Ana Vinea, the department’s newest Assistant Professor, describes herself as “a cultural anthropologist of the Middle East with general research and teaching interests in medicine, occult practices, and popular culture.” In the long-form essay below, she explores themes of language, illness, method, and structural violence, connecting her own research in the field of medical anthropology to the overlapping crises of COVID-19 and struggles against white supremacy
Language and heroes
More than 40 years ago, in 1978, Susan Sontag wrote Illness as a Metaphor, a beautiful reflection on language and illness under the shadow of her own breast cancer diagnosis. In that essay, she is concerned with how metaphors come to cling to illnesses in ways that moralize and discriminate sufferers, as well as thwart scientific understanding. Hers is a call for a kind of purification of illness, a stripping away of metaphoric thinking in favor of the material body, the literal illness. This is an important call insofar as it fights the prejudice that accompanies some diseases, including COVID-19. Yet, it is a call that most medical anthropologists would question, based as it is on the assumption that diseases and their causes are confined to the body and can be fully comprehended by science only, stripped of history, culture, and society. COVID-19 demonstrates the fallacy of this assumption by exposing the bodily impact of entrenched systemic and institutional racism. It also does that through the divergent trajectories of the pandemic in different countries, trajectories shaped by social and political factors, as much as by biological ones.
This caveat aside, what Susan Sontag does so masterfully is to draw our attention to the language we use to talk about disease. And I start with her work because ever since COVID-19 transformed our lives in March, I’ve been fascinated with the language surrounding the virus and with what that language does – how it shapes our understandings of the pandemic and how it allows us to see certain things and blinds us to others.
Military terminology abounds: medical staff is at the “frontline,” “battling”/”fighting” an “invisible enemy.” States “at war” with the virus take, or should take, “mass mobilization measures.” The virus, a submicroscopic biological organism without consciousness, has gained nationality; for some it is a “Chinese virus” – a deeply racist metaphor of precisely the type Susan Sontag warned against. Other metaphors are more moralistic: SARS-CoV-2 is “mother nature’s revenge” for our continuous mistreatment of the planet, a “pause” during which “the earth needs to heal.” Healthcare and occasionally other essential workers like grocery, farm, meat, or cleaning workers are described as “heroes” or “superheroes,” military and pop culture figures at once. Occasionally other actors also become super/heroes like researchers at UNC or other scientists working on the novel coronavirus. The virus to which no one is immune is a “great equalizer,” hence “we are all in this together” when confronting it.
The widespread, and global, use of combat metaphors should not come as a surprise. War language has long been used in biomedical texts and popular media to talk about the immune system, AIDS, or cancer, as well as about other equally non-military matters: drugs, poverty, crime. And, of course, it has been employed in relation to past epidemics. There is something ostensibly compelling about this language – it creates a sense of urgency that appears to fit the moment. Yet it remains a problematic language. If we are at war, does this mean that we are all potential soldiers now? Should the exigency of war on the virus allow for authoritarian measures in lieu of public health policies? Labelling the virus as the “enemy” and giving it a nationality enforces the stigmatization of Asian-American communities, helping it spread alongside the virus, in similar insidious ways. The language of war enshrines violence and destruction at the center of medicine and healthcare. Such combat metaphors do not only shape how we see the pandemic, but also reflect the society confronted with it, something that medical anthropologists like Emily Martin, who has analyzed the imagery of the immune system as a nation at war, have long observed. The ease with which we have recourse to this language speaks of the pervasive militarization of American society, as it speaks of the way we tend to think of solutions to our problems in mostly aggressive ways involving attacks, enemies, or sacrifices. Of course, as a medical anthropologist who sees all diseases as culturally and socially embedded, I do not think that there is a neutral, non-metaphoric language to talk about disease, including COVID-19. The question is what are the metaphors that can help us think about and deal with the pandemic in ways that are more conducive to social justice, community building, free access to healthcare, and global solidarity. Can we find a way to cure without waging war? And I have to say that demilitarizing our language is not an easy task – many times while writing these lines I have caught myself wanting to use combat metaphors! Several voices in the past months have similarly underscored the necessity of this double task of critique and recreation of our COVID-19 metaphors. Readers can see some examples here and here and here, among others.
The explosion of the language of “super/heroes” of the “fight” against COVID-19 is another instance of the war language that is simultaneously compelling and problematic. It recognizes and valorizes the tremendous, and relentless, efforts of medical staff (from physicians to nurses to researchers) to understand and combat the SARS-CoV-2 pandemic, and to care for patients with COVID-19. Yet, what does it mean to call medical personnel heroes while at the same time failing to provide them with the necessary PPE (personal protective equipment) to keep them safe and with the necessary medical devices (ventilators, beds) they need to treat patients? Is the widespread use of this language a way to gloss over the failures and vulnerabilities of a market-based health system where hospitals are primed to compete not collaborate and where elective and specialty care is more lucrative than public health or is this language a way to highlight the work of the medical staff despite these structural constraints? Are these medical specialists heroes or victims? It is interesting to see the kind of pushback that the language of heroism has received, especially when originating from the heroes themselves. Similar to Dr. Rieux in Camus’ The Plague, some medical professionals have rejected the rhetoric of sacrifice and heroism or expressed ambivalence toward it. They noted that they are just “doing their jobs,” as “professionals” trained to face risks in their work. Some have argued that this language does not make space for, even silences, their much more nuanced experiences and emotions of dealing with the new coronavirus that range from anger and frustration to fear for themselves and their families.
Heroes, especially superheroes, are not only war figures. They are also central in popular culture. Putting aside any unease with the language of war, the image of the doctor/nurse as superhero has been artistically generative. Urban walls across the world have been embellished with coronavirus-themed murals that prominently feature health workers as heroes – they wear the “S” superman logo on their chest or face mask, adopt combative stances, wear boxing gloves or flex their biceps, occasionally punching the virus in the face. In other representations, or combined with the hero imagery, health workers exhibit religious features – they are surrounded by saintly halos or they sport angel wings. These images marry religion and science in a pop culture imagery of the “fight” against COVID-19 (the war metaphor seems apt here!). In the US, images in the same genre have celebrated Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases and a member of the now defunct White House coronavirus task force. The celebration of medical staff also took other forms besides murals. Front lawns have switched elections signs that dominated in February to new ones thanking frontline health workers or marking a house as inhabited by “heroes.” In some European countries, beginning first with Italy, people have instituted what could be called rituals of gratitude, daily clapping to honor health professionals’ work that also serves as community-making ritual, forging social connection between isolated households in a kind of acoustic public sphere.
Production of knowledge
Part of my current project has to do with how knowledge is produced across different medical practices, some incorporated in the established medical field (psychiatry) and others rejected by it (religious healing). Because of this pre-existing interest in knowledge production, it has been fascinating to observe how scientific knowledge about COVID-19 has evolved in the past months, and how it has circulated and been discussed by the non-specialist public. What the pandemic offers, I think, is a kind of mediatized, real time view into the complicated work of “making science” (and I use science here to encompass a wide variety of disciplines: virology, infectious disease medicine, public health, and epidemiology).
Even if SARS-CoV-2, the virus behind the pandemic, is new, it is by now well understood in its genetic make-up and taxonomy. This is not the case for the disease it causes, COVID-19. Its risk factors, clinical manifestation, infectious and fatality rate, or its long-term health effects remain to a certain extent surrounded by unknowns, uncertainties, and shifting, sometimes contradictory data, confounding efforts to act against the pandemic at all scales, the micro one of our own lives and the macro one of governance. There are myriad such past or present uncertainties. High-risk categories have been identified on the basis of epidemiological data, but vulnerability remains inadequately captured by these categories, especially taking into account reports of “chronic COVID-19” and of healthy young people dying or disabled by strokes. The understanding of the role of asymptomatic patients in transmission shifted, in time leading to changing recommendations about face masks. The mortality rate varies greatly across countries linked as it is with pre-existing pandemic preparedness, public health and hospital capacity, testing scope, and mitigation measures – all factors that are not purely scientific or medical. The clinical manifestation of the disease remains as Dr. Fauci recently noticed a “work in progress.” Initially thought to be respiratory tract disease, COVID-19 turned to be more complex with a vast array of effects implicating multiple systems in the body – immune, neurological, or cardiovascular. Other uncertainties surround the efficacity and safety of suggested medications, compounded by ungrounded opinions of political figures. Even harsher uncertainties and contradictions occur once we move from the lab and the hospital to the level of governance. What are the best models that can predict how the pandemic will play out in the future and how can these models guide mitigation strategies and policies? Should states impose strict lockdowns (Italy), soft social distancing recommendations (Sweden), or follow an intensive strategy of testing, tracing, and isolation (South Korea)?
I have seen posts circulating on social media platforms that, after astutely noticing some of these uncertainties surrounding the pandemic, have jokingly commented that they indicate that science has been wobbly in this pandemic. Yet, science is always wobbly, so to speak. What the interdisciplinary fields of science and technology studies (STS) and history of science, disciplines that have influenced my own work on Islamic healing in contemporary Egypt, show is that the process of building scientific knowledge is less a uniform progression towards absolute facts, and more a complex and gradual process, contingent on social, economic, and political factors. Science, STS teaches us, is always already full of uncertainties, changing evidence, disagreements, and controversies. And it is never divorced from the wider society or immune to politics. Such a perspective can help us make some sense of some of the uncertainties, changing recommendations, and controversies around COVID-19. To give a close to home example, an STS-sensitive eye can aid us in understanding (at least analytically) why universities’ divergent plans to reopen or not in fall, to regularly test all students, faculty, and staff or not can all be based on the advice of public health and infectious disease experts. This is not only because science is not divorced from local political and financial calculations, but also simply because experts disagree. If that is the case, what is needed when taking such decisions is a more expansive understanding of safety, risk, and vulnerability that recognizes that these are not only medical issues, but also issues of ethics, justice, and equity.
If from an STS perspective the complexities, uncertainties, and contingencies of COVID-19 are not surprising, what is unprecedented, at least to my knowledge (but I can of course be wrong here), is the extent to which these characteristics became visible in the public space, revealing to the internet-hooked public the process of knowledge formation in medicine and science in all its messiness. As a result, technical terminology long used in specialized fields – “social distancing,” “flattening the curve,” or “personal protective equipment” – has become not only part of our daily lives, but also of our political vocabulary. Public exposure to the process of making science has been aided by the explosion of scientific papers about SARS-CoV-2 and COVID-19, more than 4000 a week according to some reports. In the rush to understand and control the pandemic, journals have shortened time between submission and publication, and pre-print papers that have not undergone the typical peer-review process have been published in open-access venues. The results of some of these studies have been reported in the press and have been consumed by the public. Some were later retracted, or their methods and results were criticized. This phenomenon has increased uncertainty among the public, all the while revealing the complexities of creating medical knowledge.
And speaking of the explosion of knowledge production seen in medical sciences and epistemology, a similar trend has occurred in anthropology beginning with March. It is amazing, and rather overwhelming I might add, the amount of thinking and writing generated by the pandemic in my discipline. Major journals like Cultural Anthropology or The American Ethnologist as well as online blogs like Allegra have curated COVID-19 forums, ranging from diaries, to observational pieces (mini-ethnographies, if you wish), to analytical insights, and reading lists. The website of the American Anthropological Association has started to bring together these disparate resources. As expected, medical anthropologists have been particularly active. Projects to manage and make accessible the volume of information have appeared and calls to action for medical anthropologists were issued identifying core research issues for investigation with the goal to inform health providers of social aspects of the pandemic, assess existing COVID-19 policies, and generate new ideas for pandemic response. Medical anthropological insight and research are essential in the current pandemic in myriad ways: scholars have decades worth of experience studying infectious diseases and epidemics like cholera or HIV/AIDS; a central theoretical strand in medical anthropology (critical medical anthropology) is dedicated to analyzing how structural violence impacts disease and health, as well as medical care; medical anthropologists have foregrounded the importance of people’s experience of illness and of their narratives; and applied medical anthropologists have long been working in local communities and collaborating with medical experts to improve health care and outcomes. One could teach an “Introduction to medical anthropology” course through the lens of the pandemic only. Of course, other humanistic and social scientific disciplines are equally important in creating knowledge of the pandemic and, as important, in rethinking the world in its midst.
I suspect that this avalanche of COVID-19 anthropological studies will continue in the future as the pandemic itself evolves. I don’t mean only in medical anthropology, but also in other subfields – anthropology of religion, kinship studies, economic anthropology, political anthropology, and so on. In the end, the pandemic seems to touch our lives and societies in all their aspects. While I have been fascinated by this explosion of anthropological knowledge, it has also at times made me slightly uneasy. Keeping in mind differences in proportion and context, the pandemic brought to mind echoes of the period immediately following the 2011 Egyptian uprising when I was in Cairo to conduct field research. For some time, it seemed that the uprising was the only possible topic to study, as COVID-19 also seemed to be, at least until the current protests against police violence and racism. Recently, some anthropologists have expressed a similar unease and have warned about the danger of a single topic.
The Work of Witnessing
The scholarly work of anthropologists, as well as of historians, area and ethnic studies specialists, and other humanistic disciplines, is central in making sense and acting against the pandemic. In the past months I have spent quite some time reading such scholarly interventions. Yet the genre of writings that I found most impactful and that really brought home to me the reality of the pandemic is testimonies, accounts of the experiences of those closest to the virus and the disease it causes – patients, families, medical staff. Not separate from it, but interwoven with analytical labor, the work of witnessing, of letting them speak, of listening to and foregrounding such testimonies is essential in this moment.
These accounts are raw, gut-wrenching; they speak with no euphemisms of suffering, loneliness, and death intermingled with care, love, and compassion. They are not a comfortable read. They tell many stories. Stories of families whose loved one died without a chance of saying good-bye or with the only option to talk one last time over the phone or Facetime, families who after that had to postpone the funeral or conduct a socially distant one or perhaps a Zoom-funeral. Then there are stories of exhausted medical staff trying to treat patients and deal with the staggering number of deaths. Among them – this one has been the most touching to me. These are stories of physicians, and especially nurses, thrust into new roles that blur the boundaries between medical providers and families, compelled to provide comfort, presence, and human touch so that people do not die alone. They are stories of physicians for whom the pandemic might mean a shift in careers. And of course there are the stories of those who deal with the deluge of dead bodies. In addition to narrative accounts, visual stories provide another kind of testimony into the reality of the COVID-19 pandemic. In New York, a photographer turned nurse grabbed her camera to visually chronicle the unfolding pandemic in her place of work. Established photojournalist John Moore, who had covered the Ebola epidemic in Liberia, has turned now to do the same with coronavirus in New York. An Italian photographer captured the exhausted faces of physicians, marked by the traces of PPE. A group of contemporary photographers initiated the Covid-19 Visual Project, a multimedia platform conceived as a visual archive of the moment.
“I think of a Jennifer, I think of Moyshe, I think of a Santiago, I think of a Melissa, I think of a Bessey and a Betty, I think of an Hernan. I can’t stop thinking of them.” This is how a worker in an improvised morgue in New York ends his account. We also should not stop thinking of them or of the more than 115,000 people who have died in the US since March, including more than 600 health workers. The work of remembering those who have died, of collecting and telling some of their stories or at least of offering a one sentence glimpse of personhood as the NY Times has attempted to do is essential. The work of witnessing is not only a human and ethical act, it is also a political one.
It is political because of how in the rush to reopen states, businesses, universities we seem to forget that between 800 and 1,000 people die each day of COVID-19. It is political because we cannot seem to find a way to go beyond the dichotomy of saving lives vs. saving the economy. And it is political because we tend to ignore countries that have dealt with the pandemic in more successful ways, countries that happen to be non-Western and non-white (like Cuba or Mongolia, among others).
This is also politically essential work because of those who are most impacted by the pandemic in the US (and in other countries). With a troubling consistency, data has shown that minorities – – Black, Native American, and Latinx communities – have higher morbidity and mortality rates; they are more at risk of contracting COVID-19, of having poor health outcomes if they do, and of dying from it. These groups have also been those most affected by the economic impact of the lockdowns put in place last minute to mitigate the spread of a virus too long left unattended. In that sense, to circle back to the widely circulated statement “we are in this together,” while technically true (in the sense that nobody has pre-existing immunity to the novel coronavirus), the statement also functions to mask structural racism and its killing capability. In themselves, these data are not surprising to those who study and fight to address how health is impacted by systemic inequality. The pandemic has just made this even more clear and pushed it into the center of public debates. That a nation-wide uprising against anti-Black police brutality, racism, and white supremacy has erupted in response to the murder of George Floyd by a police officer in the middle of a pandemic that disproportionately kills black Americans and other disadvantaged groups is telling. They are both struggles to breathe.