The debate about lifting lockdown restrictions for controlling coronavirus transmission in the UK is intense and challenging. Elements of the current discourse are unsettling, not least for people deemed ‘vulnerable’. In late March I received a letter from the NHS placing me in that category – at risk of more severe COVID-19. I had not waited for the government to warn me – I had adopted stringent personal shielding several weeks before. I attended scientific meetings on COVID-19 in February and the accounts from China and the sense of unprecedented scientific uncertainty did not leave me with any doubt. This was not a virus I wished to get. Most especially not during this time of enormous unknowns and no tested treatments.

Taking it personally

The lack of UK government action only made this realisation more acute. The ball was in my court. Reading as much as possible about COVID-19 across my research domains was now not limited to an academic exercise to ‘stay abreast’, but a matter also of protecting my own health. I tried to extract nuggets of certainty from the emerging picture. Indeed, uncertainty was no longer just an interesting conceptual hook for thinking about the limits of pandemic preparedness, but an existential reality in my personal life.

I have in the past offered criticism of the emphasis of global health interventions on the ‘silver bullets’ of vaccines and drugs, to the exclusion of the complex social contexts of disease outbreaks. But in this new reality, I found myself buoyed by the news that Oxford was trialling a vaccine and that trials of treatments were under way.

And yet personal experience also underscored the fact that outbreaks are not just situations for ‘technical’ response and an apolitical, value free ‘science’; epidemic preparedness and response are political processes shot through with social, economic and ethical ramifications. Policy decisions have significant biopolitical implications, not least for categories of ‘vulnerable’ people – be that biological, or vulnerability of a social, economic or political kind.

The images from Italy of overwhelmed hospitals and doctors balancing decisions on the allocation of critical care resources were deeply upsetting. The NHS, where I have worked as a doctor and received care as a patient, has been an unshaking source of support. I have deeply appreciated the freedom that comes as a patient when finances are delinked from interpersonal clinical interactions. I had never contemplated before that my very ‘vulnerability’ might become a reason for not getting access to resources.

The interviews with eminent bioethicists made intellectual sense – the implications of a shift from an ethics of treating the sickest and focusing on those most likely to die, to a ‘wartime’ ethics of giving scarce medical resources to those most likely to live. Yet in the night I would ponder a strategy for not disclosing medical vulnerability if I contracted the virus, hoping that age would count in my favour. Of course it would be unlikely in practice, but I considered how I would argue for the value of my life and communicate my will to live, if it came to that.

In the week that the UK government declared that testing and tracing had become futile (or beyond existing testing capacity?) and the briefings about ‘herd immunity’ emerged, I had a visceral reaction. What were the implications of this for those like me, at the sharp end of a biopolitics beyond our control? The immune response to SARS COV-2 was still an unknown and the uncertainty about the mortality rate suggested even at best that many would then die as the virus ‘ran through’ the population. As Johnson ‘levelled’ with the populace that many would lose loved ones, it was hard not to ask whose deaths were going to be the ‘collateral damage’ of herd immunity.

My responsibility

The UK is currently in a situation where the case numbers are high and ‘test, trace, isolate’ is facing challenges of implementation. It is hard not to wonder if public health concerns about a still tenuous grip on an epidemic are being sidelined for economic aims. It is a reality that, in a country struggling to get on top of control, those deemed ‘vulnerable’ are now at great risk of infection if we do re-assume physically present social lives. It seems responsibility is being pushed onto the shoulders of the population; the onus will be on me in the months ahead to assess what might be safe in an unstable scenario.

Listening to media interviews can be an uncomfortable experience as the ‘hawks’ who argue for opening the economy make statements that implicitly suppose that a further death toll amongst those deemed vulnerable is inevitable. Of course the current situation is deeply complex and the secondary health impacts of closed health services and of economic downturns alone make options even more difficult to unpick. What a relief though as a ‘vulnerable’ person to hear the voices of those who are able to take the scenarios beyond a utilitarian trade off, to ask questions about the wisdom of weighing the relative value of lives, and about the values of society as measured against its treatment of the more vulnerable.

My privilege

In all of this I realise of course that I am actually in an immensely privileged position. I might have a biological vulnerability, but I am not suffering economically from the COVID-19 pandemic and I have social networks that support me in a myriad of ways, not least in getting a grip on understanding the emerging findings and the implications for care and survival. The NHS critical care capacity has not been overwhelmed, even though the mortality in care homes and personal homes adds an edge to that outcome. I find myself fantasising about living in Germany or Australia – perhaps then my life would have a greater chance of some social normality in the next months. But I can at least feel that I can again trust the NHS to support my life.

Not so for very many people in other parts of the globe. The inequalities in access to healthcare and their implications have been starkly laid bare. Those of us who work in global health fear for settings with lack of Universal Health Coverage, or very weak health systems. I think of the people I have met doing research in the health care system in South Africa and in the low income urban settlements that have long histories of structural violence. The COVID-19 guidelines and briefs bemoan their lack of ability to physically distance or the dreadful reality of the life-threatening hunger brought on by lockdowns.

The trade-offs and decisions being debated in the UK reach a different level of intensity in low and middle-income countries. Yet I experience a measure of hope when I recall from my research sites in South Africa the networks of informal care and the local institutions for supporting people who are ill and in need that I have encountered – social responses that have always been deeply humbling to document ethnographically, even as the precarity of lives and livelihoods is so evident.

This moral economy of care that links to kinship, social solidarity forged by shared experience, religious groups, street committees, as well as a vibrant civil society that holds the state to account and responds to the gaps in service-delivery – these are all becoming evident now from the accounts emerging of responses on the ground in the areas struggling with the effects of public health restrictions.

I hope that those adapting guidelines to these settings at the sharpest edge of the biopolitics of COVID-19 can consult and allow people to express their own views – on local understandings of the ethics of care, resource allocation, the burden of suffering, and the complex implications of the responses being debated for policy.

Too often people in settings like these, considered most at risk, are perceived as only passive, and ‘acted upon’ by public health interventions. People have views and these are worth listening to, even when the imperative to act is urgent. As public health and societal debates play out in the coming months across the world, I very much hope that we can hear more of the voices of those deemed ‘vulnerable’ in the many places feeling the scourge of this virus.