Emergence and re-emergence of pathogens is difficult to avoid in a global society, especially because we sometimes fail to recognise the relevance of social and cultural features for the spread of infectious diseases. Neha Deopa and Piergiuseppe Fortunato write that this failure not only puts us at risk of pandemics but undermines our ability to fight them.
A photo taken towards the end of COVID-19’s first wave in Munich and later circulated on social media generated some consternation in Italy. The photo portrays several groups of people sunbathing on the shores of the Isar river on a sunny April Saturday. At a time when most Italians were still mourning their dead and complying meticulously with the “stay at home” requests of the government, the behaviour of the Bavarian trippers appeared to many as an open challenge to common sense.
Questa fotografia è stata scattata alle ore 15 di oggi, sabato 18 aprile 2020, sulle sponde dell'Isar, nel cuore di Monaco di Baviera.
Alcune riflessioni sul perché sarebbe il caso di studiare un po' meglio chi, come la #Germania, è stato più bravo di noi: https://t.co/r9nHIf0EXM pic.twitter.com/1TqaR9IqdW
— Corrado Formigli (@corradoformigli) April 18, 2020
The blatant neglect of social distancing, the return to a certain normality evident in the photo, was not the only detail that caught the attention of the Italians. The distribution of bathers was also peculiar. Not crowded into large and noisy family groups, as is often the case on Italian beaches or parks, but orderly distributed in micro-groups of two or three people placed at an adequate distance from one another. A configuration that shielded them from contagion, or that at least greatly reduced that risk. Physical distancing replaced social distancing.
It was not by chance that the photo came from Germany, a country where individuals are culturally accustomed to maintain relatively distant personal interactions and display high levels of generalised trust towards others. They therefore expect a relatively responsible behaviour and the respect of hygienic rules, like appropriate mask-wearing and frequent handwashing, on the part of fellow citizens. A habitat that reduces the danger associated with social interactions. Broadening the perspective, behavioural attitudes and values shaped by cultural context and transmitted from generation to generation affect the diffusion of communicable diseases especially when, as in the case of COVID-19, the virus can spread through airborne transmission. Typology of family ties, interpersonal distance preferences, universalism, or collectivist orientation all have implications for behaviours that are relevant to the spread and impact of contagious diseases.
Our original research shows that the peculiar combination of traits that characterise different cultures has played a significant role in explaining heterogeneity in exposure to the new coronavirus both across and within countries. This is true even comparing individuals living de facto in the same communities, with access to the same health infrastructure and subject to identical administrative restrictions, but with a different inherited cultural background.
Our research also shows that cultural origins can go a long way towards explaining why compliance with non-pharmaceutical interventions, such as social distancing measures and “stay at home” campaigns, varied widely with the local context. In the absence of perfect enforcement capacity by public authorities, cultural attitudes and behavioural norms can make an important difference and justify deviations in voluntary compliance. This is all the truer when it comes to individual mobility decisions, which entail a delicate trade-off between the chance of contracting (or diffusing) a disease and the economic (and individual well-being) costs associated with significant alterations of daily activities. But it is also the case, albeit to a lesser extent, for vaccination campaigns. Indeed, vaccination coverage in the context of COVID-19 has varied significantly depending on cultural background, political ideology, attitudes and values, despite the general uniformity of the vaccination strategies employed.
Since the response to public health measures ultimately depends on the cultural background and on the behavioural norms diffused in the population, so it should any meaningful policy decision. Rational and forward-looking policymakers should design interventions taking into consideration the likely reaction of their citizenship. Different measures should be deployed to contain the spread of communicable diseases in different cultural contexts.
In many countries, however, the cultural background is far from homogeneous. Sudden surges of migration have regularly occurred in industrialised economies throughout the last two centuries. The latest such wave started in the 1990s and is an integral part of “globalisation” – the increasing cross-border flows of information, internationally portable capital, globally tradeable goods and services, and, most importantly, ever more mobile people and, along with them, the values and norms that they embody. According to the International Organisation for Migration, a total of 281 million people lived in a country other than their countries of birth in 2020, over three times the estimated number in 1970. This figure does not include second generation immigrants (individuals with at least one foreign born parent), whose relevance has constantly been on the rise in the last decades especially in western economies. Only in the United Sates, for example, second generation immigrants were over 30 million in 2017, accounting, together with first generation immigrants, for around one fourth of the total population.
We now live in multicultural societies composed by people with different ethnic, linguistic and religious origins that maintain their particular identities while residing in the collective. While being desirable from many perspectives, multiculturalism complicates enormously the quest for an “optimal” disease control policy that, being conditional on the individual cultural background, should in principle vary across the different groups composing a population. This difficulty contributes to explain why multicultural western democracies, as for example the United States of America, capitulated earlier to COVID-19 than more homogeneous East Asian societies.
Globalisation has another significant fallout on the spread of communicable diseases. Greater connectedness and integration within a global society naturally increases the interactions between diverse populations and the pathways through which potential pathogens can travel and hence emerge and re-emerge in a local population. Unless a disease is eradicated, an extremely rare occurrence in human history, pathogens always have a chance of making their way back even to countries that proved relatively effective in combating them. Until recently, for example, big Chinese cities had been far more successful at controlling the coronavirus than many European or American cities of their size, but the latest waves of infections swamped their medical systems and forced the administration to enact unprecedented, prolonged lockdowns in Hong-Kong as in Shanghai before the final capitulation. At the same time, Taiwan was forced to change its zero-Covid policy stance after the “Omicron tsunami”.
The continuous shift of the pandemic from one region to another also facilitates the emergence of new variants. The virus seems to adapt to public health measures more swiftly than public health measures adapt to the virus. From the data at our disposal, it seems that SARS-CoV-2 Omicron new sub-lineages exhibit higher transmissibility than previous sub-variants and a surprising immune evasion capability. This in turn may affect the effectiveness of vaccine boosters in achieving broad-spectrum protection.
Between the 13th and 12th centuries BC, a series of communicable disease outbreaks (smallpox, bubonic plague and tularemia) aided the end of the Bronze Age in the Near East, amid a combination of interconnected crises. At that time the Mediterranean Sea was characterised by intense trade flows and important episodes of mass migration, which historians have later defined as pre-modern globalisation. The interconnections between the different shores of the Sea certainly facilitated the migration of the pathogens along with their vectors, in a similar vein that modern globalisation is facilitating the emergence and re-emergence of COVID-19.
Nowadays we can count on much more advanced medical research. Never before in the history of medicine has the spread of an infectious disease been halted so early by the development of vaccines. Medical research alone, however, was not enough to spare the world over 14 million deaths and it will not be enough to shield us against emerging infectious diseases in the future. COVID-19 has taught us that failing to recognise the complexity of the globalised social ecosystem in which we live not only puts the world at risk of further pandemics but can also limit our ability to effectively counter them.