AHI on controlling the COVID_19 pandemic

AHI has been campaigning for adopting a holistic approach that foregrounds human values to control the spread of COVID_19 since 2020.

COVID-19 is a social-psychological behaviour disease: brief comments on the AHI approach to controlling the COVID-19 pandemic.

Professor Wagner Marcenes

COVID-19 is a very serious multi-system disease, meaning that it can trigger a huge range of health problems (Noris, Benigni, & Remuzzi, 2020). COVID-19 disease originates in the lungs causing severe shortness of breath, coughing and fatigue (Varga et al., 2020). This is a result of the severe inflammatory host immune response that affects the lungs, diminishing oxygen uptake which results in endotheliitis and thrombotic events and intravascular coagulation (Noris, Benigni, & Remuzzi, 2020). Additionally, endothelial cell involvement was identified across the vascular system of different organs in a series of patients with COVID-19 (Varga et al., 2020), which may explain the multiorgan damage (Noris, Benigni, & Remuzzi, 2020). COVID-19 affects the biological functioning of vital organs by causing cardiac, acute kidney and brain injuries (Noris, Benigni, & Remuzzi, 2020; Varga et al., 2020; Yachou et al., 2020). The latter can cause long-term psychosis, delirium, anxiety and confusion (Zhang et al. 2020; Heneka et al. 2020; Serrano-Castro et al., 2020). Symptoms may be permanent as these biological changes are irreversible (Noris, Benigni, & Remuzzi, 2020). As the number of COVID-19 survivors increases, it is becoming evident that in addition to respiratory disease, COVID-19 has long-term consequences threatening other organs.

The COVID-19 pandemic seems to be out of control in many countries as surveillance systems which are used to monitor the Coronavirus Disease 2019 (COVID-19) pandemic shows. Indeed, there is an urgent need of a more effective global strategy to control the COVID-19 pandemic.

The biological pathway for controlling the pandemic is unlikely to be more effective than the pathway of social-psychological behaviour. As with the HIV/AIDS epidemic, many people at risk of contracting COVID-19 will not have access either to a vaccine, or to the drugs required for prevention and treatment – the biological pathway for controlling the pandemic. If success was achieved in the fight against HIV (UNAIDS, 2010; Halperin et al. (2004), this was thanks only to prevention efforts; although antiretroviral medications are now available in many developing countries, providing medication to millions of people would have been an overwhelming drain on government health resources (UNAIDS, 2010). Zimbabwe’s approach to preventing HIV transmission succeeded only because of its focus on behavioural change (Halperin et al. 2011), a situation mirrored in Uganda (Stoneburner & Low-Beer, 2004; Hallett et al., 2006), urban Kenya (Hallett et al., 2006), urban Haiti (Hallett et al., 2006), Dominican Republic (Halperin et al., 2009) and Thailand (Nelson et al., 1996). If HIV is now contained, this has had nothing to do with a vaccine, for which we are all still waiting. Instead, it was achieved thanks to a shift in sexual behaviour (Halperin et al., 2004), underpinned by massive campaigns in favour of protected sex. Convincing people to wear masks in public places and keep a two-metre physical distance to slow the spread of COVID-19 should be a far easier task than convincing people to wear condoms for sex. Promoting COVID-19-safe behaviour is feasible, if we take lessons from successful approaches to address other epidemics.

Even if a vaccine is produced, it is unlikely to be manufactured in sufficient quantity to immunise the world’s population. Furthermore, in countries where the vaccine will be available to all, people still need to agree to take it. Anti-vaccine groups are well mobilised against a vaccine that has the potential to save millions of lives, while anti-science groups dismiss all scientific information out of hand. Self-styled ‘freedom-lovers’ forget that liberty must be balanced against fair play, and that the concept of freedom does not stretch to jeopardizing others’ lives. It is a fact that countries whose leaders disregard the behavioural factors associated with the COVID-19 pandemic are leading the world in numbers of deaths. In such nations, where levels of social inequalities are also pronounced, death has become commonplace. People in the poorest neighbourhoods in affluent countries are up to four times more likely to be killed by the virus compared with those in the richest areas (Office for National Statistics, England).

The major challenge in containing the pandemic and prevent it from becoming a disease of the less affluent citizens is, therefore, the choice of a global approach in promoting population-wide behavioural change. The behavioural pathway for controlling the pandemic must not discount the well-demonstrated theory that social conditions are the fundamental cause of health inequalities. This enduring association stems from the fact that higher socio-economic position embodies an array of resources, such as money, knowledge, prestige, power and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time; it takes resources to avoid risk (materialistic pathway) and adopt protective health behaviour (Phelan, Link & Tehranifar, 2010). Social psychological theories and research on intergroup relations, including prejudice, discrimination, stereotyping, stigma, and threats to social identity, contribute another explanation for the presence and persistence of health inequities (Major, Mendes, & Dovidio, 2013).

The latter examples of intergroup relations lead to social exclusion (Major, Mendes, & Dovidio, 2013), which manufactures a breakdown in society. The dynamics of interaction between socio-economic barriers and intergroup relations play a major role in the transmission of COVID-19. Societies characterised by fragmentation will struggle to control the pandemic; those, in contrast, with satisfactory levels of social capital, characterised by strong interpersonal relationships and community engagement, shared trust, and high levels of reciprocity, are more likely to succeed (socio-psychological pathway). Only with concerted efforts by governmental and nongovernmental organisations and strong engagement by the population will the COVID-19 pandemic be controlled globally.

To that end, a holistic approach that foregrounds human values is urgently required. It is in human nature to adopt protective behaviours for survival and to preserve the species; therefore, it is reasonable to expect that a comprehensive approach towards promoting the adoption of safe behaviour by individuals – in order to protect themselves, their families and their communities – would be effective. Social conditions (materialistic pathway) explain, in part, variations in the distribution of diseases, yet some degree of health inequality remains even after accounting for differences in structural and economic factors (Major, Mendes, & Dovidio, 2013). It is for this reason that the psychological determinants of behaviour change (psychological pathway) must be considered.

To effectively develop public-health behavioural-change interventions to protect the world population from the COVID-19 disease, policymakers need to move beyond the outdated belief that risk-awareness programmes alone lead to behavioural change. Instead, the socio-economic barriers (materialist pathway) must be addressed as a priority, concurrently with the psychological determinants of behavioural change. Explanatory theories, particularly from psychology, must be the foundation for developing population behavioural change. Addressing the synergistic contributions of the materialist and the psychological pathways, and focussing on the processes associated with health inequities, can significantly improve the effectiveness of behavioural change approaches, thus helping to rein in the COVID-19 pandemic at population level.

Amid attempts to control the COVID-19 pandemic, nearly all research funding has been allocated to biological research, while social and behavioural sciences have been neglected. Although clinical trials are vital for developing both drugs and vaccines, it is equally important to carry out social science research in order to emphasize and further understand the socio-psychological determinants of protective-behaviour adoption – including willingness to take a vaccine. This understanding may hold the key to controlling the COVID-19 pandemic. COVID-19 is a social-psychological behaviour disease.

References

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