The COVID-19 Pandemic in Sri Lanka: Contextualising it geographically

By Dr. Nalani Hennayake and
Dr. Kumuduni Kumarihamy

(Continued from Friday)

The statistics and information aside, what this tells us is that the hope for immunization through a vaccine for the coronavirus could be far off than we think. Dynamics of vaccine politics exists within global politics and the capitalist economy. The Drug Controller General of India has approved the Oxford COVID-19 vaccine developed by AstraZeneca and another by the Indian manufacturer Bharat Biotech for emergency care. During his recent visit to Sri Lanka, India’s Foreign Minister had pledged that India would prioritize Sri Lanka when supplying vaccines to other countries. In the same meeting, the Indian Foreign Minister had reiterated “India’s backing for Sri Lanka’s reconciliation process and an ‘inclusive political outlook’ that encourages ethnic harmony while the Sri Lankan Foreign Minister rejoiced in the merits of ‘Neighbourhood First Policy’.” At the same time, it was reported that Sri Lanka is making plans to sign an agreement to secure the COVID-19 vaccine through the COVAX facility, which is already approved by the Cabinet.

Various news reports indicate that Sri Lanka is discussing whether to obtain the vaccines from the United States, Britain, or Sputnik V vaccine from Russia. However, it is clear that Sri Lanka has entered into world politics of vaccines. Such vaccine politics tells us that we need to steadily continue controlling strategies such as social distancing, contact tracing, antigen, and PCR testing, significantly raising awareness at the micro-community level. The kind of resilience that local people display when a family member undergoes an infectious disease such as measles and mumps are remarkable. People must be reminded of their resilience and caring. The communities must be made aware of the importance of safeguarding against the coronavirus, given its increased politicization and uneven possibilities of immunization and care.

While it is difficult to anticipate an equitable distribution of the vaccines globally, Sri Lanka’s situation will be determined by the number of vaccines received and the pandemic’s increased politicization. The WHO recognizes four categories of vulnerable persons/groups: Persons at risk of more serious illness from COVID-19, persons or groups with social vulnerabilities, persons or groups living in closed settings, and persons or groups with a higher occupational risk of exposure to the virus. What guarantees that these groups will be considered on a priority basis and the process of immunization will not be biased towards economic and political power? The global geographies of vaccines communicate to us two important messages. First are the difficulty and the disadvantaged position of obtaining vaccines for Sri Lanka as a less-developed country, and as a result, the COVID-19 pandemic can be protracted. Until the vaccines are obtained and a sizeable population of, at least, the risk category – including the frontline health care and security personal – are immunized, we will automatically be identified as vulnerable territories in terms of bio-security. Second, this vulnerability can be manipulated politically, both globally and nationally, to negotiate other deals with powerful countries to trade with vaccines.

The possibility of uneven geographies of care is a fact that should be anticipated given that a majority of the infected are from what we call ‘low-income, low-social status’ communities. There is now a tendency to identify COVID-19 as a disease of the impoverished. The local government bodies such as Municipal councils must reevaluate their position, not how they have acted to control the pandemic, but what they have failed to do in addressing the social welfare issues of the urban low-income communities.

As we look at the possible geographies of care, it is evident that the existence of a relatively good hospital network (at national, regional, and local levels) with relatively good coverage of the entire country has been immensely helpful in treating and caring for COVID-19 patients and those suspected. In addition to the already existing hospitals, the government has converted various government institutions into treatment centres in different parts of the island. This provides breathing space for the government hospitals when dealing with COVID-19 patients and patients who need critical medical care for other illnesses. It should also not be forgotten that the Public Health Inspectors were a category of lesser-known among the hierarchy of the health workers. Their role in curtailing the COVID-19 pandemic has been indispensable: Working not under the best of circumstances and with the minimum personal protective equipment. The average labourer who was entrusted with the strenuous task of sanitizing public places must be cared for too.

The public health system operationalized through MOH areas, a total of 347 MOH areas, as per the Annual Health Statistics Report 2017, is an essential component of controlling the pandemic now or in the future. The health sector generally receives only 1.59 percent of the GNP and 5.94 percent of the National Expenditure, a measly share for an essential sector. According to the same Report, Sri Lanka records an acute shortage of health personnel. There is a significant shortage of nurses and doctors: One doctor for 1083 people, one nurse per 471 people, one Public Health Midwife for 3533 people. As we look into the possible geographies of care, the significance of Primary Health Care Units, the MOH-based public health system, in maintaining a healthy country is indisputable.

Micro-geographies of COVID-19

In its interim guidance issued on May 18, 2020, the directive issued by the WHO is as follows: “Physical and social distancing measures in public spaces to prevent transmission between infected individuals and those who are not infected, and shield those at risk of developing serious illnesses. These measures include physical distancing, reduction or cancellation of mass gatherings and avoiding crowded spaces in different settings (e.g., public transport, restaurants, bars, theatres), working from home, and supporting adaptations to workplaces and educational institutions. For physical distancing, WHO recommends a minimum distance of at least one meter between people to limit the risk of interpersonal transmission.” Thus, the WHO recommendation includes two components: physical distancing of one meter between people and social distancing as much as possible in the social events, gatherings, etc.

This requirement was initially communicated as social distancing (සමාජ දුරස්ථභාවය) in Sri Lanka. The exercise of ‘physical and social distancing’ during COVID-19 reminded us of the work of two Political Geographers, Robert E. Norris, and L. Lloyd Haring. They argued that “every person has [is] a portable territory that is larger than the space s/he physically needs” (1980:9). They further wrote that “This territory is called personal space. It is similar in some ways to a political territory. Both personal space and political space are bounded, occupants of each type of space interact with each other of their kin, and uninvited intruders in both types of areas cause stress and behavioural changes within the intruded area.” It is imperative to understand that the personal space or the portable territory is unique to each individual in both size and shape, and they may vary over time and space, according to their specific individual requirements. In such a situation, how can we/how do we regiment this personal space in fear of the uninvited intruder of the coronavirus pathogen, through a standard measure of one or two meters between individuals? Until the COVID-19 pandemic emerged, this space, the portable territory of ours, had been taken for granted. We operated with a sense of relative autonomy over our portable territories. Now, we are told by the state and those in charge of controlling the pandemic how to operate these portable territories, maintaining a distance of one to two meters from each other. It is also expected that every person would carry out this ‘social distancing’ uniformly.

In early years, geographers were influenced by the science of spatial distancing, proxemics, introduced by the Cultural Anthropologist Edward T. Hall, who studied proxemics to understand human spatial behaviour at a micro-scale. In his famous book, “The Hidden Dimension,” published in 1966, he introduced a typology of human spatial distancing. This typology classifies the micro-spatiality of human beings into four types of spaces: intimate space, personal space, social space, and public space. Each type of space is demarcated with a specific distance, internally divided into a near phase and a far phase. The ‘portable territory’ mentioned above includes the intimate and personal spaces in this typology. According to Hall’s generalization, these portable territories end at four feet (1.2 meters), where social space begins. In his typology, ‘social space’ (See Diagram 01) spans between four to twelve feet, which is housed between personal and the public space. Edward T. Hall elaborates that “a proxemic feature of social distance is that it can be used to insulate or screen people from each other” (1966: 123). Social distance thus demarcates the end of physical dominion of an individual or, in other words, literally the jurisdiction of the portable territory.

Diagram 01: Distance Typology

In the case of COVID-19, hypothesizing that every person could be a possible carrier of the pathogen, one must maintain the one-metre distance. The distance of one-meter marks the outer boundary of the personal space and the inner boundary of the social space. An effective way to control the pathogens’ spread is to ensure that one strictly remains within one’s portable territory or, control people’s proxemic behaviour. This is very challenging since human beings have been civilized as social beings with defined and undefined social spaces!

Social distancing has become our new norm, and there is an undeniable need for this restriction. However, proxemic behaviour is not entirely an individual matter of concern. People of different cultures display different proxemic patterns; in other words, proxemic patterns are culturally highly conditioned. The concepts of ‘near’ and ‘distant’ are culturally different and relative. “The specific distance chosen (between two or more individuals) depends on the transaction, the relationship of the interacting individuals, how they feel and what they are doing… (Hall, 1969: 128). Human space requirements are generally influenced by his/her environment and surroundings and cultural norms. It is essential to understand the various elements in the immediate surroundings and the larger social context that contribute to our sense of spaces, distances, and relations. Implementers of social distancing may think that all people in a queue are potential carriers of the coronavirus, and therefore, one must maintain a distance of one meter. But some people may feel uncomfortable with social distancing simply because they may have socialized into different proxemic patterns.

Our proxemic behaviour may change, given the particular circumstances. For example, the need to feed a crying child at home, ailing parents, or one’s family overrides the fear of the virus, and the social distance is often contracted, in fear the person in front may grab what you may need. How people feel about each other at a particular time in a given space is a decisive factor in maintaining distance. In his study, Edward T. Hall explains that when people are angry and frustrated, they unknowingly tend to move closer. Some people often forget or become inconsiderate about maintaining social distance simply because of the urgency that being served in a regular queue entails. On such occasions, people are often characterized and labelled as irrational, undisciplined, and even unruly, whereas in political gatherings, opening ceremonies, personalized ‘bodhi pujas,’ etc., proxemic behaviour is often overlooked.

The standard proxemics required to control the COVID-19 pandemic are not realities for people who live in congested localities such as urban low-income areas and plantation areas where COVID-19 is fast spreading. Public services and commercial activities must be streamlined to facilitate a rational proxemic behaviour to maintain the social distance (see, for example, photograph no.1), with the understanding that the proxemic behaviour is culturally conditioned. It is very self-explanatory. Our discussion on proxemics here is not an argument against the requirement of one-meter restriction or any other form of social distancing. But understanding the cultural nuances of proxemics helps us be sensitive and intelligent when handling difficult situations rather than labelling people as irrational, undisciplined, and uncultured.

Few conclusive thoughts

What we have tried to emphasize in the article is the need and value of contextualizing the COVID-19 pandemic geographically. There are two aspects to this. First, it is imperative that the prevalence of the COVID-19 is mapped at the GN level with the available data focusing on individual MOH divisions. With our ‘sample’ exercise of Kandy, we have shown that a better spatial picture can be derived from GN level mapping. Since the MOH division, among others, is a crucial operational spatial unit for matters of public health, it is essential to map the number of COVID-19 patients at the MOH level, preferably even randomly locating them within GN divisions. The unintended benefit of such mapping would be that the existing health record systems (IMMR/eIMMR, etc.) will be further developed as a spatial health record system. A spatial health record system helps to understand the ecological dynamics of any disease and can be used as a real-time health monitoring and surveillance tool. The existing health record systems contain patients’ identity numbers (bed-head ticket number), age, gender, postal address, etc. If locational information such as GN, DSD, and district can be added, the data can easily be extracted at any spatial unit from the database for analysis in a crisis. Moreover, the postal addresses can be converted to Geographic Coordinates, indicating the patients’ geographical locations, using geocoding techniques.

Second, it is essential to understand the socioeconomic and ecological contexts of areas where the disease spreads at high intensity. Such a task is made difficult because of the unavailability of data relating to socioeconomic contexts at the GN level. However, the existing administrative system and its resources (Divisional Secretaries, Grama NIladharis, etc.) can be utilized to gather information about local areas. The process of controlling the pandemic must be localized with the MOH as the key operational spatial unit while adhering to national health guidelines and ethical concerns. It is time for the MOH-led system to take pro-active measures (i.e., creating awareness), in collaboration with the existing administrative setup, community organizations and networks, to safeguard the areas where the disease has not yet spread. Most importantly, this process needs to be monitored at the district level. Perhaps, district task forces need to be established to assess and take stock of the district’s current situation, preferably at the GN division level, and implement management and preventive measures.

In its recommendations, the WHO has repeatedly emphasized the need to adhere to both public health and social measures and, very importantly, select and ‘calibrate based on their local context.’ The WHO writes very clearly in its ‘COVID-19 Global Risk Communication and Community Engagement Strategy,’ that “COVID-19 is more than a health crisis; it is also an information and socioeconomic crisis.” It highlights the need to be ‘informed by data that cover the community needs, issues, and perceptions’ and engage with the communities. When the pandemic becomes protracted and the vaccines are not within reach, it is crucial to engage with the communities at the lower levels to respond to the COVID-19 pandemic. The authorities must pay special attention to the areas that it has not yet spread and take pro-active measures to safeguard those areas, perhaps with the assistance of community organizations and institutions to create awareness among communities.

It appears that people are becoming complacent, and this can exacerbate the situation. Generally, people expect the government to control the second wave and are less inclined to take responsibility for individual behaviours and public health and social measures. On the other hand, the government seems to expect the full responsibility to be taken by the individuals. As the pandemic situation is drawn out, people tend to take risks for granted and assumes normalcy. Such complacency can be detrimental to the process of controlling the pandemic. Such complacency is also a result of poor or lack of communication about the disease, specially among vulnerable communities. Although the Ministry of Health has developed a comprehensive set of health guidelines, whether they are effectively communicated to the people is a matter of concern. Many people cannot grasp the severity of the disease and the significance of adhering to preventive health and social measures. Therefore, authorities must seriously consider sharing the responsibility of controlling the pandemic with the communities.

Finally, while we encourage mapping as a tool that can facilitate better decision making, it is important to understand that maps, and even charts and diagrams, etc., can become ‘political technologies.’ Such political technologies can instil a sense of concern, fear, and anxiety among the decision-makers and the public. We see that the pandemic is fast politicized in Sri Lanka. Mapping and geo-visualization of COVID-19 should not be ruled out either in fear of exposure or political manipulation, as it may suggest how the pandemic needs to be acted upon effectively at the local level.

Dr. Nalani Hennayake teaches a range of Human Geography courses) and Dr. Kumudini Kumarihamy teaches GIS and Health at the Department of Geography, University of Peradeniya.

(Concluded)