The U.S. has bungled many of its efforts to rein in the Covid-19 pandemic. We believe that Francis S. Collins, the former director of the National Institutes of Health, perfectly captured the country’s fundamental flaw:
“Maybe we underinvested in research on human behavior,” he told Judy Woodruff during an interview for PBS NewsHour. “I never imagined a year ago, when those vaccines were just proving to be fantastically safe and effective, that we would still have 60 million people who had not taken advantage of them because of misinformation and disinformation that somehow dominated all of the ways in which people were getting their answers.”
In just 60 words, Collins captured the limitations of the nation’s biomedicine-centric coronavirus response strategy, which has grossly underutilized insights and expertise from the behavioral and social sciences that might have bolstered the likelihood that the country’s single best tool — effective vaccines — would achieve their potential to stop a highly contagious, rapidly evolving respiratory virus in its tracks.
Instead, more than 950,000 people have died in the U.S. from Covid-19. Nearly one-third of those deaths occurred after all U.S. adults became eligible to be vaccinated against the disease. Another 100,000 excess deaths have been attributed to overwhelmed emergency and critical care systems, lack of access to clinical care, including for substance use and mental health disorders, exhausted care providers and essential supplies, compromised and inequitable quality of care, overdoses, and more.
Perhaps most unsettling is the fact that much of this devastation might have been avoided by including knowledge from the behavioral and social sciences in the Covid-19 response. The global fight against the human immunodeficiency virus (HIV) offered important — yet largely unheeded — lessons for anticipating and addressing the behavioral and social dimensions of the Covid-19 pandemic.
Take, first and foremost, the impact of misinformation and disinformation that Collins referred to. In HIV prevention research, social media platforms were well-known for promoting risky sex and drug-use behaviors, spreading misinformation and reinforcing stigma associated with HIV and other sexually transmitted infections. The implications were real: Social media advertisements containing false medical information or perpetuating misleading information led half of the at-risk people in one cohort study to decide not to use a safe, effective medicine to prevent HIV infection.
The impact of misinformation or disinformation is even more staggering when its source is a government official. In the 1990s, South African President Thabo Mbeki joined AIDS denialists who claimed that poverty, unstable housing, and other illnesses — not HIV —were causing immune collapse among South Africans. Years later, a Harvard study estimated that more than 300,000 people in South Africa died needlessly as a result of the government’s position, which delayed acquisition of antiretroviral medications to prevent mother-to-child transmission of the virus.
In the U.S., a Cornell University study of social media coverage concluded that then-President Donald Trump was the single largest driver of Covid-19 misinformation in early 2020, including his endorsement of unproven medical treatments. A Lancet Commission report estimated that 40% of Covid-19 deaths in the U.S. in 2020 might have been averted had the Trump administration dispensed with tax cuts for the wealthy and instead maintained public health infrastructure, housing subsidies, and other measures common to other high income countries.
The strategy to confine the outbreak in the U.S. was based on biomedical reductionism, which reduces infectious diseases to their biological, chemical, and physical aspects. The problem with this approach is that it offers a false assurance that advances in biomedicine — new tests, vaccines, treatments, and the like — will be uniformly accepted, and all individuals will act rationally in their own self-interest as defined by medical and public health officials. But it’s been known for years that social, structural, and cultural factors influence decision-making, often in directions that run counter to scientific consensus.
Valorization of the biomedical defines not only what data are relevant to pandemic planning, but also determines who is tapped to speak publicly about the pandemic and its clinical and public health impacts. News organizations have overwhelmingly turned to virologists, immunologists, epidemiologists, and clinicians in their Covid-19 coverage. But these experts can provide perspective on only discrete pieces of the larger puzzle.
Worse, these and other “celebrity scientists” are often encouraged to proffer hunches about non-biomedical dimensions of the pandemic that experts in sociology, anthropology, psychology, and political science are better equipped to discuss.
Closer to home, we’ve observed that even at the University of California, San Francisco, the institution one of us (J.D.A.) is affiliated with, which houses an NIH-funded HIV research center with a deep bench of behavioral and social science expertise, only five of the 111 invited speakers at its Department of Medicine’s Covid Grand Rounds between March 2020 and November 2021 were people with advanced degrees in disciplines relevant to the non-biomedical aspects of the pandemic.
Federal task forces charged with developing and refining the pandemic strategy are dangerously thin on perspectives that reflect the disciplinary pluralism required to optimize the use of biomedical tools to end the pandemic and live with some endemic version of Covid-19.
Socio-behavioral research on HIV has shown that individual behaviors — including the uptake and use of biomedical tools like vaccines — are shaped extensively by the social norms and practices of the groups people identify and affiliate with. Using a social public health approach informed by these insights, San Francisco and Australia made impressive gains in stemming their respective HIV epidemics by developing and implementing interventions that built meaningful collaborations between affected communities and biomedical, epidemiological, and behavioral researchers, clinicians, and policy makers. To do so, they enlisted social influencers, such as community peers and trusted clinicians, to alter individual behaviors.
It will only be a matter of time before the next infectious disease outbreak occurs. A more comprehensive framework than has been employed so far — one that takes advantage of disciplinary pluralism to use the range of relevant scientific expertise and methods for understanding and responding to epidemics — may help optimize the response to future public health emergencies. Such a framework would reflect the reality that infectious disease epidemics, like Covid-19 and HIV, are fundamentally about the emergence of a pathogen that is transmitted by humans in social contexts.
All of these interconnected aspects must be addressed with the best available evidence born out of ongoing collaboration among, and public engagement with, experts in biomedical, behavioral, and social sciences.
Judith D. Auerbach is a sociologist and professor of medicine at the University of California, San Francisco. Andrew D. Forsyth is a psychologist and former director of the California HIV/AIDS Research Program.