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29. The sociology of epidemics and pandemics Robert Dingwall INTRODUCTION Historically, sociologists seem to have had little to say about epidemics or pandemics as social phenomena: an epidemic is a large-scale outbreak of an infectious dise...

29. The sociology of epidemics and pandemics Robert Dingwall INTRODUCTION Historically, sociologists seem to have had little to say about epidemics or pandemics as social phenomena: an epidemic is a large-scale outbreak of an infectious disease in one location; a pandemic is an epidemic on an intercontinental scale. This chapter reviews some relevant sociological resources. It recognises that epidemics and pandemics are not merely challenges to biomedicine or public health but to entire societies. As such, sociologists have a particular role to play in understanding and responding to them: a ‘whole of society’ problem requires a ‘whole of sociology’ response, one that goes beyond the traditional boundaries of medical sociology. Epidemics share common features, regardless of the specific infection that causes them. Each episode, however, also has distinctive features of time, place and culture. Readers are invited to use the material here to examine their own contexts and contribute to compara- tive case analysis. THE SOCIOLOGICAL TRADITION Sociology became institutionalised as an academic discipline during the last quarter of the nineteenth century and the early years of the twentieth (Shore, 1987; Ross, 2004). As such, it was unable to comment on earlier epidemics, especially those associated with industrialisa- tion and urbanisation. Although what we might call proto-sociological writing by people like Florence Nightingale and Frederick Engels discussed the impacts of infectious disease on nineteenth-century societies, the first opportunity for academic sociology to contribute was the global influenza pandemic of 1918–1920. This, however, passed more or less unnoticed. In some respects, the silence is surprising, given that Max Weber appears to have been one of the pandemic’s last victims when he died in 1920 (Radkau, 2011: 545–546). As a first approxima- tion, searching JSTOR for in the years 1918–1928, to allow for publication lags, found only a few Italian citations, related to social epidemiology and public health. US journals had a handful of references, although these identify issues that remain familiar. Florence Meredith (1922), in the American Journal of Sociology, observed: ‘Because the matter of bodily health is fundamentally the concern of medical science it is often not recog- nised that it is also frequently a sociological and an economic matter’ (p. 320). ‘Doctors can- not personally by their own efforts unaided by an intelligent populace bring about anything of value’ (p. 323). She discusses the difficulty of complying with medical advice without the resources to do so, citing the recommendation to secure better ventilation by opening tene- ment windows in New York, when there were ‘thousands of rooms … without any windows’ (p. 323). In the Annals of the American Academy of Political and Social Science, Raymond Fosdick (1923: 18) comments on the globalisation of infectious disease: 455 EEP_29_HAME_C029_docbook_new_indd.indd 455 26-Jun-23 21:14:28  456 Handbook on the sociology of health and medicine Is the question one of health? But health is no longer national in scope. With an influenza epi- demic sweeping the world, a problem was created which far outran the efforts of individual nations. Bubonic plague cannot be confined within the boundaries of a single country, and, as we here in the United States have learned to our sorrow, poliomyelitis is no respecter of flags. Modern science has facilitated the travel of germs as well as of men, and the problem of disease is one which challenges the brains and resources of humanity without regard to national boundary lines. Several authors discuss the impact of the influenza pandemic on minorities. In the same jour- nal, Duncan Scott (1923) notes the consequences for First Nations in Canada and Sidney Goldstein (1922) comments on the displacement of deaths between tuberculosis and influenza in US Jewish communities. E. Franklin Frazier (1925), who later became one of the most influential Black sociologists in the US (Platt, 1991), wrote, in the Journal of Social Forces, about the racism inherent in discussions of Black responses to disease: Let us consider first the conceptions held by many Negroes concerning the cause of disease. Primitive conceptions of disease are still entertained by the white population; and the Negro exhibits in this respect no special psychic traits. He has simply a larger amount of ignorance and is relatively iso- lated in his mental environment. The influenza epidemic called forth special church services among even supposedly enlightened white people. (p. 488) A similar JSTOR search for the ten years following the 1957 and 1968 influenza pandem- ics, found only one reference to a paper mainly focussed on cholera by Charles Rosenberg (1966), a social historian of medicine. He makes the case for a wider social scientific study of epidemics: An epidemic, if sufficiently severe, necessarily evokes responses in every sector of society. A study of the responses to the same sharply focused and unavoidable stimulus should provide materials for the construction of a cross-section of cultural values and practices at one moment in time. Values and attitudes, especially in the areas of science, of religion, of traditionalism and innovation are, for example, inevitably displayed during an epidemic. Medicine itself is, of course, a social context, one in which science pure and science applied necessarily function together; the nature of their interac- tion during a crisis situation should provide clues to their ongoing relationship. Thus the behavior of society during an epidemic and of medicine as a social function provides an organic context in which the structural configuration of attitudinal and institutional factors may be discerned. (p. 452) Medical sociologists did, of course, study other infectious diseases. Fred Davis’s (1963) Passage Through Crisis, on children with poliomyelitis, has had an enduring impact in its analysis of clinical and functional uncertainty. Julius Roth’s (1963) Timetables, on life in tuberculosis sanatoria, has a legacy in many hospital ethnographies. The emergence of HIV in the 1980s generated a large body of work (Epstein, 1996; Treichler, 1999). However, each disease tended to be examined in isolation. If anything was transferred, it was specific concepts rather than a systematic comparison of the diseases themselves in relation to society. Medical nosology (the classification of disease) has defined social sci- ence agendas, much as it has public health responses to recent viral infections like Covid- 19, Ebola or Zika. Each has been approached as if it were unique, which may be correct in biomedical terms but, as Rosenberg suggests, wrong for the social sciences. Each is potentially a case study capable of adding to a more general framework to understand and inform the societal response to any novel, emerging or re-emerging viral infection capable of causing an epidemic. EEP_29_HAME_C029_docbook_new_indd.indd 456 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 457 This is what makes PM Strong’s (1990) paper, ‘Epidemic Psychology: A Model’, such an original contribution. Strong wrote this as part of a study of the management of the HIV/ AIDS pandemic, sketching themes for an intended book (Murcott, 2006). Despite the title, it is a programme for the study of epidemics as societal phenomena, without being tied to any specific infectious organism. It draws on a tradition of sociological social psychology, relating collective behaviour to individual actions (Blumer, 1937; Dingwall, 2021). Much of this work might now be described as symbolic interactionist, although Strong was more influenced by Goffman’s (1983, 1986) interests in structures and frames, patterns shaping interactions rather than unique experiences. The societal response to HIV/AIDS served as a starting point for the comparative case analysis of epidemics back to the Black Death pandemic of bubonic plague in the fourteenth century CE. EPIDEMICS AND SOCIAL ORDER If the core task for sociology is the analysis and explanation of social order, Strong argued, epidemics present the discipline with a unique opportunity. They are part of a class of events that render order simultaneously uncertain and transparent. Societies are caught up in an extraordinary emotional maelstrom which seems, at least for a time, to be beyond anyone’s immediate control. Moreover, since this strange state presents such an immedi- ate threat, actual or potential, to public order, it can also powerfully influence the size, timing and shape of the social and political response in many other areas affected by the epidemic. (Strong, 1990: 249) This approach was influenced by Rosenberg’s (1989) commentary on AIDS: Thus, as a social phenomenon, an epidemic has a dramaturgic form. Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure. In another of its dramaturgic aspects, an epidemic takes on the quality of pageant – mobilizing communities to act out proprietory (propitiatory? RD) rituals that incorporate and reaffirm fundamental social values and modes of understanding. It is their public character and dramatic intensity – along with unity of place and time – that make epidemics as well suited to the concerns of moralists as to the research of scholars seeking an understanding of the relationship among ideology, social structure, and the construction of particular selves. For the social scientist, epidemics constitute an extraordi- narily useful sampling device – at once found objects and natural experiments capable of illuminat- ing fundamental patterns of social value and institutional practice. Epidemics constitute a transverse section through society, reflecting in that cross-sectional perspective a particular configuration of institutional forms and cultural assumptions. Just as a playwright chooses a theme and manages plot development, so a particular society constructs its characteristic response to an epidemic. (p. 2) This echoes Goffman’s (1959) language of dramaturgy but also resonates with situationist thought. Guy Debord (1967) described society as un spectacle, a pseudoworld of representa- tions that stand between individuals and the material realities of order: In both form and content the spectacle serves as a total justification of the conditions and goals of the existing system. The spectacle also represents the constant presence of this justification since it monopolizes the majority of the time spent outside the production process. (Debord, 2014, Thesis 6) EEP_29_HAME_C029_docbook_new_indd.indd 457 26-Jun-23 21:14:28  458 Handbook on the sociology of health and medicine It is the screen that stands between Oz and Dorothy, concealing the hollowness of the magi- cian’s claim to dominance. This screen is punctured only by occasional transformational events like epidemics. Strong’s approach, though, owed more to his fascination with the thought experiment proposed by the seventeenth-century political theorist, Thomas Hobbes, in Leviathan (first published 1651) about how order might be created in ways that would prevent selfish individualism from destroying the possibility of society (Murcott, 2006: 235– 248). The image (spectacle?) of Leviathan was critical to this, an all-powerful but benevolent form of autocratic government that would restrain the worst impulses of humanity. This model was, however, sustainable only so long as it could deliver the security and welfare that led humans to assent to its constraints. If government failed to protect its citizens, social order was vulnerable to implosion. Epidemics were moments when such failures might occur and social order become problematic. However, they were also moments of opportunity when different groups might compete to promote their visions of a ‘new normal’. THE SOCIETAL EPIDEMICS ‘Epidemic psychology’ has a double meaning. It refers both to the social psychology of epi- demics and to the epidemics of psychological phenomena that accompany mass infections. Like the disease itself, these phenomena spread from person to person, creating a major soci- etal impact. Strong identifies three societal epidemics that seem to accompany every infec- tious disease outbreak to a greater or lesser extent: the epidemics of fear, of explanation and moralisation and of action. Each of these will be examined in more detail but Strong prefaces them with some general observations. First, there is the way in which these societal epidemics may infect anyone – no person or group, including both biomedical and social scientists, is immune from the fear and everyone is capable of joining in with their views about the proper response: From a sociological point of view what is interesting about these epidemics of fear, explanation and action is that they have the potential capacity to infect almost everyone in the society. Just as almost everyone can potentially catch certain epidemic diseases, so almost everyone has the capacity to be frightened of such diseases – and, likewise, has the capacity to decide that something must be done and done urgently. (Strong, 1990: 251) Second, these phenomena are most likely to be acute when the disease is believed to be novel and not previously seen by humanity: Epidemic psychology may only rarely take the strongest of the forms sketched here but at the very beginning of a new epidemic when so much is unknown, there is always the prospect that it might. This inherent possibility is itself a powerful determinant of both the crisis and the subsequent response. Fear can feed on itself, just as governments must respond to what might happen as well as to what has already come to pass. (Strong, 1990: 251–252) Third, the return of a disease is likely to become normalised, with an established institutional response. Strong’s example is bubonic plague, comparing the chaotic societal responses to the Black Death with the Great Plague of London in 1665, where civic authorities could draw on EEP_29_HAME_C029_docbook_new_indd.indd 458 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 459 settled administrative protocols. In the same way, if Covid-19 had been a pandemic influenza virus, countries had established plans and the biomedical science community knew exactly how to make a vaccine. The initial level of fatalities might not have been much different: how- ever, there would have been a clear and certain endpoint with vaccine delivery in four to six months (Department of Health, 2011, para. 4.41). By contrast … new forms of fatal, epidemic disease can potentially be much more terrifying and may generate much more extreme reactions and diverse reactions. When routine social responses are unavailable, then a swarm of different theories and strategies may compete for attention. (Strong, 1990: 252–253) A known infection disrupts social order but is essentially a nuisance: an unknown infection is potentially an existential threat. THE EPIDEMIC OF FEAR The first, and most potent, societal epidemic is the epidemic of fear. This paralyses normal social practices and relationships: First note that the epidemic of fear is also an epidemic of suspicion. There is the fear that I might catch the disease and the suspicion that you may already have it and might pass it on to me. A second characteristic of novel, fatal epidemic disease seems to be a widespread fear that the disease may be transmitted through any number of different routes, through sneezing and breathing, through dirt and through doorknobs, through touching anything and anyone. The whole environment, human, animal and inanimate may be rendered potentially infectious. If we do not know what is happening, who knows where the disease might not spring from? A third striking feature, closely linked to the two above, is the way that fear and suspicion may be wholly separate from the reality of the disease. (Strong, 1990: 253) Covid-19 announced itself to the world for the first time in Wuhan in late December 2019. The city’s hospitals found themselves besieged by very sick people, suffering from a pneumonia that did not respond to existing treatments. This infection was not contained by existing pro- tections for hospital staff, many of whom also joined the sick and dying. Within the context of a centralised authoritarian state, public health responses were initially slow, while appropriate authorisation was obtained, and then drastic, as the entire city, and eventually the country, was ‘locked down’ (Shih, 2021). The history of this phrase is itself revealing – its original usage is to describe a situation where prisoners are sealed into their cells to contain disorder in a jail. Large sections of the Wuhan population were literally imprisoned in their homes by the state’s forces of order. In some ways, as Strong suggested, this is inevitable with a novel infection, where no one is sure how transmission occurs. The only strategy is to separate indi- viduals or communities while this is determined. When overlaid on existing social divisions, however, this easily spills over into more or less explicit forms of racism or other kinds of stigmatisation, which fail to recognise the social distribution of risk (Amnesty International, 2022). If people of South Asian heritage settled in the UK have high rates of infection associ- ated with living in multigenerational groups and overcrowded housing, this is less a reflection of culture or genetics than of the structures of employment and housing markets that impose vulnerability. EEP_29_HAME_C029_docbook_new_indd.indd 459 26-Jun-23 21:14:28  460 Handbook on the sociology of health and medicine The epidemic of fear means that society and social interaction are felt to be inherently risky. Every time you step outdoors, you are going into a place where a random stranger might infect you with a fatal disease. You do not know how to avoid or manage this risk. It is present in every human contact and, indeed, in every contact with the material world. The consequences, though, are to create the conditions that Hobbes proposed for his thought experiment, where every person is a threat to every other person: In such condition, there is no place for Industry; because the fruit thereof is uncertain: and conse- quently no Culture of the Earth; no Navigation, nor use of the commodities that may be imported by Sea; no commodious Building; no instruments of moving, and removing such things as require much force; no Knowledge of the face of the Earth; no account of Time; no Arts; no Letters; no Society; and which is worst of all, continuall feare, and danger of violent death. (Hobbes, 1909: 96–97) As Hobbes (1909: 97) saw, such a state of affairs is simply unsustainable for any length of time. Human life becomes ‘solitary, poore, nasty, brutish, and short’. Even in mid-seven- teenth-century England, people were highly interdependent for the basic conditions of exist- ence – work, food, transport, construction and learning – all of which were undermined by persistent fear and danger. Whether or not we accept Hobbes’s remedy for this condition, we can surely accept his recognition that constant fear undermines the functioning society upon which humans depend for their continued existence. Lockdowns and social distancing cannot ever be more than a temporary response to contain the immediate threat from a novel infection. They may, however, have the effect of decoupling the fear and suspicion from the reality of the disease. From quite an early point in the Covid-19 pandemic, for example, it was clear that large numbers of people were being infected without ever becoming seriously ill or, indeed, showing any symptoms. As early as 24 February 2020, a joint investigation by the WHO and the Chinese government reported that 80 percent of individuals had a mild to moderate infec- tion that did not require hospitalisation (World Health Organization, 2020). Nevertheless, the proportion of the UK population who responded to an online survey and reported being very scared or fairly scared of infection rose from 24 per cent at the end of February to 66 per cent by mid-April (Stewart, 2020). The presence of fear is entirely consistent with the epidemic psychology model. There are, however, three connected elements that are distinctive about the Covid-19 pandemic: the deliberate and calculated amplification of fear by state agents; the promotion of this fear, par- ticularly by broadcast media; and the infection of the scientific community itself, challenging its professed values of disinterest and objectivity. The Politics of Fear It is, of course, entirely rational to be anxious about a novel infection that appears to be rapidly fatal in a high proportion of cases. The situation in Wuhan during late December 2019 and January 2020 resembled the emergence of HIV/AIDS in San Francisco and New York in 1980. Fear themes were adopted by the UK government in its initial AIDS communications, like the notorious ‘Tombstone’ film of 1987 (AIDS:Monolith, 1987). The advertising agency involved proposed further use of fear-based messaging but was slapped down by the then EEP_29_HAME_C029_docbook_new_indd.indd 460 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 461 Chief Medical Officer (Burgess, 2017). He considered that emotional arousal was inappropri- ate for public health campaigns. The correct approach to AIDS was mainly educational and based on a trust in the public as citizens who had the capacity to understand sexual matters if given the information and the will to take actions to protect themselves. Perhaps this con- trasts with the distrust that underpins some current policy initiatives that envisage that we can only be unconsciously ‘nudged’ towards better outcomes. (Burgess, 2012) The reluctance to pursue fear-based messaging was supported by later systematic reviews of psychological research (Peters, Ruiter and Kok, 2013; Kok et al., 2018). There is a long history of discussion about who is really afraid in crises of this kind. Is it populations or elites? Reviewing the literature, Clarke and Chess (2008: 994) suggest that public panic is less common than elite panic: Planners and policy makers sometimes act as if the human response to threatening conditions is more dangerous than the threatening conditions themselves. Politically, the problem of panic endures because, as Tierney (2003, 2007) argues, it resonates with institutional interests. Operating on the assumption that people panic in disasters leads to a conclusion that disaster preparation means concentrating resources, keeping information close to the vest, and communicating with people in soothing ways, even if the truth is disquieting. As Tierney points out, such an approach advances the power of those at the top of organizations. The idea of elite panic has been applied to the French response of February/March 2020 (Bergeron et al., 2020). This analysis might be quite widely relevant, considering the range of control measures adopted in different countries, written into law and enforced by agents of the state. However, the Covid-19 pandemic saw the novel feature of seeking to promote com- pliance not by soothing or informing people but by amplifying fear and anxiety. In the UK, for example, the academic psychologists and behavioural scientists advising the government concluded in a briefing paper of 22 March 2020 that: A substantial number of people still do not feel sufficiently personally threatened; it could be that they are reassured by the low death rate in their demographic group … The perceived level of per- sonal threat needs to be increased among those who are complacent, using hard-hitting emotional messaging. To be effective this must also empower people by making clear the actions they can take to reduce the threat. (original emphasis) While the review by Peters, Ruiter and Kok (2013) is cited, its caution about fear-based mes- saging seems to have been overlooked: When restricted to mass media, it will probably be wisest to resort to a behaviour change method that does not involve emphasising negative consequences of a behaviour, and if that cannot be avoided, at least make sure the communication is not threatening, emotional or confronting. (Peters et al., 2013: S26) Some members of this advisory group have since complained about this representation of their position, noting that other briefing papers were more sceptical (John et al., 2022). Attention has, then, switched to the influence of the Behavioural Insights Team (BIT) (https://www​.bi​ EEP_29_HAME_C029_docbook_new_indd.indd 461 26-Jun-23 21:14:28  462 Handbook on the sociology of health and medicine.team/) and its use of ‘nudge’ theory (Thaler and Sunstein, 2021; Dodsworth, 2021). Nudging, employing psychological techniques rather than explicit rules to promote desired behaviour, has been fashionable within UK governments since the early 2000s. BIT was created as an in-house consultancy in 2010, before being spun out as a private company in 2014, offering its services to governments and corporations around the world. One of its founders has expressed his concern about the results of its work on the pandemic: In my mind, the most egregious and far-reaching mistake … has been the level of fear willingly conveyed on the public. Initially encouraged to boost public compliance, that fear seems to have subsequently driven policy decisions in a worrying feedback loop. (Ruda, 2022) There is, he suggests, a need to reflect on where we need to draw the line between the choice maximising nudges of libertarian paternalism, and the creeping acceptance among policy makers that the state should use its heft to influence our lives without the accountability of legislative and parliamentary scrutiny. Nudging made subtle state influence palatable, but mixed with a state of emergency, have we inadvertently sanctioned state propaganda? (Ruda, 2022) These are issues that might well have concerned sociologists more than they did at the time. Their discipline remained generally silent in the face of expansions of state biopower that they would normally have been quick to criticise. Broadcast Media and the Amplification of Fear If the promotion of fear was an objective of public policy, its amplification owed much to pro- cesses within mass media documented by David Altheide (2002). Although Altheide focussed on crime and terrorism, Covid-19 coverage has many similar features. Contemporary news values emphasise dramatic narrative and emotionally engaging stories. The drumbeat of death brings audiences and revives revenues that have been flagging in the face of competition from social media. The first images, from Wuhan in January 2020, were supplied either by the media of an authoritarian state or by its underground opponents, with little consideration of the biases that might have shaped these – whether dramatising the imposition of order on chaos or magnifying the chaos to criticise the state. The narrative then moved to hospitals in developed countries with emotive film of medical emergencies and intrepid reporters don- ning high-level PPE to creep into intensive care units and describe events in hushed tones. Human interest stories of the infection’s victims filled screens night after night. For at least two months in 2020 almost everything else was crowded off the TV news agenda. The same focus was apparent in print media, where it was not uncommon for more than half of the con- tent of a newspaper issue to be devoted to stories about the pandemic. Accounts of recovery were rare, as was any suggestion that the typical illness experience was of a relatively mild and rapidly passing set of symptoms. As Altheide notes, the obverse of the narrative of fear is a narrative of control, the promo- tion of ever more extreme measures. The fear feeds on itself, as Strong (1990: 252) observed and Ruda (2022) acknowledges. Whenever the state acted, as with school closures or man- dates for mask-wearing, news bulletins featured stories from other countries that had acted EEP_29_HAME_C029_docbook_new_indd.indd 462 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 463 more rapidly and more broadly. When the UK government conceded that secondary school- children might be required to wear face coverings in communal spaces at the end of August 2020, for example, BBC bulletins promptly ran a story about how other countries had gone further, requiring face covering in classrooms, in primary schools or even for newborns in maternity hospitals. UK print and online media were more diverse but divided in less predict- able ways. Newspapers that would traditionally have supported a right-leaning government became increasingly concerned about the authoritarian implications of the pandemic response and critical of the official scientific advice. Newspapers that would have been hostile to the government abandoned traditional left concerns for civil rights and joined opposition parties in demanding more, and more rigorous, controls. They promoted a narrative that the UK gov- ernment response had been uniquely chaotic, resulting in high mortality rates: in practice, the response was not radically different from many other countries, whose citizens made similar complaints (Bergeron et al., 2020; Greer et al., 2021). Both the death rate per million (Stewart, 2022) and the rate of deaths in excess of normal times placed the UK around mid-table in Europe, alongside comparable countries like France and Germany (Wang et al., 2022; World Health Organization, 2022). The pandemic also revealed the virtues and vices of online media for communications outside the dominant narratives, whether of reassurance, scepticism or panic. Fear and the Scientists The third major difference between Covid-19 and previous pandemics is the extent to which the scientific response has itself been infected by, and reflexively helped to propagate, fear. Scientists, whether biomedical, natural or social, were not exempt from the epidemic’s capac- ity to frighten everyone and authorise them to declare that something must be done, regardless of their expertise in knowing what might be effective (Strong, 1990: 251). Covid-19 is not, of course, the first pandemic of a novel virus to occur in an age of large- scale biomedical science. The 1918 influenza pandemic was seized upon in the US as a show- case for the scientific approach to medicine originating in Germany and promoted through the Johns Hopkins medical school (Barry, 2009). Viruses had not, though, yet been distinguished as a class of infective agents and scientific methods achieved little. Influenza was one of the earliest viruses to be identified, in 1933 (Bresalier, 2008, 2012), so that its seasonal return, and the pandemics of 1957, 1968 and 2009, became routinised (Strong, 1990: 253) and ‘nor- mal science’ (Kuhn, 1962). While the technology of investigation had moved on, this virus was no longer a novel object for scientists. AIDS, however, was different. Like SARS-Cov and SARS-Cov-19, HIV had not been seen before. Newly emerging infectious agents could frighten biomedical scientists in the same way as the general population: Such panic and irrationality can extend even to those who are nominally best informed about the dis- ease. Experienced doctors could still turn hot and cold when they saw their first AIDS patient, or be unable to extend the normal social courtesies to AIDS campaigners. Experienced natural scientists could find themselves unable to treat HIV like any other virus. (Strong and Berridge, 1990) In practice, this fear seems to have been more of an issue for AIDS clinicians than biomed- ical researchers, and to have resolved fairly quickly as the mode of transmission became understood. EEP_29_HAME_C029_docbook_new_indd.indd 463 26-Jun-23 21:14:28  464 Handbook on the sociology of health and medicine This might be because HIV scientists did not see themselves as personally threatened by the infection. AIDS rapidly became identified as a disease of the socially marginal – gay men, sex workers, drug users, immigrants, homeless persons – the categories often overlapped but did not generally extend to straight, white, middle-class men in white coats in laboratories. As a virus carried in blood and other body fluids, it was also hard to acquire just from being in the wrong place at the wrong time. Scientists thought they knew how to manage this risk. If, as seemed likely, Covid-19 was an airborne virus, it was a random threat. Scientists were not immune from exposure to the risk in their everyday life. Society penetrated science in ways that may be familiar to sociologists but are rarely acknowledged by scientists themselves. Fear has, then, been a consistent, pervasive and amplified consort of the Covid-19 pan- demic. At the time of writing in spring 2022, it remained a profound obstacle to moving on from the constraints understandably imposed by governments in the uncertain days of February and March 2020. By late summer 2020, this was being acknowledged in newspaper columns by government advisers: Britain urgently needs to shift its mindset from a terror of the Covid-19 virus to focus on the damage already done to our economy – and the worse that is yet to come … We have to remove or reduce fear of the virus so we can focus on the other essential parts of our recovery from the pandemic. Sir John Bell, Regius Chair of Medicine, University of Oxford. (Bell, 2020) Nevertheless, a YouGov poll immediately after the UK Prime Minister’s announcement, on 9 February 2022, of the early elimination of all Covid-19 related legal restrictions found 48 per cent of respondents still wanting permanent requirements for self-isolation imposed on those testing positive for the virus (YouGov, 2022). Although the UK government was ready to move on, the legacy of fear remained potent. This is clearly an issue in many other developed countries, particularly the United States, where it appears to be overlaid on other political cleavages. THE EPIDEMIC OF EXPLANATION AND MORALISATION One striking feature of the early days of such epidemics seems to be an exceptionally volatile intel- lectual state … When an epidemic is novel, a hundred different theories may be produced about the origins of the disease and its potential effects. Many of these are deeply moral in nature. All major epidemics pose fundamental metaphysical questions: how could God – or the government – have allowed it? Who is to blame? What does the impact of the epidemic reveal about our society? The Black Death was a challenge to orthodox Christianity, just as AIDS challenged, at least for a time, the power of biomedical science. (Strong, 1990: 254) Unlike AIDS, Covid-19 has generated a relatively modest amount of explicitly religious explanation. It does not offer conservative faith communities the same obvious moral targets. Covid-19 is just another element in a wider litany of Divine retribution on a sinful society rather than a specific punishment for wrongdoers. Within the US, however, there has been extensive litigation over the jurisdictional boundary between the state, at whatever level, and faith groups exercising their constitutionally guaranteed freedom of religious practice. This joins a wider conflict between state intervention and the libertarian thinking that has become EEP_29_HAME_C029_docbook_new_indd.indd 464 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 465 increasingly influential in many societies since the 1970s. To what extent, and under what cir- cumstances, can citizens legitimately be compelled to follow state regulations in a collective interest? Contesting a state ban on religious assembly is a prime example but there are others. Two that seem to have been particularly important are QAnon and 5G conspiracy theorists, which are associated with both far-right and anarchist groups (Bodner et al., 2021). QAnon has some links to US evangelicals but is a wider-ranging social movement, stimulated by a variety of online and social media communications to its followers (Collins, 2020; Doward, 2020) It argues that the ills of the world are attributable to the operations of a deep state, often recycling older, antisemitic, conspiracy theories. 5G conspiracies have a more conventional anti-capitalist, pro-environment analysis of the damage being done to human immune sys- tems by electromagnetic radiation (Ahmed et al., 2020). They tend to be linked with anti-vaxx and alternative health movements. Such theories and activism shade into generalised currents of populist libertarianism, which are more evident in the US than in Europe. State intervention in what are perceived to be the private choices of citizens has always been contested in the US, at least where those citizens are white and male. This has played out in conflicts about Covid management between health officials, elected representatives of communities, and local judges over the relative priority of collective social interventions proposed by public health departments and political and legal concerns for the liberty of citizens, just as in the 1918 influenza pandemic (Crosby, 2003; Barry, 2009). A newer element is the idea of the pandemic as a ‘Sin against Gaia’. This was present in the societal response to AIDS, especially as it became clear that HIV was related to African simian viruses and may have crossed into human populations through the butchering of mon- keys for bushmeat. The Ebola and Zika epidemics furthered a narrative about the emergence of novel viruses being a consequence of human pressures on ‘wild’ habitats. A mainstream ‘One Health’ movement (http://www​.onehealthglobal​.net/) seeks to unite human, animal and environmental sciences in a single enterprise. However, this has an uncertain boundary with a Deep Green view that these infections are the planet’s revenge on humanity’s hubris in imag- ining that nature can be bent to the will and purposes of a single species. The One Health platform commits itself to the ‘prevention of risks’ and the ‘mitigation of crises’, yet these reflect a prior moral position rather than the simple amoral observation of evolution at work – as it has been forever. Bacteria, viruses and parasites have always been exchanged between humans and other species (Toups et al., 2011; Spyrou et al., 2022). The incursion of ‘novel viruses’ is not a new phenomenon, but the return of a very old one in a soci- etal context that can observe it in minute detail without knowing how to live with it. Calls for ‘Zero-Covid’, the eradication of the infection by the minute regulation of everyday life to pre- vent viral transmission, rest on a profound misunderstanding of evolution and history. A virus- free world is a true ‘mirage of health’ (Dubos, 1987). It is, however, a radical expression of the moral dimension of the technoscientific rationality that has become dominant in contem- porary societies (Habermas, 1971). While this may be the main source to which governments turn to analyse, advise and supply legitimations for their interventions, ‘following the science’ is a normative commitment as much as a technical one. Biological scientists study interac- tions between organisms. These are described in the neutral language of ‘symbiosis’. The biomedical language of ‘infections’ and ‘diseases’ incorporates a value judgement that certain biological states of human organisms should be prevented, corrected, managed or regulated (Dingwall, 1977). It also asserts ownership of the goal, of remedying nature’s failings rather EEP_29_HAME_C029_docbook_new_indd.indd 465 26-Jun-23 21:14:28  466 Handbook on the sociology of health and medicine than simply observing nature’s workings. Biomedicine will, given enough time and money, subject nature to human control and eliminate imperfections like disease and death. Such a project attracts private individuals, who are either personally rich or live in rich societies and would like to use that wealth to purchase immortality, at least for themselves. Their influence easily skews the priorities of research and practice at both national and international levels. THE EPIDEMIC OF ACTION The furore and hubbub of intellectual and moral controversy may, in turn, be dramatically increased by the huge rash of control measures now proposed to contain the disease. Many suggestions for limiting the contagion may cut across and threaten our conventional codes and practice. Trade and travel may be disrupted, personal privacy and liberty may be seriously invaded, health education may be enforced on matters that are normally never talked about … because of the disruption and disorientation that such epidemics produce they are also fruitful grounds not just for moral debate and moral challenge but for all kinds of ‘moral entrepreneur’ (Becker 1963). For anyone who already has a mission to change the world – or some part of it – an epidemic is a new opportunity for change and conversion. (Strong, 1990: 254–255) In this passage, Strong points to the competition to define appropriate interventions in response to epidemics. There are many ways to respond to the demand that ‘something must be done’ and the pressure on governments to act. Whose voice gets heard, what knowledge is legiti- mated, and how does this translate into political action? If governments are ‘following the science’, which science is chosen? In the UK, for example, as Jones and Wilsdon (2018: 5) have noted, the ‘biomedical bubble’ currently dominates science policy: research in the biomedical sciences has been a great British success story. It has produced a remark- able body of knowledge with direct impact on people’s lives, through new medicines and improved health outcomes. It has underpinned the pharmaceutical industry, the UK’s leading knowledge- intensive sector. And it enjoys widespread public support, with around 11 million people donating to medical charities each month … This emphasis on the biomedical components of the wider health and research system is not well supported by evidence of impact or value for money, but reflects the power and influence of the biomedical community in shaping research priorities and the allocation of resources. Since 2013, this network has supplied successive Chief Scientific Advisers to the UK govern- ment. It is not, then, surprising that, faced with a novel infection, the government would turn to the biomedical sciences, and its health department, as the dominant voices in developing a response. This was reflected in the invitations to serve on the Scientific Advisory Group for Emergencies (SAGE), the ad hoc group convened to advise the UK government on civil emer- gencies such as the Covid-19 pandemic. SAGE’s rapid mobilisation, led by a biomedical Chief Scientific Adviser, contributed to defining the pandemic as a biomedical rather than a civil society problem. A penumbra of sub-groups was created, on modelling; behavioural (but not social) science; immunity and infection control; and environmental management, together with some shorter task and finish groups. As Jones and Wilsdon observed (2018: 6), the result was: ‘a social, political and epistemic bubble … in which supporters of biomedical science EEP_29_HAME_C029_docbook_new_indd.indd 466 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 467 create reinforcing networks, feedback loops and commitments’. Membership was based on a few elite institutions and people already connected to that network. It made visible an ‘invis- ible college’ (Crane, 1972), albeit one with media and political connections rooted in the same institutions, sometimes going back to undergraduate friendships. The social and epistemic closure of this network provoked the establishment of others, most notably the self-styled Independent SAGE (iSAGE), led by an environmental scientist who had been Chief Scientific Adviser from 2000–2007 (Clarke, 2021). Although this began with com- mitments to diversity and transparency, it rapidly established its own closure around an alter- native political agenda promoted by a shadowy group known as The Citizens (Clarke, 2021). iSAGE became identified with calls for additional restrictions and controls on the population in pursuit of eradication (Zero-Covid), elimination or maximum suppression of the virus. It seems that elite panic is not a purely conservative phenomenon, nor are social scientists exempt from it. The iSAGE approach influenced both the Welsh and Scottish governments, where it amplified nationalist agendas painting the UK government’s policies for England as less protective of their citizens’ security and welfare. Other, loosely linked, groups were established around agendas that stressed personal judgement rather than state regulation as the basis of risk management. Pandemic science became a collection of ‘invisible colleges’, competing to define what counted as legitimate knowledge and moral purpose, building their own alliances with media and political interests and ready to label each other as ‘government stooges’, ‘anti-vaxxers’ or ‘conspiracy theorists’ in the search for competitive advantage for their own visions of the ‘new normal’. Despite their other differences, and occasional mutual abuse, these groups shared a basic acceptance of the epistemic superiority of biomedical science. As Strong (1984) noted, bio- medicine depends at least as much on PhD scientists as on clinician researchers. He described this as encirclement, where researchers with other backgrounds, including medical sociolo- gists, were drawn like moths to medical research funding. Under normal conditions, this con- strained the ability of the medical profession to pursue the agenda of medicalisation, at least in its simplest versions. The Covid pandemic showed that there was a price to this. Rather than a whole of science approach to a whole of society challenge, this was filtered through previous engagements and loyalty tests. The SAGE network was dominated by people who had already been drawn into the cir- cle and embraced by its boundary work (Gieryn, 1983). Modelling was carried out by spe- cialists in mathematical epidemiology with little reference to the experience of modelling in sociology, geography or economics (Rhodes, Lancaster and Rosengarten, 2020; Rhodes and Lancaster, 2021, 2022). The airborne transmission of Covid was initially approached through systematic reviews of biomedical journal databases, excluding material published in engineer- ing and physics journals. This was partially remedied by the subsequent enrolment of engi- neers with expertise on airflow in hospitals, rather than in, say, supermarkets. Psychological input was dominated by health behaviour researchers, excluding expertise on, for example, the social, linguistic or emotional development of children. While bioethics might have seemed a candidate for inclusion, it was marginalised by the focus on science rather than society (Pyckett et al., 2023). Similarly, although health and safety specialists were included, the professionally led movement to improve outcomes through collaborative design of systems of working rather than narrow regulation (Dingwall and Frost, 2017) had no impact. Other sources of knowledge, particularly from the social sciences and humanities (Pickersgill and Smith, 2021; Pickersgill, Manda-Taylor and Niño-Machado, 2022) that had not previously EEP_29_HAME_C029_docbook_new_indd.indd 467 26-Jun-23 21:14:28  468 Handbook on the sociology of health and medicine entered the magic circle were simply ignored. Proxemics, the social science of social distanc- ing (Baldassare and Feller, 1975; Hayduk, 1983), has never found biomedical applications but is an active research area in transport studies, designing tolerable passenger spaces, and in human/robot collaboration, programming manufacturing robots not to threaten humans. The socio-legal literature on rules and compliance was similarly excluded: technocratic rationality assumed that rules were self-interpreting, and compliance easily accomplished by policing and sanctions (Meers, Halliday and Tomlinson, 2021). The reservations of computer scien- tists about the operability, confidentiality and privacy of vaccine passports and other medi- cal apps received little attention (Checkpoints for vaccine passports, 2021). Historians might have contributed to a more proportionate response to a pandemic that was not particularly severe in comparison with previous experiences (Honigsbaum, 2019). Social science research on disaster management and recovery (Easthope, 2018, 2022) was overlooked, although this found an alternative entry point to government through the emergency planning team in the Cabinet Office. Other countries made other choices and created different networks. The important point is that these were choices. The UK government, for example, chose to discard the work that had been done on pandemic planning in the early 2000s, which envisaged a cross-departmental approach to a pandemic as a whole of society problem, led by the civil emergencies team in the Cabinet Office (Department of Health, 2011). Something very similar happened in France, which saw a struggle for leadership between the Health Department and the President’s office throughout the spring of 2020 (Bergeron et al., 2020). Sweden, on the other hand, adopted a much more traditional public health approach (Anderberg, 2022). This involved fewer and lighter restrictions on public activities, including an absence of mask mandates. It has attracted much international criticism but does not seem to have produced a worse mortality outcome with less damage to the economy or civil society. If the dominance of biomedicine was a matter of choice, then sociologists can ask how and why that choice was made (Fassin and Fourcade, 2021). THE ROAD TO IATROCRACY? Medical sociology has long struggled with an identity crisis. Is it a sociology in medicine or a sociology of medicine (Straus, 1957)? Is it part of the academic encirclement, aiming to help biomedicine become a more effective, efficient, equitable or humane enterprise? Or does it stand at a distance, as Parsons proposed when he analysed the sick role as the strategy of a major societal institution that contributed to the production of order by managing part of the boundary between the ‘deviant’ and the ‘normal’ (Parsons, 1951)? This is not a simple mat- ter of political stance: many self-styled ‘progressive’ sociologists accept the injunctions of biomedicine and seek to distribute its claimed benefits more equally or to promote more civil interactions between health professionals and patients. ‘Conservative’ sociologists are equally concerned about the accretion of unaccountable power to biomedicine: where law depends on the public actions of legislatures and judiciaries, biomedicine is answerable only to itself and its private systems of review and reward. The Covid pandemic has exposed precisely this crisis of identity. Is it the role of medical sociologists to promote adherence to the well-intended pronouncements of biomedical experts and reinforce the imposition of their preferred order? Are they allies in the social control EEP_29_HAME_C029_docbook_new_indd.indd 468 26-Jun-23 21:14:28  The sociology of epidemics and pandemics 469 described by Parsons? Or is their duty to hold that expertise to account, to interrogate its conclusions in the light of previously accepted public standards of evidence and to explore the consequences of defining order purely in the biomedical terms of the avoidance of death? Epidemics and pandemics create what Agamben (1998, 2005, 2021), following Schmitt’s (2005) analysis of the liberal order, first published in 1922, has described as ‘states of excep- tion’. These are moments when politics transcends law and sovereignty may be exercised without restraint. They are the dark side of Hobbes’s Leviathan, a state that is not necessarily concerned for the welfare and security of citizens but with the protection of itself. Biomedicine, Agamben argues, has divided human experience into two: bare life, pure biological survival; and the life of society and culture. The project of social distancing isolates people, restrict- ing them to bare life, in the interests of a biosecurity state that preserves its model of order at the expense of their humanity. As Ivan Illich (1975) pointed out, where biomedicine remains silent on the inevitability of death, or markets immortality as the legitimation of its power and influence, human societies lose their capacity to embrace the transience of individual existence. Agamben (2021: 40) quotes the seventeenth-century French philosopher, Michel de Montaigne, writing in a tradition that goes back to the Greek Stoics: It is not certain where Death awaits us, so let us await it everywhere. To think of death beforehand is to think of our liberty. Whoever learns how to die has learned how not to be a slave. Knowing how to die frees us from all subjection and constraint. If death is the fate of all humans, then we should be concerned with the richness of an exist- ence that is more than Agamben’s bare life, the mere avoidance of death. Epidemic times, however, create the permanent risk of sliding into what Lévy (2020), cit- ing Plato (1995), called an ‘iatrocracy’, a society ruled by doctors in the interests of health alone. Such a society would be ‘an incestuous union of the political and medical powers’ (Lévy, 2020: 16). In Agamben’s (2021: 52) formulation, the right to health turns into a duty to be healthy – at the expense of ‘freedom of movement, of work, friendships, love and social relationships, and of their own religious and political beliefs’. Everything must be sacrificed for the preservation of the health system. ‘Following the science’ abdicates the proper role of the politician to place the pursuit of health within a wider context of possibly desirable human ends. The Ancient Greek philoso- pher, Plato (1993, 1995), discusses the relation between medicine and politics. Medicine is at once the servant of the state and the source of laws to be obeyed without question, as beneficial both to citizens as individuals and to the state as a collective. Plato hesitates, though, when it comes to the idea of physicians as rulers. We may think they have our best interests at heart but they know us only in the aggregate. The art of the politician is more like that of weaving, where different strands of experience and expertise are brought together as a basis for a good society, without any one necessarily dominating. Plato’s politicians do not follow the science but hold it in balance, resisting the inherent imperialism of medicine. The state of exception, though, allows for this balance to be disrupted, for biomedicine to play upon the fear of death to strengthen the grasp of the medical-industrial complex on economy and culture. It is understandable that medical sociologists have been seduced by the attractions of join- ing the ring of commensals that dine from the crumbs of the biomedical table. Sociologists have their own material interests. But it is perhaps time to revive a sociology of medicine that is not co-opted to biomedical agendas but focussed on analysing biomedicine’s place in the fundamental ordering of modern societies, not as an ideological project but as a deep EEP_29_HAME_C029_docbook_new_indd.indd 469 26-Jun-23 21:14:28  470 Handbook on the sociology of health and medicine investigation of the impoverishment of modern, and postmodern, understandings of pain, suf- fering and death revealed by the Covid pandemic. REFERENCES Agamben, G. (2021). Where are we now? The epidemic as politics. Translated by V. Dani. London: Eris. Ahmed, W., Downing, J., Tuters, M. and Knight, P. (2020). Four experts investigate how the 5G coronavirus conspiracy theory began. The Conversation, 11 June. 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