Robert Dingwall interview: the damage done by our refusal to accept disease and death are part of life

In this interview with Reaction’s Deputy Editor Alastair Benn, Professor Robert Dingwall of Nottingham Trent University argues that the UK’s Covid-19 pandemic response is rooted in a narrow technoscientific worldview. We must learn to live with the virus, he says, as we have done with the many viruses that have emerged throughout history.

Robert Dingwall has advised the British government on pandemic policy for nearly two decades. He is a member of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), an expert committee which advises the government on the threat posed by new and emerging respiratory viruses.

He spoke to Reaction in a personal capacity.

Alastair Benn: Have we forgotten how to live with death?

Robert Dingwall: It is a characteristic of contemporary society that we have developed this conceit that we could live forever if only the technology were right or if only we might micro-manage our health correctly. In the process, we have lost sight of the fact that pretty much anything we do merely prolongs life, and that it often does so at the expense of the quality of life we live towards the end.

Brillat-Savarin, a French philosopher and early writer on cookery, recounted a conversation with his 90-year-old great grandmother who said: “When you get to my age, you get to realise that death is as necessary as life.” Death is a moment in living. It is our ultimate experience. The Stoic philosophers talk a lot about the importance of accepting death, of thinking about how to die well, rather than to struggle fruitlessly against it at great psychological cost.

AB: We see less death first hand.

RD: We see less of it in part because infant mortality is now very rare. The spacing out of generations means we don’t have to think through that experience. You might live 60 years before a parent dies in their 80s or 90s. In that time, you are not really forced to confront the reality of deaths among people who are close to you in ways that previous generations might have done.

AB: Why did the Spanish Flu, even with its huge mortality, leave less of an imprint on history than other events of the time?

RD: You have to remember that in 1918 you are on the cusp of a major social change. It’s really the point at which the average patient going into the average hospital being seen by the average doctor is going to see some benefit from it. It is one of the frequent anachronisms of historical novels or films about 19^th century history – the notion that the medicine has any effectiveness. That people go to a doctor and expect to be cured as opposed maybe having some alleviation of their symptoms or some psychological benefit to having a label attached to their condition. Up to the First World War, most medical interventions don’t achieve very much.

Things had been developing very rapidly in the leading centres from the 1890s onwards. What the First World War is to drive forward some fairly significant improvements and make those generally more available. The population in 1918 are drawing on a very different understanding of the relationship between medicine and illness and what it is possible to achieve than would be the case in 2020.

There is also an acceptance of death – not a cult of death, as the Victorians would have had it. What you saw was much more typical of responses to responses to infectious disease over the hundred years previously. When infectious diseases first arrive in a population, there is a great panic. If you go back to the 14^th century and read accounts of the Black Death, people are convinced that they are all doomed.

The Black Death does have a huge mortality. It keeps coming back. But the population is more resistant. The authorities have some way of managing it. Essentially, it is bureaucratised. It is regarded as one of the hazards of life. These things happen from time to time. They are not existential threats to humankind. We can live with them.

That’s been broadly true of influenza ever since. I was in my first year at university in ‘68 and I have no particular memory of the 1968 flu pandemic being disruptive to my time there. What we’ve had this year is a little more comparable to what happened with the early years of HIV in the eighties. It was a similar kind of social panic. In those years, we thought, well, perhaps, we are all going to die.

We then realised that the disease is entirely manageable through simple precautionary measures that are not disruptive to ordinary life. Within a few years, we got reasonably effective therapies. Forty years on, we still don’t have a vaccine but we have an effective preventive therapy. We learned to live with it. The question with Covid-19 is how long it takes to accept that this is not something we can eradicate.

This will rumble along at a low level in our societies for many years to come. A vaccine may play some part in control. But it will ultimately be our choice how far we tear up our society by the roots in the process. We may have to accept that most of us will get this once or twice, or three or four times in our lives. It may be the thing that accelerates our death at the point that we are already frail from our other causes.

AB: How do we repair the damage our preventative measures have made on social life?

RD: Part of the problem has been this reluctance to recognise that when you have a novel disease, which is new to medicine, all you can do is try to slow the transmission enough to allow the biomedical sciences to catch up. We saw that early on with HIV. It was such a radically new kind of virus. Nobody really had a great understanding of this strange phenomenon of retroviruses. It was quite clear that any sort of vaccine would be years off. The only thing we could do was persuade people to take more precautions in their sexual relations.

The condom is a well-established technology and was useful. We also tightened up PPE in a few environments. Dentistry became concerned with transmission risk, for example. Dentists started wearing gloves, masks or visors. There were new technologies to reduce aerosol sprays. All these things happened in a short period with a very clear specification of what the risk was and what the action might be.

During the Ebola outbreak in West Africa in 2013 there was not enough attention to social behaviour in the early management of the outbreak. You had people from organisations like MSF, very medically dominated, who were driving up to remote villages in white land-cruisers, grabbing bodies, putting them in body bags and carting them off, and wondering why villagers were throwing stones at them and hiding the corpses.

It took a while for the people managing the outbreak to recognise that they had to talk to anthropologists who could illuminate the significance of the dead body in the traditions of the people in those villages. Once that was better understood there were ways of accommodating the response with that and improving it. This actually brought the outbreak significantly under control.

We have failed to learn these lessons with Covid-19. The leadership has fallen to a particular group of medical and biomedical scientists. Many of them are brilliant people. But they have a particular way of understanding the world. They have a rather narrow conception of what kinds of knowledge are relevant in the development of those kinds of interventions.

AB: What kinds of assumptions drive that worldview?

RD: There is an issue about the moral nature of medicine. Biology is morally neutral. Biologists look at relationships between organisms. Some of those relationships are supportive. Some of them involve one organism flourishing at the expense of another. There is no moral agenda there. But when you turn to the biomedical scientists, you have this rather different notion – you have words like “infection” or “disease” which are simultaneously scientific terms and moral terms.

An infection is something to be corrected. The biomedical scientist doesn’t just watch nature happening. The objective is to correct nature and improve on nature. If there is an outcome that can be defined as socially or morally harmful, the thinking goes, then something must be done about it. You have an instant lock-in. Covid-19 is an infection. Something must be done and the thing that must be done must be led by the biomedical world.

AB: It’s a worldview then that does not allow itself to be limited by the insights of other fields of knowledge.

RD: What we’ve got is essentially a techno-scientific approach which rarely stops to ask itself the question – what is the point? What are we trying to achieve here? What is achievable? We have had this distortion of priorities. Many other causes of death are now considered to be less important than Covid deaths. We have the evidence of exceptionally high rates of death from cancer and heart conditions and so on. Somehow these don’t count in the balance in the same way.

We are not looking at managing all deaths and thinking about the place of Covid deaths within them. What we are thinking is – we must address the Covid problem. The attempts to question whether this is an appropriate priority tend to be dismissed as immoral simply because they tend to challenge the implicit and unexamined moral agenda of a particular section of the biomedical world.

AB: The debate also includes things that are far outside the biomedical viewpoint – there is a sense that the disease is conceived of as a disease of city dwellers. I’ve felt that travelling out of London to rural areas.

RD: That is provoked by a fashion for the pastoral, the fashion to argue that the city should be constructed around the 10 minute, 15 minute or 20 minute neighbourhood. This idea that our lives should be lived within walking radius. These are things which early sociologists very much wrote against. These were the visions of a particular kind of conservative at the end of the 19^th century. The idea that the problems of urban life would be resolved by a return to the countryside, that the disruptive working class should be encouraged to be jolly peasants, live in thatched cottages and keep a couple of pigs out back. Particularly a German sociologist called Georg Simmel was very suspicious of this.

Simmel writes about the dynamism of cities. Cities are precisely the place where innovation happens, where people get mixed up, where you get diverse communities. In that diversity, new ideas, new technologies and new social orders emerge. That’s something that has a big influence on American sociology in the 1920s. Look at a city like Chicago which had many problems, illness, poverty and environmental degradation. But at the heart of it there is this great energy and dynamism that comes from mixing, the encounters of people of different values and talents.

All of that energy crystallises in this sense that the city is a place where the future happens. The 15-minute neighbourhood? What does that say? It says that we will only live in a neighbourhood composed of people like us. It is instantly a recipe for social and ethnic separation. Those places still need to be joined up. So what do we have? We have an underclass of people, the successors of the gig economy if you like, who transport all the things around between the 15-minute neighbourhoods. They are an invisible servant class. Nobody talks about them inside the 15-minute neighbourhood. This is the social exclusiveness that would emerge from this model of city life.

I would also say that we have yet to create a virtual environment that is capable of generating the random encounters of the city. The virtualisation of a lot of activities means we are burning through a legacy of social capital which we are not renewing. The relationships we would have formed with colleagues, the processes by which new people would join organisations and learn new things. The encounters we might have in the coffee shop or the pub. All of those things have been stripped away. The result will ultimately be a social, economic and intellectual impoverishment.

AB: A lot of the antagonism about the disease has fallen along generational lines – young people as spreaders, old people hoarding capital.

RD: Intergenerational tensions have been rummaging around for much of the last decade. The economic and political failures of the last 20 years have created tensions between people like myself, at the tag end of the baby-boomers, who, looking from a 2020 perspective have had an extraordinarily privileged life. It might not have felt like that at the time. Until 2008, we thought that we had worked all our lives, we were part of a buoyant society, we thought we were entirely justified in taking our inflation-proof pensions.

All of a sudden the world changes economically. People in their 20s, 30s, coming into their 40s even, are more likely to live in a more pressured environment. They are much poorer. That poverty will be greatly accentuated by lockdowns. We are going to be a much poorer country for a generation and the baby boomers have locked in their gains. That is inevitably a source of some tension.

We have this rather unhelpful bifurcation that you have described. I personally think that a zero-Covid strategy is chasing unicorns. This is not a disease we can eliminate. This a disease we are going to have to learn to live with at some level. Even if a vaccine comes along the thinking seems to be that that the vaccine would be part of a portfolio of interventions and we will need to have a discussion about the measures we should keep on alongside the vaccine. There will be people who desire for the vaccine just to be added to the current package. I’m hoping to push for a different view, a zero-based approach. Any continued restriction has to justify itself on the basis of evidence. If it cannot do so, we stop doing it.

One of the mistakes of the Great Barrington Declaration is to put everyone over 65 into the same category of risk. The risk is not evenly distributed among those at a given age. Most of the risk even for people in their 90s the risk is carried by a small number of people. Some should be allowed to shield and supported in that endeavour. For others, it is much better to give people information about the additional risks that they carry and inviting them to make their own choices. It comes back to this rather patrician stance, adopted by elements of the biomedical world, that we should be able to micromanage the everyday lives of other people to achieve a vision of health that they have decreed but which other people might not necessarily share.

AB: I was sceptical early on about the wartime rhetoric that emerged early on, clearly motivated by a search for the spirit of ‘45. The Second World War created a very different, new social order, a new consensus across the West among policymakers about what had to be done. But disease tends to amplify existing social antagonisms. The ancient poet Hesiod blames the emergence of disease on women via the myth of Pandora, for example.

RD: These are really unhelpful ways of trying to think about a disruption in the equilibrium between humanity and nature. It is generally accepted that infectious diseases are a phenomenon of the emergence of human settlements about 15,000 years ago. Prior to that they couldn’t transmit with sufficient freedom for the organism to become established in human society. The Covid-19 pandemic is layered onto existing social tensions and inequalities. It has been a stress test for a lot of states and societies.

It is fundamentally different from warfare. It is not at all clear what would count as winning and losing. You can mobilise a population in warfare to a degree around the notion that one day we can hoist all the flags and declare that we won. It didn’t work like that for my generation with Vietnam, or more contemporary generations in Iraq. If people cannot see an endgame, it is very hard to sustain that solidarity. Nobody is prepared to talk about the endgame. When Keir Starmer demands a temporary circuit breaker it is just kicking the can down the road. There is no vision of “how do we bring this pain to an end.”

In that context, it is not surprising that people become more and more mutinous, more and more grumbling. It is quite hard to imagine a real popular mobilisation when you have the full forces of the state weighed against that. But the idea of what I would describe as compliance without commitment. People will put on a face covering to go into a supermarket without any belief in it but simply to just avoid trouble and conflict. This doesn’t feel like a very good way for people to go about living their lives.