Abstract
More than a year after the first reported cases of COVID-19, the world is still submerged in the doldrums of the pandemic. Wave after wave, measures taken to stem the epidemic are being repeated, failing to contain the phenomenon in most countries. The world is struggling against SARS-CoV-2; its pulse beating to the rate of the mediatised number of cases, hospitalisations, and deaths. Doesn't this continuous and massive publicity of the COVID-19 figures constitute one of the key problems of the crisis policy? By relentlessly making these specific epidemiological data salient and visible, the risk is taken of rendering invisible other problems, disorders and diseases, at least as serious; this risk is all the more worrying as the crisis becomes chronic.
Public policies have mobilized, not always effectively, the classic tools for responding to acute epidemic phenomena: detecting, isolating and, henceforth, vaccinating. But COVID-19 is not just an epidemic, it is a syndemic (1). It is asymptomatic or minimally severe for a very large majority of the population and is only aggravated by other factors of vulnerability, notably the combination of age, morbidity and social conditions. It has socially stratified effects and certain populations, because of their living, employment and housing conditions, are particularly vulnerable (2). In this respect, universal measures have barely been adapted to the peculiarities of different contexts, whether geographical, cultural, political, etc. (3). In the panic, a total, universal and centralised approach was chosen almost everywhere in the world: closure of living and teaching areas, physical distancing and general confinement. The determinants of living together have been frozen over a very long period in an attempt to limit the spread of the virus and avoid hospital saturation in intensive care.
For what results? COVID-19 has killed nearly 3.2 million people, almost exclusively over the age of 65 and/or already sick (4). It is currently difficult to know to what extent this rate has been affected by the measures decided upon. Studies highlight the effectiveness of certain measures on the spread of the virus under certain conditions (5), while others show that they either do not influence, or negatively influence the death rate in the population (6). On the other hand, data are now available showing the consequences of these measures on the health of the population: 100 million new people in extreme poverty (7), doubling of the unemployment rate in OECD countries (8), increased mental disorders and anxiety (9–12), lack of care for chronically ill patients and slower prevention activities (vaccination, screening) (13). Worse still is the toll for children: 142 million have been plunged into poverty (14), 463 million who have not been able to access distance education will experience learning delays (15) and subsequent health problems (16), worsening mental health problems (17,18) with probable consequences for the growth and development of younger children (19). There are fears of a collapse of decades of progress in child health, the consequences of dramatically disrupted immunisation and antenatal care policies (20,21) and policy-induced malnutrition (22). Finally, confinement measures overexposed children to domestic violence in a context of weakening child protection services (23,24). This observation, which is striking in its scale, its gravity and its victims, the youngest and the most vulnerable, calls out to the principles of beneficence to which public health interventions should refer (25). How could we have forgotten that the social determinants of health are interdependent, that health is rooted in social fact and that, therefore, in the long term, such measures can only be destructive (26)?
The answer could be quite simple: the method used. Let us recall a fact that those involved in health promotion know perfectly well. Health proceeds from a process of empowerment, namely the capacity of individuals and groups to act on the social, economic, political or ecological conditions they face. In the context of COVID-19 (7), to be able to act, those affected must have the opportunity to participate, own and adjust the response. However, in many countries, all public communication on the epidemic has been deployed intensely without engaging in dialogue with civil society or health promotion professionals. The main objective seemed to be that of eliciting support for government measures by focussing communication on the individual responsibility of people and by mobilising worn out registers of fear and guilt (27). However, political science has shown this for a long time: what the governor believes to gain in autonomous decision capacity, by centralisation and monopolisation of the decision, he loses in implementation capacity (28). In addition, the limits of this anxiety-inducing strategy have long been known, especially when it is not shared and, consequently, the communities cannot play the role of moderator, resource or support (29–32): strategies of avoidance or withdrawal into oneself, anxiety and defensive behaviors, even pathological, linked to induced chronic stress. This deleterious combination of ‘pandemic fatigue’ (33) is observed worldwide, weakening the population and therefore the fight against COVID-19. To fight against this phenomenon, the World Health Organisation (7) nevertheless calls for modifying the method around four principles: (a) facilitating community responses by improving the quality and consistency of approaches; (b) basing actions on the mobilization of evidence, but also on the specificities of the contexts, capacities, perceptions and behaviors of the community; (c) strengthening local capacities and solutions by facilitating the skills and competencies of communities and the participatory evaluation of measures; and (d) favoring collaboration and mobilization of common interests between groups, structures and territories in the effort to respond to COVID-19. These four principles, good and well-established health promotion practices, refer directly to the need to combine expertise, disciplines and sectors. And this is the second weakness of the method used so far.
By favoring a biomedical approach where it is a question of suppressing or containing a virus rather than studying its encounter with a population forming a system (34), prevention and health promotion professionals, researchers in the human and social sciences, and citizens were excluded. However, how is it possible to embark hundreds of millions of individuals in a collective dynamic that directly concerns only a fraction of them, to choose the right communication in the long term, to adjust measures to territories, to vulnerabilities, without the achievements of these specialties? For 50 years, the guides in this field have been spangled from charter to charter, from consensus conference to consensus conference, to recall that ‘the coordinated action of all those concerned’ is necessary because ‘the programs and strategies for health promotion must be adapted to the possibilities and local needs of countries and regions and take into account the various social, cultural and economic systems’ (35). Principles endorsed by most of the nations concerned today, principles that have not been applied, are undoubtedly unknown to the rulers and experts mobilised in the management of this crisis.
In the approach as in the method, in its results as in its impacts, the management of the COVID-19 pandemic can only appeal to health promotion professionals. Why are they not heard? Certainly we had prepared for a sprint and it is a marathon that we are going through. Admittedly, the virus is agile, devious because it is silent and opportunistic, as always. Of course, hospitals are drained from years of neoliberal reforms. But while surprise, even astonishment, could excuse the initial choices of those in power, stubbornness and/or blindness to their consequences are not allowed. Continuing to sacrifice many segments of the population, in the name of universal measures, when measures proportionate to the vulnerability of territories and people could be put in place, is no longer permitted. If the advocacy mission is central to health promotion, it has never been more important than today when the world stumbles on SARS-CoV-2 generating multiple social, territorial, generational and community divides and where the expertise mobilised so far is conscious of its limits (36).