Kelly et al’s ‘Uncertainty in times of medical emergency…’

In this session of the Self-Isolation reading group, we continue the discussion about the relationship between crises (including, but not limited to, public health crises), knowledge/ignorance, and forms of global governance.

“Uncertainty in times of medical emergency: Knowledge gaps and structural ignorance during the Brazilian Zika crisis” is a collaborative paper written by Ann H. Kelly, Javier Lezaun, Ilana Lo, Gustavo Correa Mattad, Carolina de Oliveira Nogueirae, and Elaine Teixeira Rabello (further referred to as Kelly et al.) that came out in Social Science and Medicine at the start of 2020. While the paper was written before the onset of the Covid-19 pandemic, and thus does not engage with it directly, it offers a number of useful perspectives for thinking about the relationship between knowledge, (un)certainty, and mobilization of different forms of (national, local, and supranational/global) actors in the process.

You are welcome to post comments, questions, and thinkpieces in response to the article, or the review itself, below. Please observe the standard rules of academic communication; any offensive comments will be deleted.

The discussion session for this reading takes place on 1 May, 4.30-5.30PM, BST, online via Microsoft Teams. All are welcome; the link to join the meeting is here.

Jana Bacevic

Uncertainty and the subjects/objects of knowledge

Kelly et al. focus on the case of the Zika crisis, the outbreak of a disease associated with microcephaly in newborn children in Brazil, in 2015/16. Zika had been known to medical professionals at least since mid-20th century, but it attracted the attention of the global health community in August 2015, when reports began to emerge of an unusual cluster of microcephaly and other neurological disorders among newborns in areas where the virus had been circulating. The authors note that it was, at least in part, the visual power of photographs – images of infants with unusually small heads – that helped mobilize the response in the media.  The Brazilian Ministry of Health declared a Public Health Emergency of National Importance on 11 November; reports of a potentially high rate of transmission, in turn, led the World Health Organization to declare a Public Health Emergency of International Concern (PHEIC) in February 2016.

What makes the Zika crisis particularly interesting is that, as authors note, “‘the declaration of emergency was not made on the basis of what is currently known about Zika virus infection’ which was very little, but rather ‘on the basis of what is not known about the clusters of microcephaly, Guillain-Barre syndrome, and possibly other neurological defects’ (Heymann et al., 2016)” (Kelly et al, 2020:2). In other words, the WHO did not act on the basis of knowledge (or assessment) of what the cause of microcephaly, and its relationship between mosquito-borne disease could be, but rather on the absence of it. This creates an interesting opening in Frank Knight’s famed distinction between risk and uncertainty: risk is supposed to be calculable uncertainty. Thus, when the WHO acted, it acted not because there was a measurable expression of the likelihood of Zika turning into a global health crisis, but because it was impossible to quantify such likelihood.

[On a side note – if you are interested in the distinction between risk and uncertainty and its historical genesis, and want to move beyond Ulrich Beck, I wholeheartedly recommend Jens Zinn’s ‘Social Theories of Risk and Uncertainty‘; if you are into the core philosophical/epistemological arguments in these discussions, there is a lot of literature but one of best recent things I have read is Eric Schliesser’s series of posts (you can start here – I understand this may cover too wide a ground, but it also provides links to some of the original work in the area). Anyway, back to the main post]

What I found most appealing in Kelly et al.’s article is their distinction between three types of uncertainty: (1) global health uncertainty; (2) public health uncertainty; and (3) clinical uncertainty.

(1) Global health uncertainty concerned the lack of clear evidence for the link between Zika and pre-natal microcephaly (lack of brain growth in foetuses), initially its most pronounced and gravest consequence.

(2) Public health uncertainty concerned the transmission routes and vectors (i.e., whether the condition was mosquito-borne, and how it spread).

(3) Clinical uncertainty concerned lack of clear indicators how to treat cases of Zika or risk to pregnancies, compounded by social inequalities in access to healthcare.

Following the approaches in sociology and anthropology of ignorance (e.g. McGoey, 2012), Kelly et al. are interested not only in the levels on which these ‘unknowns’ were operating, but also what kind of action these kinds of ignorance afforded. In other words, it is by recognizing the productivity of ignorance – the fact that ignorance is not (‘just’, or perhaps even at all) an absence of knowledge, as a strategic method of [un]knowing – that they reconstruct different ways of dealing with the Zika virus (as a generic ‘unknown’). In my own framing, they address the question of how (one and the same) epistemic object (i.e. the Zika virus) can galvanize, or agentialize, different kinds of epistemic subjects (‘knowers’).

As the authors write, while uncertainty on the global level (recognized, in part, through WHO’s declaration of PHEIC) galvanized research into the causes of Zika, this research was mostly focused on the development of explanatory models and predominantly carried out by researchers and institutions in the Global North. Public health uncertainty – concerning, in this case, primarily the transmission within Brazil – enabled, on the one hand, more careful monitoring of conditions of ante- and post-natal care and in Brazil, but, on the other, also raised concerns of discrimination on the basis of location and socio-economic background. Clinical uncertainty, finally, led to very little improvement of overall healthcare provision or treatment; in particular in the case of pregnancies, the states and federal agencies shifted the burden of responsibility to individual women, advising them not to get pregnant at least until uncertainty on the global health level was resolved.

This (inevitably brief) summary illustrates well the kind of global public health inequalities that we encountered, though in sightly different form, in Lakoff’s article. Namely, global systems of public health governance – and, concomittantly, global systems of knowledge production – tend to privilege (and I mean this both in the epistemic and in the more conventional, political-economic sense) the kind of knowledge and the kind of subjects that can speak to concerns of the ‘developed’, rich, Western world. Concerns that fall ‘below’ or ‘outside’ of this scope are usually left to nation-states to solve, and, often – especially in the context of neoliberal health care reforms – even shift the responsibility onto individuals, as in the case of asking women to defer pregnancies in the absence of reliable clinical knowledge. Now, I believe there are clear parallels to be made with the Covid-19 pandemic – for instance, between acts of individual responsibilization (handwashing); structural racism and xenophobia (for instance, the ‘unexpectedly’ high percentage of BME medical professionals dying of Coronavirus infection in Britain; Trump’s notion of ‘Chinese virus’ and, more broadly, racist abuse directed at Asian-looking people); as well as, of course, the privileging of specific centres of knowledge production (for instance, the production of ‘ignorance’ about the effectiveness of methods such as test&trace in South Korea among scientific advisory bodies in the UK – I am writing a paper on this atm).

More broadly, however, here are a few questions I’d start us off with:

•  What are the analogies between Kelly et al.’s analysis, in particular the tripartite classification of uncertainty, and the Coronavirus crisis? Are there other levels, or ‘kinds’ of uncertainty, we could identify? (e.g. economic uncertainty? Political?)
• What kind of knowers or epistemic subjects (institutions, individuals, agencies) are agentified through the Covid-19 pandemic? How are they related? Do we see any contestation between them? (e.g. between different epistemic communities?)
• I’m interested in what people think about the intersection between race/racism, gender, and the ‘visuality’ of Zika vs. Covid-19 crises. On the one hand, as Kelly et al. argue, it was certainly in part the visual salience of microcephaly that helped raise the global alert about Zika; on the other hand, those representations are both racialized (in different ways) and very traditionally gendered (women were presented in their most ‘natural’, traditional, patriarchal role as mothers). How do we judge the ‘non-visuality’ of Covid by comparison (‘the invisible agent’?) How do we think about race/racism, but also gender and class in relation to this?

Looking forward to the discussion!