Big Events theory and measures may help explain emerging long-term effects of current crises

ABSTRACT

Big Events are periods during which abnormal large-scale events like war, economic collapse, revolts, or pandemics disrupt daily life and expectations about the future. They can lead to rapid change in health-related norms, beliefs, social networks and behavioural practices. The world is undergoing such Big Events through the interaction of COVID-19, a large economic downturn, massive social unrest in many countries, and ever-worsening effects of global climate change. Previous research, mainly on HIV/AIDS, suggests that the health effects of Big Events can be profound, but are contingent: Sometimes Big Events led to enormous outbreaks of HIV and associated diseases and conditions such as injection drug use, sex trading, and tuberculosis, but in other circumstances, Big Events did not do so. This paper discusses and presents hypotheses about pathways through which the current Big Events might lead to better or worse short and long term outcomes for various health conditions and diseases; considers how pre-existing societal conditions and changing ‘pathway’ variables can influence the impact of Big Events; discusses how to measure these pathways; and suggests ways in which research and surveillance might be conducted to improve human capacity to prevent or mitigate the effects of Big Events on human health.

KEYWORDS:

• Complex emergencies
• HIV
• drug use
• social movements
• coronavirus

The world is undergoing a Big Event

Big Events (Bunting et al., 2021; Friedman, 2021; Friedman et al., 2006; Friedman et al., 2009; Friedman et al., 2013; Friedman et al., 2015; Friedman et al., 2015b; Friedman et al., 2017; Friedman et al., 2020a; Friedman & Rossi, 2015; Nikolopoulos et al., 2015; Pouget et al., 2015; Pouget et al., 2016; Vasylyeva et al., 2018) are periods during which ordinary life is disrupted, expectations and assumptions become destabilised, and beliefs and norms can change rapidly; they often involve abnormal political events and social and/or revolutionary movements which can occur acutely or emerge progressively over time, any one of which might be viewed as a ‘crisis.’ The emergence of the COVID-19 pandemic, and its resulting changes in regulations and daily life, greatly exacerbated the economic slump that began in Fall 2019. Further, the ever-worsening effects of global climate change on human societies have created crises in many countries, and is likely to cause future pandemic crises as well (Davis, 2012; Dobson et al., 2020; Friedman, 2021; Malm, 2020; Preventing the next pandemic - Zoonotic diseases and how to break the chain of transmission, 2020; Sharp & Hahn, 2011; Wallace et al., 2020; Wallace & Davis, 2016; Weiss & McMichael, 2004). Global climate destruction, the COVID-19 pandemic, and the 2019 economic slump combine to create a global Big Event (Salas et al., 2020).

Globally (WHO Coronavirus Disease (COVID-19) Dashboard, 2020), as of 12 January, 2021, there had been over 89 million confirmed cases of COVID-19, including almost 2 million deaths, reported to WHO. The four countries with the largest numbers of confirmed cases were United States, India, Brazil and the Russian Federation. Death rates per 100,000 population as of that date were highest in Italy, Czechia, United Kingdom, United States, and Spain as given by https://coronavirus.jhu.edu/data.

Economically (Trading Economics, n.d.), the world economy was in what the International Monetary Fund called a ‘synchronized slowdown’ by mid-2019 (Gopinath, 2019), and may already have been slipping into a recession by Fall 2019, but we can say with a certainty that the COVID-19 pandemic, and the shelter-in-place strategy which it evoked, led to an economic crisis (Global Economic Prospects, 2020). Well-documented consistent statistics demonstrate the pandemic-affected a broad array of major economies including the United States, the European Union, the United Kingdom, and Japan which have undergone great declines in GDP and in corporate profits, and seen large increases in unemployment. For example (Trading Economics, n.d.), the Euro Area economy, stagnant since Summer 2019, shrank 11.8 percent in the three months to June of 2020. China experienced similar declines, but has recovered to some extent (although the continued decline in the world economy threatens this (Global Economic Prospects, 2020)). Over the course of 2020, it became clear that national patterns of economic decline varied widely, but as the World Bank argued in June, 2020, future effects could be severe globally (World Bank, 2020).

The United States provides a clear illustration of the convergence of multiple, intersecting crises in 2020. These include the COVID-19 pandemic and its associated social distancing policies, an economic crisis and rapidly increasing economic inequality, For example, the Gini Coefficient of income inequality for the United States increased from 1990 to 2008, and since then hovered near 0.48, but all indications are that inequality in the United States (and many other countries) increased greatly during 2020 (Qureshi, 2020; Statista, 2020). These crises also include a major social movement challenge to long-established patterns of racist policing (Vitale, 2017), racist politicians (Clark, 2020), long-term disparities and oppression, together with the development of sometimes-violent racist responses to this. Further there have been the beginnings of what could be a major strike wave in multiple trades and sectors (Greenhouse, 2020), anda range of climate disasters in different parts of the country, including widespread fires, spreading drought and increasing frequency of severe hurricanes, There has also been serious political polarisation in which disagreements among the powerful have eroded trust in public, particularly public health, institutions and for some in the integrity of electoral processes (Dovre, 2020).

This paper presents and discusses(Bunting et al., 2021; Friedman, 2021; Friedman et al., 2006; Friedman et al., 2009; Friedman et al., 2013; Friedman et al., 2015a; Friedman et al., 2015b; Friedman et al., 2017; Friedman et al., 2020a; Friedman & Rossi, 2015; Nikolopoulos et al., 2015; Pouget et al., 2015; Pouget et al., 2016; Vasylyeva et al., 2018) a ‘Big Events’ framework with which to understand potential effects of these events on public health, particularly but not exclusively in the United States, with considerable emphasis on the spread of infectious diseases and on potential increases in numbers of persons who use high-risk drugs. The Big Events framework was originally developed through trying to understand the effects of earlier Big Events that in some places seem to have initiated major HIV epidemics whereas in other places they did not(Friedman & Reid, 2002; Friedman & Rossi, 2015). This research made it clear that the public health effects of Big Events are not deterministic, developed hypotheses that certain key (‘pathways’) variables would affect the outcomes, and that more research is needed on what constellation of forces and pathways of change actually lead some Big Events to lead to epidemics and others not to do so. Thus, this Big Event framework can point to possible interventions to avert additional public health problems that can develop as a result of Big Events.

The rest of this paper first presents a framework with which to guide this research, including a select number of hypotheses about potential short-term and long-term consequences of these Big Events. It also briefly summarises a number of innovative questionnaire-based measures (Friedman and Rossi, 2015; Friedman et al., 2020a; Friedman et al., 2013; Pouget et al., 2016) which we developed to assist in such research as well as in surveillance systems to determine if a given Big Event (such as the world is now going through) will lead to epidemics or other public health disasters or not.

General model of Big Events processes (Rossi, 2015)

Figure 1 presents a general model of how Big Events can affect a number of social conditions, life conditions, subcultural norms, risk environments, risk and protective practices and networks, and infectious diseases (Arinaminpathy & Dye, 2010; Barnett & Whiteside, 2007; Bonovas & Nikolopoulos, 2012; Friedman et al., 2009; Friedman, 2021; Friedman et al., 2009; Friedman et al., 2006; Friedman et al., 2015; Friedman et al., 2020a; Friedman et al., 2017; Friedman & Rossi, 2011; Friedman & Rossi, 2015; Friedman et al., 2009; Friedman et al., 2013; Friedman & Reid, 2002; Hankins et al., 2002; Nikolopoulos et al., 2015; Pouget et al., 2015; Pouget et al., 2016; Rhodes et al., 2002; Rhodes & Simic, 2005; Roberts et al., 2010; Robinson, 2011; Rossi et al., 2011; Strathdee et al., 2006; Vasylyeva et al., 2018; Wallace & Wallace, 1998). Big Events and their effects interact with pre-existing social and political institutions, ongoing (behavioural, social and structural) trends that reflect more gradual processes of change over time, and a given distribution of socioeconomic conflicts and cultural divisions(Barnett et al., 2000; Davis, 2012; Dobson et al., 2020; Foster & Brooks-Gunn, 2015; Friedman, 2021; Malm, 2020; "Preventing the next pandemic,’ 2020; Sharp & Hahn, 2011; Wallace et al., 2020; Wallace & Davis, 2016; Weiss & McMichael, 2004).¹ These social structures, social processes, conflicts and divisions contribute to how people experience Big Events and how they are or are not able to react to them. Big Events can increase social and political divisions and further exacerbate marginalisation and deprivation of historically marginalised and impoverished groups. Big Events can lead to unemployment and disrupt other economic activities. They can also alter young (or older) people's sense of possible futures (for worse or better). Some Big Events disrupt educational systems, or greatly alter people's ability to manage their time or their living conditions in other ways. Such disruptions by Big Events can lead to the reshaping of people's social networks, their normative environments, and their thoughts and worldviews about their lives, futures and society. Negative health consequences often result, as is described below.

Figure 1. General model of Big Events Processes end Epidemiologic Outcomes.

Importantly, Big Events may lead youth to perceive the life histories, norms, and values of parents and grandparents as irrelevant to changed realities and thus ignore them in responding to the new social circumstances. Such ‘intergenerational normative disjuncture’ can lead to independent youth cultures that generate beliefs, values and codes that differ from previously dominant patterns. As happened in the Former Soviet Union, but much less so in Argentina, intergenerational normative disjuncture led to a great increase in drug use and risky sexual practices among youth.

Big Events may also disrupt or otherwise alter political, social and public health institutions, and thus the ways in which people can get help (or are harmed by) institutions.

This model can be clarified by examining the conditions in Russia, Ukraine, and many other former Soviet bloc countries. The Big Events of the 1980s and early 1990s led to the fall of the former Soviet Union, the selling off or seizure of many State enterprises, the disruption of social support systems, and an economic collapse (Aral & St Lawrence, 2002; Friedman & Reid, 2002; Friedman et al., 2009; Friedman et al., 2009; Friedman & Rossi, 2015; Jenkins et al., 2005; Lagerspetz & Moskalewicz, 2002; Rhodes et al., 2002; Strathdee et al., 2006). In these countries, many adults found their lives, daily routines and incomes disrupted and their futures unclear. Alcoholism, diseases related to alcoholism, mental health problems, and poverty rapidly increased. Many teenagers and emerging adults found themselves in a state of intergenerational normative disjuncture because the world of relatively stable jobs and social and income supports that their parents had based their values and norms had been disrupted by these broad social changes. Facing dreary and unpredictable futures, a widespread youth culture of substance use and/or sexual enjoyment developed. For many, particularly women, this led to earning money or goods through sex trading, and perhaps to sexual abuse and exploitation. Drug markets rapidly expanded, and injection drug use became very widespread. Huge epidemics of sexually transmitted infections (STIs), viral hepatitis and HIV/AIDS followed. In Russia, State ‘narcological’ institutions retained historical ideological continuity in supporting punitive approaches to drug use and eschewing harm reduction approaches such as methadone treatment and syringe exchange; and the HIV and hepatitis C epidemics persist on a large scale. In contrast, in Ukraine, widespread harm reduction was adopted to public health scale in the first half of the 2000s, and HIV incidence rates have since fallen.

Other countries that went through Big Events have gone through somewhat parallel processes. As and after apartheid was defeated, many non-White residents of South Africa experienced considerable mass disappointment, as their prior hopes for higher real incomes and equality went unfulfilled. Alcoholism and sexual risk behaviours were already high, though it is unclear and extremely hard to measure whether they then changed. Residential and travel patterns changed with the end of apartheid in ways that probably altered sexual mixing patterns, but again more research is needed to understand the effects of this on HIV or other diseases. Whatever changes did take place interacted with pre-existing patterns of group sex with women who sold sex in the mines and of sexual violence. These changes and failures in prevention and care (see below) set the stage for the world's worst HIV epidemic. Furthermore, the Big Events around the fall of apartheid and what turned out to be an austerity approach to economic development under the new regime led to bureaucratic delays and to reductions in size and state funding of public health systems, which slowed the response to the emerging epidemic (Decoteau, 2014; Friedman & Reid, 2002; Friedman & Rossi, 2015; Jaiswal et al., 2020; Kalichman et al., 2010; Marais, 2007; Strathdee et al., 2006). The effect of this was greatly magnified by HIV denialism by the Mbeke presidency after he replaced Mandela as the country's leader. In Greece after the economic crisis that began in 2008 and an ensuing period of massive demonstrations and political uncertainty, many people who already injected drugs became homeless, and there were increases in risk behaviour, in the density of risk networks, and reductions in harm reduction services leading to an HIV epidemic among PWID (Nikolopoulos et al., 2015). A number of other countries have also had major infectious disease outbreaks and/or increases in substance use or alcoholism after Big Events (Becker & Drucker, 2008; Daniels, 2019; Friedman et al., 2009; Friedman & Rossi, 2015; Khang et al., 2005; Kondilis et al., 2013; Strathdee et al., 2006).

On the other hand, such negative consequences do not always occur (Becker & Drucker, 2008; Friedman et al., 2009; Friedman et al., 2009; Friedman & Rossi, 2015; Spiegel, 2004). In Argentina after the major economic crisis beginning in the later 1990s and after social and political mobilizations that ousted five successive presidents in December 2001-Januray 2002, social involvement and struggle remained high. (This included efforts by neighbourhood activists, families of drug users, drug users, and harm reductionists to shape the extent and nature of drug use.) Due to the threat of social revolution, international power centres allowed the reformist government of Nestor Kirchner to retreat from neoliberal austerity, which let the economy stabilise to a large degree. Community groups and workers came to feel an increased sense of effectiveness and thus were able to establish somewhat new ways of thinking and acting suited to the new situation. Intergenerational normative disjuncture did not occur, and although there was some growth in coca paste use, there was no widespread increase in HIV or other risk behaviours, and no large-scale outbreak of substance use or of infectious diseases.

Similarly, wars and similar events in Africa seem not to be correlated with the magnitude of their HIV epidemics (Becker & Drucker, 2008; Spiegel, 2004). Social crises and the fall of the dictatorship in the Philippines in the late 1980s likewise did not lead to a large HIV epidemic.

Big Events theory was developed as a way to understand what appear to be contingent outcomes of major crises (big events)—that is, what circumstances and processes shape the probability that a Big Event will or will not lead to large epidemics in a given time and place. As will become clear, these processes can include bidirectional causation, uncertainty, feedback loops, and a wide range of pathways variables.

Example of the current Big Event: The United States

To exemplify the logic of Big Events and how they affect public health, we will discuss how these are developing in the United States. Given the global importance of the US, these events are likely to ramify to other countries economically, socially, politically and epidemiologically.

A number of salient pre-existing characteristics have shaped who has suffered during the Big Events of 2019–2020 in the United States, how these individuals have reacted, and what the national policy responses have been. Characteristics of the USA in early 2019 include ("COVID-19 Strike Wave Interactive Map," n.d.; Goldfield, 1997; "Intergovernmental Panel on Climate Change," 2014; Levy & Patz, 2016; Moody, 2014, 2018; Volkow, 2020):

1. Hegemonic neoliberalism and possessive individualism

2. 45 years of ‘one-sided class war’ and neoliberal reaction that lowered workers’ earnings and gutted public health infrastructures (Friedman, 2020a)

3. Large wealth and income inequality

4. Political division with racist and sexist national leadership and rancorous political stand-off between two political parties

5. Structural racial oppression, including housing and occupational segregation, mass incarceration, and racial-ethnic disparities in comorbid and syndemic non-communicable disease epidemics including obesity (Petersen R & Blanck, 2019), diabetes (Rodríguez & Campbell, 2017), and heart disease (CDC, 2019; Graham, 2015), each of which is a risk factor for COVID-19 disease, and all of which are in part driven by structural factors and neoliberal policies and practices (Swinburn et al., 2011; "Where Health Disparities Begin," 2011).

6. Considerable mass activism and mobilisation around racist policing. This took form in the early years after 2011, became large scale in 2014 around police killings and other racial policing in Ferguson, Missouri, and then greatly increased in 2020 after police killings of Black people (Breonna Taylor in Kentucky and George Floyd in Minnesota).

7. Millions of members of younger age cohorts had become alienated and somewhat activist around issues of mass shootings at schools, looming climate catastrophe, student debt, and constipated economic prospects

8. Large scale social movements were already developing around Black Lives, Latinx and other oppressed groups, climate, and labour conditions. Mass teachers strikes took place in the years leading up to 2019.

9. An enormous opioid/stimulant/overdose that had grown rapidly since the mid-1990s and were killing approximately 70 thousand people per year through overdose

10. A (global) climate crisis already beginning to manifest in increased forest fires, drought, and hurricanes in various parts of the country.

These characteristics shaped the United States experience of the Big Events of 2019–2020. An economic crisis began to emerge in 2019, and then COVID-19-related social distancing and closure of many workplaces greatly deepened both the economic crisis and pre-existing sociopolitical crises. Policies to maintain people's income, housing access, and utilities access were implemented at first (although to a lesser degree than in many other countries) but were then reduced or ended. People's ability to work remotely, or even to shelter-in-place or self-quarantine, has been (and remains) highly variable depending on race and class differences in housing and income. More than one fifth of US households lack the space or plumbing to adhere to guidelines to limit household transmission of COVID-19 (Sehgal et al., 2020). People who were able to work remotely and whose jobs did not disappear were somewhat cushioned against the economic slump, but millions of other people lost their jobs or had their working hours (and pay) reduced. ‘Essential workers’ may have retained their jobs, but often had to work in unsafe conditions, and thousands became sick and died from COVID-19. Both those who lost jobs (or pay) and those who had to work (Baker et al., 2020; "Characteristics of Health Care Personnel with COVID-19,’ 2020; Oliver, 2020; Ramos et al., 2020; Silver et al., 2020)in unsafe conditions were disproportionately poor and or members of racially-oppressed groups.

Unlike in many European countries, there was no attempt to guarantee continued employment to workers threatened by layoffs, but instead a few months of income support were provided to people who needed it plus a limited support programme for businesses. Housing supports for those requiring quarantine were limited. Restrictions on movement and rules about wearing masks in public were sporadically enforced—and, in some cases, were mainly enforced, and punished visited upon, Black people and other racial or ethnic minorities (Parshley, 2020). Maks wearing and social distancing became highly politicised: extreme right-wing individuals and groups sought to build support by appealing to neoliberal and earlier anti-State ideologies to organise demonstrations and mass defiance of these rules. Further—and in this the United States resembled other capitalist countries—many businesses pressed to remain open or to re-open as soon as possible even in circumstances where this would worsen the pandemic.

Additionally, the US public health infrastructure is weak, fragmented, and ineffective(Barnett et al., 2020; Maani & Galea, 2020; Schultz, 2020; Woolf et al., 2013), as is true of many other countries (although arguably uniquely so.) It has been estimated the US faces a $4.5 billion shortfall needed to enable a minimum standard of foundational public health response (Maani & Galea, 2020). This meant that coronavirus testing, isolation, quarantine, and contact tracing efforts needed to interrupt viral transmission were limited—and the conflicting messages emerging from a polarised political leadership and sometimes-complicit local and national health bureaucracies made it even harder to reduce coronavirus transmission.

Since US labour unions are very weak and the working class lacks a strong political presence in American politics (Friedman et al., 2020b), most workers in many occupations lacked ways to demand working conditions that would not expose them to the coronavirus and little ability to win access to adequate personal protection equipment. Many lacked paid sick leave and thus went to work even if they were sick. Many hospital workers were required to take care of infected patients with inadequate access to personal protective equipment, and were asked to re-use face masks or other equipment in circumstances where this clearly was dangerous. These conditions led to many workers in hospitals, nursing homes, meatpacking industries, warehousing and public transportation, among others, getting infected and, in some cases, dying (BMJ, 2020; Cordon, 2020; "Essential and Vulnerable,’ 2020; Guse, 2020; Harrison, 2020; Long & Rae, 2020; Ranji & Salganicoff, 2020; Rankin, 2020; Rivett et al., 2020; Waltenburg et al., 2020; White et al., 2021; Xu et al., 2020). During massive outbreaks of COVID in meatpacking facilities in the US, the administration classified these facilities as ‘essential’ by activating the Defense Production Act, which forced an already exploited workforce to show up to their shifts and risk acquiring COVID or stay home and risk their wages and their jobs (Krebs, 2020).

These conditions contributed to a wave of wildcat and official strikes in meatpacking, warehousing, nursing and other occupations. In late Summer and early Fall, 2020, as schools were reopening, teachers unions mobilised to a limited degree and won some safety improvements. This extended to universities and colleges where some strikes also took place. The organising and militancy by teachers and some other workers built on widespread rank-and-file organising and a wave of wildcat and, in some cases, union-authorized strikes, by teachers in the years since 2010 (Blanc, 2019; Weiner, 2015).

Black, Native American and Latinx people were particularly hard hit by COVID-19, with infection rates, hospitalisation rates, and death rates that were disproportionately high (Artiga et al., 2020). Factors that contributed to th included: 1. their concentration in essential and other occupations that stayed open during the economic shutdowns (Rogers et al., 2020; The, 2020); 2. their overcrowded and segregated living conditions that were products of Federal and State housing policies, of bank and real estate industry policies (Akbar et al., 2019; Bond & Williams, 2007; King & Mieszkowski, 1973; Williams & Collins, 2001), 3. a long history of racist attacks on nonwhites who moved into many ‘white’ neighbourhoods (Bell, 2016; Light & Thomas, 2019); 4. less access to, and lower coverage by, health insurance in a country where health is dominated by private industry and private health insurance (Poteat et al., 2020); and 5. widespread experience of racist stigma by doctors, nurses and other staff at many clinics and hospitals that led infected members of oppressed communities to be slower to seek care (Budhwani & De, 2019). (This, in turn, meant both that they infected family members, co-workers and neighbours and also that they were more likely to have worse treatment and higher death rates once they did go for treatment (Artiga et al., 2020; Garg et al., 2020; Moore et al., 2020)).

As mentioned above, during the five years before these Big Events began, there had been many protests against police violence against Black people and other groups who are racially/ethnically subordinated in the United States. More than 1,000 Black people were killed by police in some years, for example; and police killings of Black people have been shown to be associated with subsequent rates of sexually transmitted infections in large US metropolitan areas (Feldman et al., 2017a, 2017b; Ibragimov et al., 2020). In 2020, police killings of Black people led to a great strengthening of these Black Lives Matter demonstrations, and to considerable more participation in them by youth and whites. These demonstrations in some cities became daily or nightly mass activities, usually nonviolent except when provoked by police or racist vigilantes. Racists and the reactionary right have mobilised against these demonstrations, sometimes with the tacit support of the local police, and repeatedly with support from the President of the United States and his allies. Agents of the Federal Homeland Security Department attacked protesters in extended confrontations in Portland, Oregon, and high officials referried to Black Live Matter demonstrators as ‘terrorists’ and levelied Federal charges against some of them (Ali, 2020). On occasion, workers organisations mobilised in support of these demonstrations either by recruiting members to take part in them or by taking sympathy strike action (as in a June 19, 2020 strike by longshore workers (DeManuelle-Hallenlarge, 2020)).

Social distancing closures reduced pressures of daily life (such as school or work obligations) that normally would restrict some people's ability to participate in struggles like the Black Lives Matter demonstrations or in reactionary actions against them. In addition—and perhaps central for the long-term impact of these Big Events—these closures (which can be viewed as institutional and organisational changes) have had three other potentially transformational implications:

1. First, they have disrupted many interactions at workplaces, schools and colleges that organise daily routines and time use of a majority of the population. In normal times these disruptions might lead to organisation for or against social change, including union organising and actions in workplaces that are closed.

2. Second, they have thrown many people into poverty for reasons that are clearly not due to their personal characteristics or actions, and thus may have decreased the appeals of hegemonic ideologies that view poverty or joblessness as ‘peoples’ own fault.’ These ideologies are important props of the legitimacy of economic and racial/ethnic inequality and the dominance of capital and its ability to divide potential opposition (Bakan & Dua, 2014; Friedman, 1998a, 1998b; Friedman et al., 2009).

3. Third, and related to the first two, these changes in life experiences and prospects have produced situations where many people have lots of free time to think and reflect about their lives, their families’ lives, and the general social and political situation of the world. It is still too early to know what the social, ideological and political ramifications and consequences of this individual and ‘collective’ reflection will be, but it could be profound. It could lead to massive political change or to major social movement conflict.

Hypotheses about how Big Events might increase rates of high-risk behaviours and their health sequelae such as HIV and hepatitis epidemics

In terms of public health, the effects of these changes in life activities, environments and circumstances might best be conceived of as having consequences at different time scales. The outcomes are indeterminate, as we have discussed, and probably depend on what changes take place in the pathways variables. Here, then, we offer a number of hypotheses to be tested. There are, of course, a great number of hypotheses implicit in Figure 1.

The short-term hypotheses focus on how risk and protective behaviours might be changed among population groups already at high risk, such as people who use drugs and sex workers. The longer-term hypotheses focus on changes that might increase the percent of the population who enter these high-risk groups. Importantly, we do not here consider a wide range of other harmful health impacts that these Big Events might lead to, such as those that might result if the Big Events usher in wars, revolutions, or greatly exacerbate environmental degradation.

We also illustrate how the current Big Event of COVID-19 influences short- and long-term behavioural health, overall health, and mortality (Figure 2). We express these hypotheses in terms of a number of pathways concepts. Following this section, we present some of the pathways variables we have developed.

Figure 2. Hypothetical model of how positive responses to the current Big Event by a range of potential actors might reduce or prevent otherwise-harmful outcomes.

Selected short-term hypotheses

1. Localities with higher rates of COVID-19 infection, morbidity and mortality will experience greater disruption of harm reduction, drug treatment, social support, and mental health organisation and services. COVID-19 epidemic severity will thus be associated with:

   1. Return to active drug use on the part of those who use these services to avoid use.

   2. Difficulty maintaining injection hygiene—and thus higher rates of infection.

   3. Higher rates of suicide, street violence, and severe episodes of mental health related disruption.

   4. Weakening of protective social norms and intraventions (Friedman et al., 2004; Mateu-Gelabert et al., 2017; Vazan et al., 2012) (actions that help others) among high-risk populations and thus more high-risk behaviour.

2. To the extent that a locality (or a time period during the pandemic) undergoes stronger and more consistent social distancing measures implemented without implementation of social and economic supports (e.g. housing supports, income supports), this may lead to prolongation of epidemic level COVID-19 transmission, rising disparities in COVID-19 case rates disproportionately impacting already marginalised communities, and (through increases in the numbers lacking health insurance), to high COVID-10 hospitalisation and death rates among subordinated racialized populations such as Black, Native American and Latinx people in the United States.

3. To the extent that a locality (or a time period during the pandemic) undergoes stronger and more consistent social distancing procedures (and fear of becoming infected), this may lead to increased loneliness and, for people who use drugs and for sex workers, to risks of police harassment or arrest if they seek drugs or customers as well as to disruptions of social and medical services they depend on (Cowan et al., 2021). This will lead to less ability to seek safer drugs, to maintain strict injection hygiene when injecting with others, more frequent injecting alone, and less ability to weed out sexual customers who might be more likely to be violent. Stronger social distancing measures will thus be associated with:

   1. Higher risk of infection with blood-borne infections;

   2. Higher rates of fatal overdose.

   3. Higher rates of injurious or fatal attacks on sex workers.

4. At both the individual level (in terms of self-reports about local social environments) and at the local geographic level (in terms of rates of adverse outcomes), higher scores on normative disjuncture, dignity denial and high-risk norms scales in response to ongoing Big Events will be associated with higher-risk behaviour, probability of overdose, and rates of infections with blood-borne and sexually transmitted infections (Kosten & Petrakis, 2020). Higher levels of solidarity and altruism will be associated with lower rates of these outcomes. We base these hypotheses both on the general theory of Big Events and on correlations between innovative measures we developed for normative disjuncture, dignity denial and norms and various behavioural variables in the study in which we developed and validated these measures (Friedman et al., 2015; Friedman et al., 2020a; Friedman et al., 2017; Friedman et al., 2013; Pouget et al., 2016).²

5. Since policing of social distance measures and the severity of the COVID-19 epidemic are all racialized, harms related to drug use, sex work and mental health are likely to increase more among racially oppressed populations. In the United States and Canada, this means that Black, Latinx and Native American people, in particular, would undergo more negative health consequences.

Selected long-term hypotheses

1. More severe local manifestation of the Big Events will be associated with more disruptive changes in people's lives, more disruption of social and medical institutions, more intergenerational normative disjuncture, and more dignity denial.

2. These, in turn, will be associated with higher rates of young people engaging in high-risk drug use, group sex and other high-risk sexual patterns, and sex trading. Alcoholism and mental health problems will be higher in all age groups.

3. Large-scale social movements will mediate and moderate hypotheses 1–3, and will also have independent direct effects. These long-term effects will depend upon the strength of the movements—and, crucially, upon their degree of success or failure. In the Former Soviet Union and some Eastern European countries, and arguably in South Africa (Bond, 2014; Clarno, 2017; Decoteau, 2014; Marais, 2000; Susser, 2011),and, where initial success led to continued or even intensified problems for large proportions of the population, this movement failure led to severe intergenerational disjuncture and other social problems, and to increases in numbers of persons engaging in high-risk behaviours. These resulted in severe HIV outbreaks and in some cases increases in STIs and hepatitis C. In Argentina, relative movement success moderated all these effects. We thus hypothesise that movement failure will be associated with higher degrees of intergenerational normative disjuncture and dignity attacks, lower degrees of protective altruism and solidarity, and thus with increases in rates of high-risk drug use, high-risk sexual patterns, overdose and diseases among PWUD and sex traders.

Hypothesis for both short-term and long-term:

1. Impacts on health (while indeterminate) will almost always be mitigated by reinforcing and expanding effective public health infrastructure and ensuring its adequate and ongoing funding.

In the short run, our own research into how social distancing may have affected people who use drugs indicates that it has caused many problems for them, but also has led to considerable introspection, some disruption of sociomedical services some of them have relied on, and some potentially-useful changes in service delivery (Bunting et al., 2021). There is considerable evidence that this may have led to an increase in overdose mortality (Ahmad et al., 2020; McCann Pineo & Schwartz, 2020; Slavova et al., 2020; Tyndall, 2020). It is too soon to be sure of the medium-term impact of these changes on the infectious diseases such as hepatitis and HIV transmission, or the rate of successful medical care for these infections.³

These hypotheses thus imply, among many other things, that continued austerity and/or the success of racist policies in the United States or Europe might lead to increases in the proportion of young adults (or other groups) who use drugs and/or who inject drugs, or who exchange sex for money or drugs; to increases in alcohol use, and to a further increase in rates of drug overdose and overdose mortality.

Pathways to measure

As we suggested earlier in this article, the impacts of Big Events on health are indeterminate, but can be studied and intervened upon (except in situations of extreme conflict; Figure 2). In the current Big Events that involve the combination of the COVID-19 pandemic and economic hard times, community mutual aid efforts have helped relieve economic and mental distress to a limited extent in some communities, access to medications for opioid disorder was made easier in many jurisdictions, and contact tracing interventions, where they could be carried out, sometimes reduced viral transmission(Koetter et al., 2020; Malm, 2020; Nordeck et al., 2020). In addition, some states in the United States froze utility shutoffs due to COVID-19 economic difficulties.

We have suggested that there are a number of pathways variables may determine whether Big Events lead to large increases in the number of people with alcohol problems, people who use drugs and sex traders, or may lead to widespread breakouts of infectious disease epidemics based on famine or these or other social changes. These pathways variables measure changes in institutional structures, individual experiences, world views, hopes and normative expectations. The importance of quality data collection about these variables during this time is crucial both for documenting the impact of the crisis on the population, and for helping to fund and allocate resources proportional to the need.

We have written a number of articles about pathways measures that can be measured through questionnaires (Friedman et al., 2015; Friedman et al., 2020a, 2020b; Friedman et al., 2017; Pouget et al., 2016). We have shown that many of them seem to be reliable and valid among populations such as people who inject drugs, men who have sex with men, and high-risk heterosexuals—all of whom have been central to epidemics of HIV/AIDS, hepatitis B and C, and additional STIs. Here, space will not allow us to list these variables (except in abbreviated form—see Table 1).

Table 1. Categories of pathways that may help predict and understand whether Big Events are leading to socially-based epidemics (Items appear in our articles).

INTERGENERATIONAL NORMATIVE DISJUNCTURE (BY AGE CATEGORY) to measure how social or economic changes, or migration, lead to normative chasms between generations. This may be a key set of measures for what follows the current crisis, particularly given the youth alienation that pre-existed the crisis

DIGNITY DENIAL (can be viewed as a process that produces stigma; clearly relevant to racial/ethnic and class-based crisis)

DEPENDING ON OTHERS

FORMAL AND INFORMAL GROUP INVOLVEMENT

ACTIVE NORMS AND RULES ABOUT BEHAVIORS IN PROXIMAL SOCIAL CONTEXTS (This category is designed for HIV related norms; similar measures can easily be developed for other concerns)

PERSONAL OR CULTURAL ORIENTATIONS (‘cultural themes’ from Friedman et al 2009) (Samuel R. Friedman et al., 2009) ABOUT HOW TO RESPOND TO DIFFERENCES, THREATS AND OPPORTUNITIES

Orientations measured include solidarities, hostilities, altruism, traditionalism, competitiveness, hostility, survival

SOCIAL CONFLICTS AND REACTIONS TO THEM

ATTITUDES TOWARD AND PERCEPTIONS OF OTHERS’ ATTITUDES TOWARD MALE SOCIO-SEXUAL DOMINANCE AND GAY PEOPLE

In addition, many area-level pathways variables are well developed and often available (some through publicly available sources). These include measures of area-level economic factors such as measures of income inequality, various unemployment rates which consider wider or narrower definitions of unemployment, measures of area level racial/ethnic housing segregation, measures of economic crisis magnitude (Engle & Ruan, 2019), of the extent of neo-liberalization (Miller et al., 2020), and of occupational and of class distributions. For some infections, such as both HIV and HCV, there are area level measures of ‘community viral load’ which can be utilised; and social network viral load measures have also been developed (Das et al., 2010; Jordan et al., 2020a, 2020b; Skaathun et al., 2018).

Once measured, these group level factors can be examined in ecologic analysis with respect to group level outcomes; and hierarchical, nested and multilevel analyses can examine individual and supra-individual level factors within a given analysis. Further, these factors can be examined as time dependent variables to facilitate to allow the study of big events as the temporal processes that they are. Further, as many relevant factors may not have well development measures, more work is needed toward their development, and this of necessity includes qualitative research to identify potentially relevant themes and constructs.

Conclusions

The Big Events of 2020 have created many uncertainties about the future of society and of public health. They have exacerbated, and in turn been exacerbated by, the rapidly deepening ecological crisis, as is shown by the fires in California, Oregon and Washington states in the US, in Siberia, and in the Amazon, and the plight of climate-induced refugees in camps or jails (such as many of those in the United States) where COVID-19 has spread rapidly and killed many ("Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities," 2020; Hamilton, n.d.; Marcius, 2020; Skarupski et al., 2018) or where excessive lockdowns on refugee camps created unbearable conditions and mass actions by the refugees, as in Greece (Kitsantonis & Kingsley, 2020).

It is too soon to know what the political and economic sequelae of these Big Events will be. As is shown by the example of the United States, they have strengthened both left forces such as worker organising and the Black Lives Matter movement, and reactionary forces, and intensified pre-existing polarisation among the political parties and their backers. Some of these movements have themselves issued suggestions for how to respond to the pandemic both in the short and long term. The Movement for Black Lives in the United States has issued such a platform (https://m4bl.org/covid-19-platform/), as have individual scholars involved in various movements such as that against climate change and other environmental destruction (Foster & Brooks-Gunn, 2015; Malm, 2020). Unless the economic and social crises quickly resolve—and there is no reason to think that they will—a potentially protracted period of intense social and political conflict may emerge in many countries. Where such conflict already exists, it may intensify. Outcomes of such conflicts are unpredictable, and likely to have profound effects on public health.

These Big Events and conflicts may lead to institutional, normative and experiential changes conducive to large increases in high-risk populations such as PWUD and sex workers. These groupsmay become core groups for the spread of HIV, hepatitis and other epidemics as well as overdoses and a variety of related social problems. In addition, massive increases in numbers of sex workers or PWUD may themselves have political effects. These negative impacts are likely to be greater if the social movements are defeated or do not lead to increases in equity, justice and perceived human freedom to be creative.

Public health researchers need to investigate the possible pathways leading to epidemics and how to develop interventions reducing the impact of those normative changes in the spread of infectious diseases. The pathways measures we have discussed may be useful in conducting such research. Part of this research should be to discover pathways for which adequate measures do not now exist and to develop ways to measure them.

Nations and other units undergoing Big Events—at the moment, this would include a great many nations--should conduct a repeated series of surveys and other studies to enable surveillance of pathways variables, including those we created and others. In addition, theyshould continue, to the extent possible, to collect and make available area-level measures of economic, social and other variables described above. Analysis of these data may help our ability to understand how Big Events affect public health and how to respond to them effectively.

It may be hard to maintain effective public health programmes during Big Events. Budgetary pressures may create pressures to cut back programmes. Political pressures may create pressures that render them ineffective. And disruptive social conflict may weaken or destroy the capacity of some or all programmes to operate. Nonetheless, maintaining and increasing effective public health will decrease morbidity, mortality and social disruption due to the negative health effects of Big Events, and should be supported.

Acknowledgements

This work was supported by the US National Institutes on Drug Abuse under Grant numbers P30DA011041, R01DA031597, 5R01DA045872, R01DA041298, R01DA041501, 5T32DA007233 and DP1DA034989; and National Center for Chronic Disease Prevention and Health Promotion grant U48 DP005008. The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by National Center for Chronic Disease Prevention and Health Promotion: [Grant Number U48 DP005008]; National Institute on Drug Abuse: [Grant Number 5R01DA045872,5T32DA007233,5T32DA007233, P30DA011041,P30DA011041,P30DA011041, R01DA031597,R01DA041298, R01DA041501].

Notes

1 Causal patterns are often bidirectional in processes such as these that emerge over time. Social structures and other crises can help cause the Big Events, and the Big Events can in turn affect the other crises and social structures. Thus, COVID-19 emerged at a time of emerging economic crisis and of political crises in some countries that in themselves might have served as a Big Event that triggered important social and health consequences in some countries. Furthermore, these crises shaped the patterns of response to COVID-19, and thus potentially the effects of the pandemic on the pathways variables and health outcomes described in this model. The United States and Brazil, for example, were undergoing political crises prior to COVID-19 that weakened their responses to the pandemic, and may thereby affect the health sequelae as discussed in this article. Some analysts of the COVID-19 pandemic (Davis, 2020; Friedman, 2021; Foster; Malm; and Wallace), furthermore, have argued that the emergence of COVID-19 and other potential pandemics is in part caused by a relatively slow-acting global crisis of capitalist social relations, which could be interpreted as a slow-acting Big Event. Thus, we think that Big Event models are somewhat dialectical and bidirectional in causation, with research needed in specific cases to help us understand these complexities better.

2 This study validated measures among population of people who inject drugs; men who have sex with men; and high-risk heterosexuals.

3 Yet there is growing evidence that social distancing measures can substantively contribute to control of the COVID-19 epidemic that has been and continues to disproportionately impact Black, Native American and Latinx people and that in implementing these public health intervention careful attention needs to be given to existing disparities such as in housing, employment status or types of employment, and distributions of comorbid and syndemic conditions, and in the need for, and manners or delivering care and prevention services.