logic and rationale for decision-making. This choice is seen as proper and adequate by most commentators, given the nature of the problem.
Because the problem has already been framed in epidemiological terms, we do not question the central role of epidemiology itself
But the choice has deep consequences in terms of framing the problem. Framing is here understood to comprise defining a problem, attributing causality and blame, and identifying remedial action (Entman 1993). Because the problem has already been framed in epidemiological terms, we do not question the central role of epidemiology itself. Even the appointment of experts for advisory bodies is not seen as a choice, where another choice could have led to other courses of action. It is seen as a ‘natural’ reflection of the problem.
This is not to say that epidemiology is not important. Of course it is, and it was most instrumental to alert politicians to the exponential nature of the pandemic in early 2020. However, it is time to recognize the consequences that arise from its privileged position in the process of producing and delivering expertise for what is necessarily political decision-making, and what other perspectives could be useful that have been pushed into the background.
Not only has a particular academic discipline been privileged, but academic research as such. But expertise is far broader than science based. As I will argue below, there are important sources of expertise in civil society, and in the professions. These sources need to contribute more vigorously to a debate about how we should deal with the pandemic, what principles should guide us, and what society we want to build.
Hulme et al. (2020) cogently argue that “because decisions with far-reaching consequences are being made now, it is precisely the right time to call for a greater plurality of knowledge. This entails bringing in broader sources of knowledge to the decision-making process, promoting more transparent decision-making processes and dismantling unhelpful ‘hierarchies of knowledge’. In these ‘hierarchies’, certain forms of knowledge (e.g., certain disciplines within natural sciences) are seen as inherently superior, rather than as complementary. Such a diversification of knowledge would benefit both the effectiveness of decisions made, as well as the legitimacy of those decisions among publics.” (Hulme et al. 2020).
The necessary but insufficient role of epidemiology
My argument is that Covid-19 has been framed as a problem by, and for epidemiology. Several countries have seen epidemiological knowledge as the only legitimate and relevant knowledge when it comes to making decisions. Other forms of scientific knowledge, and other forms of expertise, have been marginalised.
The dominant, epidemiology-based approach has three salient elements (which were developing over time, with overlaps). First, it emphasized the crucial role of diffusion of infections, measured by the reproduction rate R, and the need to reduce this via non-pharmaceutical interventions (NPIs). Social distancing, hand hygiene, mask wearing, and isolation were the tools for the job. Then pharmaceutical treatment options were discussed, and recommendations about effective medicines were made. However, the main method to eradicate the disease was the development of an effective vaccine. This would be the game changer in the pandemic, allowing us all to return to social life as we knew it. Research and investment in effective treatment has paled in comparison.
Waves of new infections are recurring, even in countries with high rates of vaccination
Surprisingly, vaccines became quickly available, if extremely uneven across the globe. But they did not prove the game changer they were expected to be, and it is an open question if they ever can be. To avoid misunderstanding, all of the above measures have contributed to a significant amelioration, but the trend of infections, hospitalisations, and deaths has not been uniformly downward. Waves of new infections are recurring, even in countries with high rates of vaccination. This indicates that we need to talk about the limits of the epistemic model which provides the foundation for these strategies and hopes.
It is no surprise that the epidemiological model has come under pressure from its nemesis, vaccine critical voices. They represent different social groups, and it is tempting but futile to dismiss them as irrational and irresponsible. To be sure, higher vaccination rates lead to fewer infections, severe cases, and deaths. But based on current evidence, the vaccines will not lead to an eradication of Covid-19. There are several reasons for this. The virus has become endemic, and it is present in several animal species. There are new variants against which existing vaccines may be much less effective.
The virus, and its ever-evolving mutations, is present in all countries and can move from a high incidence country to a low incidence country. Medical researchers from the USA put it this way: “Rather than die out, the virus will likely ping-pong back and forth across the globe for years to come. Some of yesterday’s success stories are now vulnerable to serious outbreaks. Many of these are places that kept the pandemic at bay through tight border controls and excellent testing, tracing, and isolation but have been unable to acquire good vaccines. … But even countries that have vaccinated large proportions of their populations will be vulnerable to outbreaks caused by certain variants. That is what appears to have happened in several hot spots in Chile, Mongolia, the Seychelles, and the United Kingdom.” (Brilliant et al. 2021).
The authors make the perhaps provocative statement: “The virus is here to stay. The question is, What do we need to do to ensure that we are, too?”
… what makes Covid-19 so difficult to combat is that it is an airborne illness with so much asymptomatic transmission
Their answer is informed by the epidemiological model, too. The main recommendation is to vaccinate in, and around hotspots of infections, something practiced in the 1970s smallpox outbreak in African countries and India. Such ‘ring vaccinations’ would solve the problem of shortages of vaccine supply. The authors acknowledge the challenge to their approach but remain optimistic: “Of course, it was a different disease, a different vaccine, and a different time. Part of what makes Covid-19 so difficult to combat is that it is an airborne illness with so much asymptomatic transmission. Today, however, epidemiologists have the added benefit of powerful new tools for detecting outbreaks and developing vaccines. They can use these innovations to build a twenty-first century version of surveillance and containment for the battle against this pandemic.”
Asymptomatic transmission of Covid-19 is what makes the virus so persistent. While this was known early on, the fact that it was also airborne came as a later insight. Both elements combine to make existing models of prevention so fragile. This would also be the case with ring-vaccinations. Even vaccinated people can become infected and transmit the virus without showing symptoms. As we have also learned, electronic surveillance systems have not delivered what they were hoped to do.
While the above-mentioned approach recognizes the challenge, and is cognizant of many social variables that are important to consider (including the need to build effective international institutions to deal with this, and other pandemics), it still is heavily influenced by the epidemiological paradigm.
The role of science, expertise and decision-making
Above I have pointed out that science scientific advisors in the pandemic tend to be epidemiologists. Other forms of expertise need to be identified. I specifically draw attention to commentators, professional specialists, and lay experts (Grundmann 2017, 2018, 2022). They all bridge the gap between knowledge and decision-making, but do this in different ways. While policy advisors are usually working behind the scenes, in close proximity to government, other scientists are speaking up as commentators in public debate, communicating their views of the problem, sometimes suggesting solutions. Professionals have specialist knowledge of relevant technical aspects or social practices, and the scope for intervention. Lay experts offer views from civil society based on experience, and reflecting social concerns. It should be noted that the WHO advocates the inclusion of communities; they should have a voice, be informed and engaged, and participate (Habersaat et al. 2020; Marston, Renedo, and Miles 2020; WHO 2020).
Governments have pursued different policies in the their fight against Covid-19 (Stevens 2020). Where we see relative success, this does not seem to be due to better scientific understanding, but due to preparedness in public health administrations, especially via functioning test and trace and systems, vaccination programmes, adherence to distancing rules, and hospital treatment. It is still unclear how close the link is between government regulations and success in fighting the disease.
A commentator in the Financial Times wrote, “a few countries, it is true, have almost unambiguously good stories to tell. But it is some feat to spot the values and institutions that link Israel, the United Arab Emirates and Mongolia. As if to tease us, when a theme does emerge — the heedless ‘neoliberalism’ of Anglo-America — it wilts on further evidence. That is, we have learnt less and less over time. The past 18 months are so haunting in part because they lack all pattern and meaning.” Even this assessment looks doubtful one month after publication (I am writing this on 31 August).
The dominance of epidemiology has led to a focus on eradication of the Covid-19 virus
The dominance of epidemiology has led to a focus on eradication of the Covid-19 virus. This seemed plausible with the unexpectedly fast development of vaccines. A technical solution seemed in sight which would allow societies to return to normality in the course of months.
However, the vaccines have their own problems, they are not 100% safe, nor effective. As with all vaccines they come with side-effects. They also lose effectiveness after months, and are perhaps not effective against mutations of the virus. Pharmaceutical companies are going to benefit from booster vaccinations, maybe for years to come. At the same time they reject all liability for side-effects, pushing it onto the purchasing countries, as leaked documents show. Their rent-seeking strategy has been rewarded with vast sums of government money, which overall reduces the appetite to spend on other forms of treatment.
Such news gives further support to vaccine critical groups which, in turn, poses a serious problem to the epidemiological paradigm, as a certain percentage of immunity needs to be achieved in order for the epidemic to recede. Statisticians Spiegelhalter and Masters reckon this to be around 86% of the population.
Some authors argue that the problem is lack of information, and the pernicious effect of disinformation campaigns. For example, Baldwin & Lenton (2020) emphasize the eminent role of scientific consensus v disinformation. As several studies have shown, vaccine hesitancy is a more complex phenomenon (Hobson-West 2003; Reicher and Stott 2020). Issues of trust vis-à-vis the government and its public health institutions are crucial in this respect. Information campaigns will change very little, especially if they are ‘talking down’ to those who are not convinced.
The spread of the virus is uneven across the world. No matter how much progress one country makes with vaccination programmes, new variants can appear in other countries and spread across the globe. The is no global governance institution to co-ordinate the response measures. The powers of the World Health Organization (WHO) are limited and its advice to governments has been disregarded in the past. Attempts at international co-ordination and co-operation are minimal (Brown and Susskind 2020; Buck et al. 2020; Grundmann 2021), although some collaboration has been underway in the search for a vaccine (Kupferschmidt 2020).
… rich countries have secured the lion share of vaccines, leaving large parts of the rest of the world without
National responses have been the standard mode of operating, and this will continue to be the case. Vaccine nationalism has been evident in the procurement and distribution of vaccines, and in the politics of recognizing vaccination certificates across borders. Most importantly, rich countries have secured the lion share of vaccines, leaving large parts of the rest of the world without. Ethical debates have emerged about the prospect of having booster jabs or vaccinations for children in rich countries while the poor go without.
All this points to the question of how we, as a society, and as an international community, could deal with the challenge. What is our aim? What is the strategy? As soon as we pose these simple questions, we realize that the answers are far from clear.
Sometimes some governments have stated the eradication of the virus as their goal (‘zero-Covid’). More modest goals are: contain the spread of the disease, reduce hospitalizations and severe cases, or keep the health system going. Others argue that ‘living with Covid’ is the only realistic option as the problem will not go away any time soon (Brilliant et al. 2021). This requires several measures, like continuing with social distancing, mask wearing, and providing effective treatment in severe cases. For some, disrupting social life is not legitimate, especially when the number of severe cases and deaths reaches low levels comparable to other diseases.
‘Wicked problems’ only can be managed better or worse, not be solved once and for all (Grundmann 2016; Rayner 2006; Rittel and Webber 1973). The verdict is still out if Covid-19 falls into this category of social problem. The quick development of vaccines has given hope that successful vaccines will solve the problem. Initial enthusiasm has given way to a more sober assessment as the virus has shown several mutations which may hinder the vaccine effectiveness (Vogel and Kupferschmidt 2021).
Nevertheless, the availability of vaccines could be seen as a ‘technological core’ which can be refined over time (Sarewitz and Nelson 2008) so that herd immunity can be achieved. Cheap vaccines that can be easily stored and administered would help. However, as the above has shown there is not enough supply of vaccines across the world, new variants are likely to emerge, and vaccine hesitancy may be a force that could limit such efforts. Wicked problems have no stopping rules; if zero Covid is not a realistic prospect we will see different definitions of success come and go.
Given these parameters I am convinced that the involvement of all forms of expertise will be required so we can discover ways that work to keep the problem at bay. A broad range of expertise is required, from advisors, professionals, commentators, and civil society. This will help to develop and support social practices that are embedded in our daily lives. We already have become frustrated by the on-off logic of large lockdowns that are based on territories and industries. Engineers may develop standards for well-ventilated rooms in which it is safe to congregate for prolonged periods of time. Community leaders may develop early warning systems that allow for timely interventions. Policy-makers need to find solutions to the competing jurisdictions between private and public bodies, and between different levels of government. They also need to incentivise efforts to find effective treatments. Health professionals may develop testing regimes that are quick and reliable and allow targeted responses. Global institutions need to ensure that resources to fight the pandemic are distributed fairly among countries. Pressure groups could campaign against the rent-seeking behaviour of big pharma. In sum, the governance of Covid-19 is something that needs to be established as a problem. Only when it is recognized as such will we be able to get away from an important but overly narrow definition of the problem, and open new avenues for intervention.
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Reiner Grundmann is Professor of Science and Technology Studies at the University of Nottingham (UK). He holds a first degree in Sociology (FU Berlin), a PhD in Social and Political Sciences (EUI Florence), and a Habilitation from Bielefeld University. He has a long-standing interest in social theory, sustainability issues and global environmental problems. His current focus is the relation between knowledge and decision making. He has published on the nature of expertise in contemporary societies in various journal articles, and this is also the topic of his forthcoming book, Making Sense of Expertise. For Frontiers in Climate, he is chief editor of the special section Climate and Decision Making.
Header image credit: Pixabay
TO CITE THIS ARTICLE:
Grundmann, Reiner 2021. ‘Covid, Expertise, and Society: Stepping out of the Shadow of Epidemiology?’ Discover Society: New Series 1 (3): https://doi.org/10.51428/dsoc.2021.03.0003