Covid-19, public health, and the politics of prevention

If the global HIV pandemic and more localised outbreaks of SARS, Ebola and the Zika virus, among others, did not convince us that infectious diseases have been far from conquered, then COVID-19 must certainly have done so. In the past few months, questions about the global coronavirus pandemic – its cause, distribution, health and social impacts, and how best to limit its reach through public health measures – have re-centred emerging infectious diseases in public and scholarly discourse.1 Like past epidemics, COVID-19 has been characterised by widespread fear and anxiety, social disruption and dramatic inequalities of suffering and death. The incredible speed with which COVID-19 has become a worldwide phenomenon, the dramatic force of public health responses, and the endless cacophony of information about the virus and pandemic strain collective efforts to make sense of what is going on. In thinking and writing about COVID-19 we have found the notion of the ‘politics of prevention’ a helpful orienting concept. Much sociological writing on public health and on epidemics is coordinated conceptually by trajectories of thought about risk and risk governance (Bunton et al. 2003, Petersen and Bunton 1997, Petersen and Lupton 1996, Polzer and Power 2016).2 This makes good sense, given the centrality of technologies and discourses of risk within public health. And yet, the established possibilities for critique afforded by risk thinking, including the now characteristic, if belaboured, focus on neoliberal forms of healthy citizenship and governance of the self, seem too limited to fully address the political, social and economic consequences of the public health response to COVID-19. In this commentary, we suggest how the politics of prevention can act as a heuristic device for framing reflections on key dimensions of the public health response to the COVID-19 pandemic. We begin by sketching out what might be meant by the politics of prevention, emphasising two linked, underlying assumptions: the possibility of scientific prediction and the capacity for controlled government intervention in social life (Freeman 1992). Drawing on the situation in Ontario, Canada, we then offer remarks on tensions and struggles arising in efforts to scientifically know COVID-19 and to intervene through a range of different public health measures. We stress, in our concluding remarks, that officials have accorded insufficient attention to a variety of unintended consequences that accompany these measures that sociologists of health and illness are well positioned to help illuminate. By using the politics of prevention as an organising concept we do not mean to jettison risk from analysis of the many implications posed by COVID-19. After all, prevention is about efforts to act on the present in an attempt to reduce the likelihood of future harms. What we do hope to do through use of the term is foreground how COVID-19 is a crisis of public health, centre prevention within discussions about pandemic response, and bring forward some of the antinomies with which prevention is associated. Prevention has long been a fundamental principle of public health reasoning and practice. It enacts a temporal logic sequenced in terms of past, present and future. Within this logic, actors learn from the past and intervene in the present with hopes of preventing harms from manifesting in the future. Today, prevention has the dual character of being widely accepted – who, after all, objects to reducing future harms – while, at the same time, having a low public profile. Public health prevention initiatives typically work in the background; they often have the curious quality of seeking to preserve the nonevent and they demonstrate effectiveness when nothing happens. When prevention works well, it is given little attention. While the idea of prevention may be ‘soothing’ (Freeman 1992:47), prevention also has a less sanguine side. Historical scholarship on colonial medicine (Arnold 1994, Anderson 1995, Porter and Porter 1988, Bhattacharya 2012) and social science research on infectious disease in our present (Farmer 2001, Quinn and Kumar 2014, Weait 2007) demonstrate that preventing the spread of infectious disease too often involves curtailing the liberties of those living in conditions of social and economic marginalisation in order to protect the health of those who are most privileged. Perhaps because of its common-sense nature and proximity to practical domains of action, prevention has not generated sustained scholarly reflection of the sort sociologists of health and illness have given to concepts such as structure or risk. One of the few scholars to engage critically and theoretically with the idea of prevention is Richard Freeman (1992, 1999). Freeman understands prevention as central to multiple domains of policy-making and intervention including, for example, crime, child welfare and public health. He emphasises that prevention is a quintessential modernist project, a social engineering effort that builds on common sense ideas embedded in culture and institutions about managing threats. As noted above, Freeman suggests that the concept of prevention is an ‘amalgam of two others: prediction and intervention’ (1992:35). It rests on underlying assumptions about our ability to: (i) use scientific knowledge to predict the future; and (ii) intervene to forestall future harms through organised government action (Freeman 1992, Gough 2013). The phrase politics of prevention is used widely in the social science literature to signal a critical disposition towards cross-cutting ideological, political, economic, scientific, technological and cultural developments that support or discourage a range of preventive initiatives related to disease and injury (Mamo and Epstein 2014, Padamsee 2017, Roumeliotis 2015, Stewart 2016). One of the earliest uses of the phrase can be found in the work of sociologist Rosemary Taylor (1982). Taylor argued that the popularity of individual, lifestyle forms of health prevention in the US was not inevitable but arose as a result of political struggle among and within government, the medical profession, public health, corporations, trade unions and social movements, each of which supported particular versions of lifestyle prevention for strategic reasons. A second important use of the term is found in an article that prefigures later scholarship on health, identity and biological citizenship. Also writing from the US context, Deborah Stone (1986) argued that in the 1980s, the politics of prevention had shifted from health reformers pursuing prevention to alleviate health inequities to groups of individuals (e.g. immunisation critics) who organised around victim identities to seek exemption from the reach of prevention interventions. This commentary focuses on dimensions of the politics of prevention that relate to what might be called the unintended consequences (Broom 2008) of public health efforts to prevent the onward transmission of SARS-CoV-2, the virus that can cause COVID-19. We recognise that a range of public health measures including physical distancing, isolation, quarantine, handwashing, wearing masks, the temporary closure of public spaces, testing and contact tracing may be necessary to control the COVID-19 pandemic. And yet, we are concerned that these measures and the manner in which they are enforced may aggravate structural inequalities based on intersections of race, gender, class and other dimensions of social differentiation. We thus explore the politics of prevention as a matter of tensions internal to the project of limiting the reach of infectious disease. Doing so reanimates longstanding social justice traditions associated with public health, while focusing attention on structural inequalities that, at times, are not fully addressed by other modalities of critique. In earlier work, we emphasised how efforts to prevent the spread of infectious disease outbreaks beyond national borders mobilised concepts, methods, practices and apparatuses designed to detect and know health events as (or even before) they unfold (French and Mykhalovskiy 2013). Organised internationally as an early warning outbreak detection and alert system and often characterised as a post-Westphalian intervention in sovereign control over infectious disease reporting (Weir and Mykhalovskiy 2010), these efforts aim to know about outbreaks of potential international concern as quickly as possible through ‘real-time’ forms of surveillance. The idea is to prevent the spread of local infectious disease outbreaks by bypassing sluggish sovereign channels of official disease reporting and leveraging online sources of news and other informal information about outbreaks accessed through the data mining strategies of early-warning actor-networks (Mykhalovskiy and Weir 2006). Now seven months into a global pandemic, it is clear that early-warning outbreak detection did not successfully contain COVID-19 and that proclamations of a post-Westphalian system of global public health governance underestimated the durability of state control over epidemiological knowledge of infectious disease. State-based reporting of formal epidemiological case data and mathematical modelling that aims to predict COVID-19 trajectories on the basis of alternative public health response scenarios are at the forefront of pandemic response. Preventing the further expansion of COVID-19 is now less about circumventing formal epidemiological knowledge with informal sources of information than it is about the widespread use of epidemiological case data and its popularisation through media and other channels. The salience of epidemiological knowledge for prevention is central to Freeman’s analysis of prevention. Freeman (1992: 36) takes aim at the population-based, statistical nature of epidemiology that, he argues, ‘makes for controversy over the legitimacy of preventive interventions in respect of actual individuals’. Our concerns about knowledge and the politics of prevention centre less on the formal character of epidemiology or its application to individual circumstances and more on the configuration of actual systems of epidemiological disease surveillance. We are particularly concerned with how decisions about what is measured and how – what Martin and Lynch (2009) call the politics of counting – can contribute to prevention efforts that may aggravate structural inequalities. Given protests against anti-Black racism that have occurred across the world in recent weeks, an important site for considering COVID-19 and the politics of counting is the measurement of race and class. Sociologists of health and illness have made important contributions to a long history of research that identifies and critiques the sources of race and class health inequities (Cockerham et al. 2017, Feagin and Bennefield 2014, Phelan et al. 2010). Historical work on epidemics has also shown that the harmful effects of pandemics are disproportionately felt by racialised immigrants and people living in circumstances of economic and social marginality (Hays 2009, Rosenberg 1989, 1992, Snowden 2019). These insights have not always translated into an architecture for epidemiological surveillance and pandemic modelling that fully takes into account race, class and other social determinants of health, with potential serious limiting consequences for preventive interventions. A particularly stark example is the longstanding failure to systematically collect race-based health care data in Canada. At the height of the pandemic, multiple jurisdictions released epidemiological data that clearly demonstrated the disproportionate number of COVID-19 cases and deaths taking place among racialised populations (Perkel 2020). Not so in Ontario, Canada’s largest province. It was only with the provincial government’s reluctant release of neighbourhood data showing high rates of COVID-19 in areas with large racialised populations, that Black and other community health advocates could support, with epidemiological evidence, what, from experience, they knew to be the pandemic’s impact on their communities. In Ontario, community-led struggles for the systematic collection and communication of race-based data were a central dimension of the politics of prevention. The absence of race-based epidemiological data delayed widespread recognition of the scale of race-based disproportions in the impact of COVID-19 upon which prevention efforts addressing structural inequalities in health might have been based. In the context of growing calls for racial justice, struggles to establish race-based epidemiological data collection should not be understood simply as technical tinkering in epidemiological measurement. Rather, they are interventions in White privilege (Massaquoi 2019). They seek to create knowledge of COVID-19 that represents how race and other structural forms of inequality shape contours of the pandemic. They are part of efforts to redirect prevention away from its characteristic individualist focus to forms of prevention that address conditions of precarious employment, underhousing, public transit safety and other dimensions of structural inequalities that heighten vulnerability to COVID-19 for Black and other racialised people. Related concerns have been raised about the measurement assumptions built into mathematical modelling efforts to predict the spread of SARS-CoV-2. Mathematical modelling has captured the attention of policymakers around the world and, through widespread media coverage, has emerged as an important basis for public knowledge about COVID-19 (Rhodes et al. 2020). In Ontario, Rangel et al. (2020) offer an important critique of the mathematical model released by the provincial government on 3 April 2020. They call attention to how the model propels decisions about the use of containment measures on the basis of preventing a narrow range of indicators – COVID-19 cases, COVID-19-related deaths and hospital intensive care utilisation. Drawing on a social determinants of health perspective, they call for an expansion of what gets measured to include, for example, the health and social and economic costs of job loss, accumulated family debt, intimate partner violence and social isolation that are associated with protracted containment measures. Such changes, they argue, are necessary in order to make known the unintended consequences of public health measures on health inequities among Indigenous, racially marginalised and economically disadvantaged people. Their critique illustrates very well Freeman’s observation that, when it comes to the politics of prevention, what is often at issue ‘is not so much the problem itself, but its passage from one social domain to another’ (Freeman 1999: 239). In ‘disappearing’ certain facets of a problem or some kinds of problems from view, powerful actors like states may be working to absolve themselves of their responsibilities and the of data called for by Rangel and do they a of that against structural inequalities into prevention In to the prevention politics of we should critically about the prevention politics of Our earlier work (French and Mykhalovskiy et al. these prevention politics by for the to to the configuration of actor-networks designed to intervene illustrates the of this focus for reasons. as the of the in 2003, its public health system was the of critical in the early (e.g. Ontario, and and In the months and the it was widely that public health at that time, was and in of and also and and The 2006). the some to begin to public health system in the SARS, the in attention quickly the and provincial seeking to were public health As et al. for the of a model in in reducing capacity in the of the of In the months to the COVID-19 pandemic, the government the of Public – the public health which was in response to – and to public health by over a 2020). These politics a key public health prevention in the absence of a crisis like a pandemic, can that to be in the of such have the capacity of local and provincial public health to to and given a failure to in social welfare that address and and (e.g. et al. Power et al. et al. health officials have been with few this perspective, it has not been to public health officials in and even response to after the people not to about was to prevent the from to public the et al. 2020). it then a state of and the closure of some including and This was by the closure of on and by the closure of provincial and by and Public These which a of the to in made a certain of sense, at for those living in the of and privilege that a with to they did not help those living on the in precarious in or in care They were not done with about how they might people. an unintended of these measures with in the of at work by government may have been to contribute to the in transmission of in for that people living in areas with (e.g. working in care or were at risk of into contact with SARS-CoV-2. of conditions in these characterised by with many family a the for if a were It is now to be by that the most of our are at risk of this pandemic of and 2020). As we noted in the the while insufficient for fully the of inequality in this pandemic, its disproportionate the of COVID-19 in ‘is in areas are more racialised the and are and rates are for racialised people also Ontario, Public At the of in Ontario, have been over cases of COVID-19 disease of care and over cases of COVID-19 disease in these and health care have Public The situation so – with so many and – that the called in the What the when they was in very to a of at one a COVID-19 in with with a COVID-19 found in states of that had not been and a of for and The of is too long to it to that care which should have been the focus of public health emerged as an in the prevention politics of COVID-19. as the knew about and to address structural problems in so too has it known about and to address the structural conditions of but is now with a of COVID-19 cases, with than having been and with who have 2020). As argues, are of care including and to healthy from those who become and some of which are and the of from to and from the of that who for COVID-19 to working as long as they 2020). of this to of a failure to intervene in that address structural and forms of inequality and in rates of a range of other consequences from these measures including health effects associated with the situation of the of and and a dramatic in deaths to an in the use of support in circumstances of (e.g. 2020). the of COVID-19 has an important dimension of the politics of prevention – the of public health and their with respect for liberties and individual As public health and government officials have with their response to the pandemic, has a of designed to the that questions about the and of the of liberties and 2020). The of a state of to public health into for and the of and While the has as a matter of to the to with public health at individuals have COVID-19-related most often in the context of or et al. 2020). have to by and in public health to of and physical often of actual to the April to some COVID-19-related had been in the et al. 2020). In for not the closure of public can be to and can people to for of to upon of 2020). While data on who has been to is of this sort to heighten inequalities as they be felt disproportionately by and people for and physical are to a action and and (Freeman Rosenberg has on to about pandemic from epidemics, while its character through a of individual and collective and closure seven months into the global COVID-19 pandemic it is not clear what and political and to public to the pandemic, have the of a the much for and or medical to One has only to be of the HIV pandemic to be of such of As we the of dramatic in COVID-19 across the efforts to we that the virus be with us for some time, and that when (or a intervention questions of to which to the pandemic response. to of our hopes in a intervention is to on a prevention and out of this can a politics of prevention, one more than which knowledge about racism and other structural forms of and which on the social determinants of health. We do not to for the of a we can action to alleviate and living conditions and The durability of COVID-19 a number of for the of health and It some effort to preserve a within the for research that not address the pandemic. work by COVID-19 may seem a in the of the the pandemic has but it is to the of the At the same time, be for sociologists of health and illness to our to scholarly and public about COVID-19. We this commentary as a to emerging sociological work on the pandemic that to centre prevention within scholarly analysis and critique of the public health response to COVID-19. We do not aim to critique prevention We recognise the of public health measures to the transmission of SARS-CoV-2. Our remarks are more in the of a critical social science with public health that critiques with a to public health practices (Mykhalovskiy et al. 2019). In with longstanding social justice traditions within public health, we have on how public health efforts to know and intervene in the pandemic can aggravate structural and forms of We to the politics of prevention as a heuristic for further work that and the forms of reasoning and practices associated with efforts to prevent the spread of infectious disease and the political and economic consequences of those We the for their helpful and Martin like to the support of the – et culture analysis Martin analysis

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  Open Access•R P J Freeman, Richard Freeman•Children & Society•1999

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  Philip M Kayal, Sue Scott et al.•Contemporary Sociology A Journal…•1994

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