Abstract
COVID-19 is not just a medical pandemic; it is a social event that is disrupting our social order. As Leach and colleagues (2020) noted in a recent online essay: The dynamics of the virus, infection and immunity, not to mention on-going efforts to revise and improve clinical care, and endeavors to develop medical treatments and vaccines, are a critical part of the unfolding story. So, too, are peoples’ social responses to the disease and interactions with each other. COVID-19 is revealing, reinforcing, and catalyzing new social and cultural relations; laying bare inequalities and anxieties, discrimination and division; but also galvanizing solidarities and collective action.
In December 2019, COVID-19 was recognized in Wuhan, China (Wang et al., 2020). Since then, the virus has caused serious illness, death, and social disruption around the world. The scope of the outbreak is rapidly evolving and ever changing. At the time of this writing, there were nearly 800,000 confirmed cases of COVID-19 and almost 40,000 deaths (Johns Hopkins University and Medicine [JHUM], 2020). As of the end of March, the United States leads the world in case counts. Neither a vaccine nor a cure exists—and in many places, testing remains limited. Thus, in most places, public health officials have moved on to mitigation by instructing everyone to engage in hand hygiene, social distancing, and quarantine to protect themselves and others.
Outbreaks like COVID-19 draw attention to the importance of epidemiology, the study of distribution and determinants of health and illness among specified populations (Last, 1988). Epidemiology is predominantly a quantitative science in which researchers work to define an outbreak, find cases, generate rates of illness, and develop and evaluate hypotheses about the causes of illness and how it is spread. Epidemiological data have resulted in information about who is affected by COIVD-19, how it works, and who survives or dies from the illness (JHUM, 2020). Inevitably, however, quantitative epidemiological models miss the social implications of disease. They are not well suited to capture the reasons for people’s behavior, the social interactions, or the ways people make sense of what is happening around them (Leach et al., 2020). Qualitative methods are valuable alongside traditional quantitative epidemiological methods given their open-ended nature and focus not just on “what” but on “how.” Interviews, group discussions, and observations explore and embrace different viewpoints, meaning, and motivations. They can help explain the gap between assumptions in epidemiological models and social realities as well as why certain outbreak interventions work and others fail (Leach et al., 2020; Wolff et al., 2018).
Although not always as visible as the case numbers during an epidemic, a large body of evidence supports the value of qualitative methods in epidemic and pandemic research. In fact, leading global health agencies like the World Health Organization and the Centers for Disease Control and Prevention recommend using qualitative methods in epidemiologic investigations (Wolff et al., 2018). In a review of the use of qualitative methods to study health emergencies, Johnson and Vindrola-Padros (2017) identified 22 examples where qualitative methods were used to assess causes, prevention strategies and solutions, health needs, and health systems use during disease outbreaks (e.g., flu, Ebola Virus Disease [EVD], malaria) and natural disasters (e.g., hurricane, tsunami). Similarly, Crawford et al. (2016) explored qualitative lessons from recent epidemics like SARS, H1N1, and EVD identifying issues to be improved for future pandemics. They highlight how cultural and political confidence in institutions can bolster responses, whereas clashes may undermine confidence in these institutions. In fact, during the EVD outbreak of 2014–2016, anthropologists were critical to providing qualitative insight, analysis, and advice about how to engage with the social, cultural, and political aspects of the epidemic (e.g., caregiving, burial rituals) to build effective interventions (Institute of Development Studies and London School of Hygiene & Tropical Medicine, 2018). Their work is described in The Epidemic Response Anthropology Platform (Institute of Development Studies and London School of Hygiene & Tropical Medicine, 2018). Similarly, collections of qualitative data describe HIV (Geter Fugerson et al., 2019), injection drug use (Guise et al., 2017), smoking (Flemming et al., 2015), and other chronic illnesses from the perspectives of people living with and/or attempting to successfully address or treat those health challenges. These contributions are critical to understanding both people’s lived experiences of disease and the ways that individuals and communities make sense of disease endemic to their social worlds. Below, we highlight five essential contributions of qualitative methods during epidemics. 1. People’s health behaviors do not always fit neatly into epidemiologic models. This is even true in “normal times.” For instance, although epidemiological research links smoking with lung cancer, qualitative research has shown that some youth continue to smoke because they believe the disease is not a high risk for them (Hefler & Chapman, 2015). Likewise, research links unprotected sex to sexually transmitted infections. In interviews with poor, urban women at risk of HIV, however, it became apparent that condom-less sex was key for women to maintain denial of cheating in their relationships, preserve their belief in their ability to judge partners, and maintain their self-esteem (Mojola, 2014; Sobo, 1995). These examples highlight that causal links between behaviors and risks are not always sufficient for people to enact recommended preventative behaviors. Currently, health leaders are advising people to use social distancing and quarantine to limit COVID-19 exposures. Yet qualitative studies show that many different complex psychological, cultural, and social factors limit compliance. These include mistrust in government and a history of use or perception of use of quarantine as a social control mechanism (Tulloch & Ripoll, 2020). 2. Vulnerable populations. Vulnerabilities to disease are not just biological but social. Qualitative methods can shed light on the needs of particular marginalized groups during health crises and infectious or chronic illness epidemics. From its inception, for example, HIV/AIDS-affected communities and groups of people that were already vulnerable to stigma—like gay men, people living in poverty, injection drug users, and sex workers. Qualitative inquiries have played a key role in revealing that the stigma of HIV in addition to preexisting social stigmas has played a major role in limiting access to HIV information, testing, and treatment (Chambers et al., 2015). Regarding the current COVID-19 pandemic, qualitative methods can shed light on ways the virus can hurt vulnerable people like poor families who cannot eat without school meals (Associated Press, 2020), incarcerated populations who are not able to socially distance themselves (Kindy, 2020), and communities where population density is extreme but access to sanitation and food is low, such as slums (Sur & Mitra, 2020). A student in Kenya recently discussed the challenges he and other Kenyans had taking COVID-19 seriously, amid other preexisting vulnerabilities: Dear coronavirus, welcome to Kenya…here, we don’t die of flu. Don’t be surprised if you fail to succeed. Everything fails in Kenya. Kenya is not excited to host coronavirus. The locusts, the biggest infestation in 75 years, got here first. We also cannot afford to pay you too much attention because we are really, really broke. We are more likely to die of a cholera attack than to be killed by you. For us, every day is a run to escape from death. We are the walking dead. (Peralta, 2020)
His sentiments underscore the complexities that vulnerable people face during epidemics and the need to capture that complexity to understand the scope and impact of an outbreak. 3. Unexpected consequence or surprising outcomes. Qualitative methods are well suited to exploring the reasons that epidemic solutions and strategies work or fail or uncovering unexpected consequences of actions taken during epidemics. In a qualitative exploration of flu behavior during the 2009 H1N1 flu outbreak, Flowers and colleagues (2016) found that the majority of work surrounding hygiene, personal protection, and caregiving during the outbreak collided with gender inequities and unfairly burdened women, worsening gender-based inequities and women’s vulnerabilities. Via focus groups, interviews, and observations with communities after the EVD outbreak in Sierra Leone, qualitative researchers found that quarantine put people in danger of starvation given preexisting food insecurities (Kodish et al., 2019). Similarly, during EVD, bushmeat bans contradicted people’s experiences of safely consuming wild meat, and the criminalization of bushmeat worsened distrust between communities and outbreak workers (Bonwitt et al., 2018). It is early in the COVID-19 pandemic to understand all of the unexpected outcomes of public health efforts, but early fears about the virus in the United States, for example, have contributed to shortages of masks and sanitizer for medical staff who need these resources to care safely for others (Nyugen, 2020). In addition, fears related to the origins of COVID-19 have led to increases in discrimination against Asian communities in the United States (Phillips, 2020). Similarly, the expansion of preventative measures is having a profound impact on social structures and social function. Within these considerations are concerns, for example, of the impact of social distancing on mental health as well as effectively supporting individuals isolated with abusive partners. These issues need careful qualitative study, not just journalistic reporting. 4. Medical response experiences. In previous outbreaks similar in nature to COVID-19 (e.g., H1N1, SARS, EVD), qualitative approaches have been key accompaniments to traditional quantitative outbreak investigations in highlighting the needs of medical and other first responders and their interactions with affected communities. Qualitative studies during the EVD outbreaks in Sierra Leone, Guinea, and Liberia uncovered many challenges and lessons learned. These included peoples’ fears of calling the Ebola help line because their loved ones would be sent away (Yamanis et al., 2016), impassable roads causing health workers to walk up to 8 hr a day to reach remote communities (Summers et al., 2014), lack of standard procedures to clean ambulance and burial vehicles increasing infection spread (Pathmanathan et al., 2014), and fears that health care workers were injecting patients with EVD (Dynes et al., 2015). Even though we are early in the COVID-19 epidemic, qualitative reports from medical responders are uncovering challenges like limited testing availability, difficulty identifying persons with COVID-19 based on signs and symptoms alone, and lack of protective gear (McMichael et al., 2020). One can only surmise that fears similar to those of the EVD pandemic exist in the public as well, such as reluctance to report illness given fears of social isolation and limited treatment options. In the United States, lack of universal health care and access to care are additional barriers to reporting cases (National Center for Health Statistics, 2018). 5. Getting community buy-in. Public health solutions and tools are only effective if people use them. In response to the epidemic of injection drug use in the United States, for example, public health officials implemented safe needle exchange programs to support the use of clean needles, a seemingly logical way to avoid spreading illness. Bourgois’s ethnographic immersion into the lives of self-identified heroin addicts, however, showed that the logistics of addicts’ income-generating strategies, their desperate need to overcome dope sickness, and the moral economy of sharing resources among addicts resulted in daily sharing of needles despite the availability of clean supplies. Thus, a solution that public health experts considered as automatic did not work for the most at-risk drug users (Bourgois, 1998). Qualitative methods can help uncover assumptions underlying public health plans, signal the need to plan with communities, and engage communities in group and individual discussions. For example, community forums in response to SARS and H1N1 outbreaks in South Australia identified that quarantine would be more successful if community members had effective financial and psychological support plans to manage the quarantine (Braunack-Mayer et al., 2010). Qualitative methods are well suited to explore how people react to the uncertainty and disconnection that accompany methods like quarantine. Pandemic planning with First Nations communities in Ontario, Canada, resulted in refined plans for how medicines and supplies could be transported, received, and stored in remote locations (Charania & Tsuji, 2012). Similarly, a key lesson from the West African EVD outbreak was how crucial community engagement is for a successful outbreak response. Despite failed health care systems and overrun hospitals, communities were resilient and flexible. They created their own safe burial processes and ways to isolate and care safely for the sick (Abramowitz et al., 2015). The lack of cooperation with quarantine and social distancing in the United States, for instance, highlights the importance of community buy-in, among other things, in achieving effective containment of COVID-19 (Madani, 2020). Without the type of results that qualitative methods can yield about effective social response, the successful management of this outbreak may very well remain elusive.
Qualitative methods can play a pivotal role in understanding epidemics like COVID-19, the people involved in them, and effective solutions and strategies. Despite the challenges posed by this current crisis, it is precisely at times like these that we should celebrate and make use of these methods. Qualitative methods are positioned to explore the plurality of expertise and diversity of perspectives necessary to understand fully the COVID-19 pandemic as it unfolds (Leach et al., 2020). Qualitative methods can give insight into the current situation as it evolves and lessons to bring to bear on future epidemics and how to effectively manage them.