Bright interludes in dark times: On disciplinarity in the Covid response

A number of years ago, I was involved in the process to reshape a medical school. It involved three groups – one biochemical, one biophysical and one social/behavioural – pitching to a panel of eminent Deans of Medicine as to why their research should have a place in the new set-up. What struck me at the time was the look of sheer boredom and indeed irritation from the panel when, from a social/behavioural perspective, we pointed out that structural changes (such as a sewage system) and behavioural changes (such as stopping smoking) had as great an impact on human health than all the medical procedures and pharmaceutical developments ever made. By contrast when our brilliant colleagues in photonics presented new highly sophisticated and technical imaging techniques, they suddenly came alive again.

We have something to learn from others

If all this seems overly negative, carping and (possibly) evidence of a very big chip on my shoulder, it is not the main point I want to make. Indeed, I only mention it as contrast to what has happened through the pandemic. Because one of the few pleasures of these troubled times has been the experience of participation in Covid  groups – particularly the Advisory Group to the Scottish Chief Medical Officer – alongside epidemiologists, virologists, modellers, global health experts, medical practitioners and more.

At first, behavioural science was included but was marginal.

I was the only person in a group that started with some 20 people and subsequently grew. In time, one other psychologist was added, but still the representation was limited. What is more, the behavioural dimension was seen as secondary, as a placeholder until the real interventions (such as vaccines and treatment drugs) were developed. This inequality was enshrined in the term ‘non-pharmaceutical intervention’ (NPI), as if medicine was the default and behaviour was other. The term still endures, even though the World Health Organisation has replaced it with ‘Public Health and Social Measures’ – admittedly something of a mouthful.

Over time, though, that has changed and I think there are two main reasons for this. The first is to do with the fundamental human challenge posed by Covid-19. It spreads through the very thing that makes our lives worthwhile: contact with others. In all the modelling, one of the key parameters, and one of the key unknowns, was how different interventions would impact levels of contact. So how do we get people to limit the numbers of contacts we have with others? Moreover, how do we do so in a way that doesn’t just produce another set of harms in terms of isolation, despair, mental ill-health, even suicide. In other words, how do we keep people physically apart while remaining socially together? With wider recognition of this as a core dilemma, so behavioural science became wound into the core of the pandemic response, and behavioural understanding became as important for epidemiologists and modellers to do their job as it did for psychologists and anthropologists to do theirs.

Each of us learnt more about our own disciplines from the other

The second was the gradual realisation that pharmaceutical developments would never render behavioural developments irrelevant. That was something that I myself took time to realise. At the start I argued that until a vaccine came along, the main defences against infection were behavioural. I was wrong, because when vaccines did come along they only added to the relevance of behavioural factors. After all, the vaccines in themselves achieve precisely nothing. It is getting people vaccinated that makes such a difference. That puts a whole series of issues on the table such as how to deal with vaccine hesitancy, the impact of historical mistrust on the take up rates of different communities, the role of incentives, the impact of vaccine passports and much more besides.

In other words, the contributions of pharmaceutical and social/behavioural knowledge were not in a zero sum game. To the contrary, each defined new fields of relevance for the other. As we discovered more and more about the asymptomatic and airborne spread of the virus so that created new challenges as to the behaviours we would need to address in order to limit the spread of infection. As medical insights deepened the dialogue between (and priorities within) disciplines increased rather than reduced. Each of us learnt more about our own disciplines from the other. Both of us would have been fundamentally limited in our ability to contribute without the other.

Now, two years on, those whose departments I once looked on as a foreign country I now look upon as colleagues and friends (although most of us have never actually met in person) and I hope to continue to work with in the future. But, if I started off as unduly insular and pessimistic, I don’t want to end as too naïve and as espousing a view of academic history characterised by linear progress.

On the one hand, practices are unlikely to endure unless sedimented into structures. At present, these structures reproduce the hierarchy of disciplines. During the pandemic, the Chief Medical Officer and the Chief Scientific Officer fed into Government directly, but behavioural science advice didn’t have the same representation. We saw the dangers of this at the UK level early on in the pandemic when the disastrous idea of ‘behavioural fatigue’ was used to delay measures and arguably cost tens of thousands of lives. But the idea was not espoused by behavioural scientists themselves but derived from the ‘common sense’ assumptions of non-behavioural scientists. If we are to see a hierarchy transformed into a synergy of disciplines these institutional matters must be addressed.

On the other hand, as the quick and almost unlimited research funding dries up, as we face the post-pandemic (and post-Ukraine war) financial crises, there is a very real danger that we retreat into our respective disciplinary bunkers and that we then try to increase our share of a diminishing pot by re-establishing hierarchies over the other.

My hope is, as we face those straightened times to come, we cling on to those brighter elements of the pandemic response, we build back better, and that something of the mutual respect and collaborative enterprise remains.