COVID-19 and The Lessons Anthropology Learned from HIV/AIDS

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On April 24, 1980, Ken Horne, a San Francisco resident, was reported to the Center for Disease Control (CDC) as a young man suffering with an old man’s disease, Kaposi’s sarcoma. Subsequently, in 1981, the CDC identified Horne as the first patient in the US of what would (in 1982) come to be called AIDS. By June 5, 1981, a cluster of cases of AIDS were reported in the CDC’s Morbidity and Mortality Weekly Report. One of the first reported patients in the US believed to have died of AIDS was recorded in the journal Gastroenterology. HIV/AIDS, a disease that by 2018 would globally infect an estimated 75 million people and contribute to 32 million deaths, had begun to emerge from the shadows as a major threat to human life around the world. Today, the total HIV/AIDS death toll is equivalent to three World Trade Center attacks every day.

Despite its growing impact during the 1980s, Gilbert Herdt would observe in 1987 in Anthropology Today: “Thus far anthropology has had minimal involvement in AIDS prevention and understanding.” Herdt suggested two reasons for our discipline’s laggardly response to the HIV/AIDS pandemic. First, at the time mainstream anthropology had still not overcome its resistance to applied work, despite the long history of anthropological application. Second, fear of stigmatization by becoming associated with a disease found so commonly among gay/bisexual men. I would add a third reason: a lack of funding. At the time, there was one anthropological book on AIDS, a volume edited by Douglas Feldman and Thomas Johnston called The Social Dimensions of AIDS. Ultimately anthropologists would heed Herdt’s urging to address the pandemic, with hundreds of journal articles and dozens of books on the topic, as well as numerous conference presentations, task force committees, and commissions, but our discipline’s slow response to AIDS has probably played a role in our more aggressive response to subsequent pandemics, including COVID-19.

My own work on AIDS began in the mid-1990s, at a community-based center in Hartford, CT, when federal funding finally became available for such work. Prior to this, efforts by our applied research team to secure financial support from the CDC were unsuccessful. Eventually, however, our team and others were funded by several federal, state, and foundation sources to carry out multiple anthropologically informed studies of diverse aspects of the HIV/AIDS pandemic, especially the interplay of biology and social factors in the making of the pandemic. They also became quite involved as facilitators of behavioral change to prevent the spread of the disease. An important component of my own work for many years was on preventing AIDS among illicit injection drug users and their sexual partners using a harm reduction approach (a risk reduction methodology now being suggested as an approach to COVID-19). Other anthropologists have worked on assisting people living with HIV/AIDS (PLWHA) to access treatment, on improving the life quality of PLWHA, and on combating AIDS stigma.

As Brooke Schoepf points out in an assessment published in Annual Review of Anthropology, a lesson for the discipline among anthropologists working on and in AIDS is that “Disease epidemics are social processes: Spread of infectious agents is shaped by political economy, social relations, and culture.”

While HIV/AIDS still contributes significantly to the global burden of disease (there were about 1.7 million new HIV infections in 2018), the development of treatments has turned it from an aggressive acute disease into a chronic disease for those who can access available therapies. However, since the rise of the HIV/AIDS pandemic, a series of other rapidly spreading infectious diseases have gained pandemic status.

In 2002, a new zoonotic coronavirus spread from China to over two dozen other countries across four continents, causing a disease called Severe Acute Respiratory Syndrome (SARS). The new virus infected more than eight thousand people and killed almost eight hundred people, mostly in China and Hong Kong, before the pandemic was quelled in mid-2003.

H1N1 (so called swine flu because of similarity to an influenza virus strain that circulates in pigs) began causing human infections in 2009. The WHO declared it a Public Health Emergency of International Concern in April 2009, followed in June by its redesignation as a pandemic. By then, the virus had spread to more than seventy countries. The CDC estimates that between 150,000 and 575,000 people died of the disease worldwide during the pandemic, but unlike COVID-19, 80 percent of those who died of H1N1 were younger than sixty-five of age. The WHO proclaimed the pandemic ended in August 2010, although the H1N1 virus continues to circulate seasonally.

A new coronavirus, named Middle East Respiratory Syndrome (MERS) was identified in Saudi Arabia in 2012. The largest outbreak occurred on the Arabian Peninsula in the first half of 2014. The epicenter of the outbreak was the city of Jeddah, Saudi Arabia’s commercial center with a population of over four million people. By 2015, South Korea had become the center of the second-largest outbreak of MERS and more than two dozen other countries (including China, the US, Germany, and Malaysia) reported cases over the following years. The virus, which causes pneumonia, has a comparatively high fatality rate. Of the approximately 2,500 people diagnosed with MERS since its discovery, over 850 have died from the disease.

As cases of MERS were reaching their peak, the Ebola virus was detected first in Guinea and not long afterward in Liberia and Sierra Leone. Ebola was not a new disease — outbreaks had been occurring since 1976 when two consecutive outbreaks hit Central Africa, beginning in a village in the Democratic Republic of Congo near the Ebola River. The new outbreak in 2014 was the first time the deadly disease struck a densely populated urban area, an environment that allowed rapid transmission. Other facilitators were the clinical reuse of syringes and a war-weakened and unprepared healthcare system. Ultimately, the outbreak spread to seven other countries, including several European nations and the United States. Over eleven thousand died of Ebola during the period between 2014-2016. The majority of transmissions (75%) were between family members including during mourning and burial rituals.

The first known human outbreak of the Zika virus (ZIKV), which is transmitted by Aedes aegypti and Aedes albopictus mosquitoes, occurred in Uganda and Tanzania in 1952. In February 2016, the WHO declared a major Zika outbreak had begun, and by the middle of the year more than sixty countries, including 20 countries and territories in the Americas, had reported they had cases of the disease. Many people who were infected suffered no symptoms, but in some cases, Zika can trigger paralysis (known as Guillain-Barré Syndrome). Most notable during the new outbreak thousands of women infected with the virus while pregnant gave birth to babies with microcephaly, a condition in which the child’s head is smaller than normal, as well as other neurological conditions. The pandemic passed quickly and WHO announced it had ended in November 2016.

Anthropologists in recent years also have worked on dengue epidemics, outbreaks of cholera, and the continued spread of polio, as they have come to recognize the fundamental importance of infectious diseases among vulnerable populations.

Unlike AIDS, the anthropological response to these later epidemics and pandemics was often swift, with anthropologists seeking to bring insights from our discipline to increase understanding and contribute to prevention efforts. My own work, following years of studying HIV prevention, included examination of the popular reaction to Ebola and local behavioral responses in Cameroon, discussion of the syndemic aspects of H1N1, SARS, and Zika, and explication of the significant role of health inequalities during the H1N1 pandemic. Newly gained focus on communicable disease and pandemics motivated the writing of my book, The Anthropology of Infectious Disease.

Numerous other anthropologists also became involved in pandemic issues in the shadow of HIV/AIDS. Katherine Mason, for example, was teaching English in China when the SARS outbreak began. This experience led to her book, Infectious Change: Reinventing Chinese Public Health After an Epidemic, an analysis of how in the aftermath of SARS, the public health system in China was reinvented into a prestigious profession in which gaining global recognition and acclaim took precedent over focusing on the needs of vulnerable local communities in an era of emergent infectious diseases.

In Avian Reservoirs: Virus Hunters and Birdwatchers in Chinese Sentinel Posts, Frédéric Keck shows how the SARS pandemic shaped concern with zoonotic disease in Hong Kong, Singapore, and Taiwan. Employing anthropological theory and ethnographic fieldwork, Keck, a Senior Researcher at the Centre National de la Recherche Scientifique in Paris and director of its Laboratory for Social Anthropology, examined how the particular strategies adopted by these countries to address the threat of pandemics reflect varying local geopolitical relations with mainland China. Keck and colleagues also authored “Middle East respiratory syndrome coronavirus and human-camel relationships in Qatar,” published in Medicine Anthropology Theory, among other relevant books and papers.

In the case Ebola, under the auspices of the U.N., anthropologists began working on the disease in Uganda in 2000-2001 as seen in the work of Barry and Bonnie Hewlett, authors of Ebola, Culture and Politics: The Anthropology of an Emerging Disease. The role of anthropologists in responding to the disease began by implementing a series of rapid qualitative investigations of sociocultural factors that both facilitate transmission of the spread of disease and hamper emergency response efforts. At the outset of the 2014-2016 Ebola outbreak, anthropologists began advocating for supplying needed resources to West African populations. They also became actively engaged as expert-advisors to national response coordinators and global actors like the WHO. They also delivered trainings on Ebola and carried out a number of research projects. These efforts, reflecting lessons learned from the HIV/AIDS pandemic, underlined the importance of local knowledge and perceptions in responding to Ebola, identified some of the limitations of conventional public health measures and humanitarian medical responses, and countered the tendency to blame culture as the predominant driver of the pandemic. Moreover, as Sharon Abramowitz indicates in her examination of the anthropological response to epidemics in the Annual Review of Anthropology, “Anthropologists demanded that West Africans living in Ebola-affected countries be treated with basic human decency, dignity, and respect.” Within the discipline, anthropologists developed Ebola information sharing networks such as the Ebola Response Anthropology Platform and the American Anthropological Association’s Emergency Ebola Anthropology Initiative. While anthropology’s response to Ebola was not without debate and controversy (e.g., over whose voices in the pandemic were elevated or silenced through anthropological work), unlike the discipline’s initial sluggish response to HIV/AIDS it was swift and aggressive.

Similarly, anthropologists, taking full advantage of the capacities of the internet during a time of quarantine, have moved quickly to begin analyses and commentary on various aspects of the COVID-19 pandemic. Several online platforms have been set up for anthropologists to share ideas, analytical frameworks, and disciplinary perspectives, such as Pandemic Insights, a website column in the American Anthropology Association’s Anthropology News and Somatosphere’s COVID-19 Forum. Anthropological webinars have been quickly arranged to discuss ongoing global responses and impacts of COVID-19 by the American Anthropology Association and the New York Academy of Sciences. The faculties of some anthropology departments, like Duke’s Department of Cultural Anthropology, have posted thought pieces that offer insights on COVID-19. Another example is the University College London’s Medical Anthropology digital blog. “Medical anthropology weekly: COVID-19,” sponsored by the Society for Medical Anthropology, Medical Anthropology Quarterly, and Somatosphere, is a weekly compilation of the growing body of COVID-19-related materials. Academic anthropological publications on COVID-19 began to appear within months of the first announced cases. Additionally, the Anthropological Responses to Health Emergencies SIG of the Society of Medical Anthropology has issued a Call-to-Action for the critical medical anthropology of COVID-19 that identifies core issues for engaged anthropological research. At the same time, the Wenner-Gren Foundation established a Global Initiatives Program to support collaborative, capacity-building projects of benefit to the discipline and encourages applicants to consider a topic connected to the COVID-19’s impact on anthropology.

As Jonah Lipton, an anthropologist and postdoctoral researcher at the Firoz Lalji Centre for Africa comments, “I hope that in responding to coronavirus…[we] can learn something from those who have been through this before.” Thus far, it looks like we have.

Merrill Singer is an Emeritus Professor of Anthropology at the University of Connecticut. His research and publications focus on health and social inequality, environmental health, critical medical anthropology, infectious disease, illicit drug use, and syndemics, a concept he introduced to health research.