September 2021. I was in Ethiopia. On top of the war and rising costs of living, the COVID-19 pandemic was spreading widely. No one knows how many people have been infected or died due to the pandemic.
Before I go any further, I want to set something straight. Seeing what has transpired in Ethiopia and other countries, the talk of vaccine nationalism that we wrote exactly one year ago appeared to be flimsy to some extent and one-sided to a higher extent.
Life continues as if nothing has happened...
I had had my two shots of Moderna before leaving for Ethiopia. Yet, I got infected and was sick.
Masks and vaccines were available in the country. Wherever one goes — crowded marketplaces, restaurants, and other places — masks weren’t a ubiquitous sight. It seemed that most people cared less, were oblivious of the danger, or had more concerns about their daily life. A few people who were using masks wore them under their chins!
The pandemic was showing no sign of abating. While in bed for a few days due to the COVID-19 infection, a priest was preaching from a nearby church. Often religious sermons in Ethiopia — mainly by the Orthodox church and mosque from the Islamic faith — are given using loudspeakers. I could clearly hear what the priest was saying.
“This disease [the COVID-19 pandemic] is the devil’s work,” declared the priest. “I ask you not to take the vaccine. You should rather trust the power of God,” the priest continued.
Religious institutions and other traditional belief systems play an important role in influencing people’s behaviors, positively or otherwise. A word of caution: I don’t have strong evidence on the extent that religious institutions and belief systems are convincing people not to take vaccines in Ethiopia.
Vaccine hesitancy can also happen due to other reasons — from trust in science to confidence in authorities, the fear of side effects, misinformation, and complacency (do not perceive a need for a vaccine and hence do not value the vaccine). It’s a complex issue that has been around even before the COVID-19 pandemic. Now, it’s become a source of widespread tension and social division within and across communities.
Friends and relatives who called to check on how I was doing encouraged me to take some of the traditional medicinal plants… I managed to recover and in hindsight, I can only think of the vaccine that I took for my recovery.
Once cleared from the infection with a negative test, I was on my way back to Switzerland. While waiting for my flight in Istanbul, I struck a conversation with a couple about COVID-19 and vaccination. They had strong reservations about the vaccine even though they were seriously sick due to the COVID-19 infection. They said they opted for Chinese acupuncture to protect themselves.
To be fair, studies have shown that acupuncture is an effective treatment alone or in combination with conventional therapies. For example, a study in June 2021 by Xin Yin and colleagues showed that ‘Chinese herbal medicine might make the effect of acupuncture more stable; the use of herbal medicine also seemed to accelerate the absorption of lung infection lesions when its dosage was increased’.
The problem I’ve found is why China, a country that has proudly contributed to the advancement of acupuncture, didn’t opt for this method to tackle the spread of COVID-19.
The power of norms & values
Let’s face it. Norms and values have extensively been studied in the social sciences. They define how humans behave by following what society has defined as good, right, or acceptable. Not only do they influence behavior but also shape social order.
The question is: why do populations in some countries show higher uptake of vaccines and others are lagging? Among others, research indicates that social norms in the form of peers’ behavior and attitudes are robust predictors of health behaviors and norms-based intervention strategies may increase COVID vaccine uptake.
In the case of the priest at the local church in Ethiopia, the norms and values that he was prescribing are about mores. These are types of norms and values that show the moral views and principles of a group. Followers are expected to stick to them, and violation is seen as a transgression (e.g., a sin).
Another example of mores is what I encountered, once again, in Ethiopia in 2019. A project that was supporting women to improve their skills by facilitating culinary training overlooked consulting the husbands of some of the women who were selected for the training. Some of these women were supposed to work in hotels, which their husbands perceived to be ‘unacceptable’ due to the widely held view in that particular community for the women to work in a hotel.
In contrast, folkways are norms and values without any moral underpinnings. People are expected to take a course of action that is deemed appropriate in a community. A good example is Albania.
Parents in Albania seemed to have a strong influence on their children’s choices of what to study at universities or what career paths to follow. This has impacted the labor market, distorting the supply and demand of a skilled workforce. Adequate, attractive, and relevant labor market information was not accessible to young people and their parents. Labor market information sources like the media have been focused very narrowly on political news and entertainment.
Implications for development cooperation
The 2015 World Development Report was about ‘Mind, Society and Behavior’. Incidentally, 2015 was also marked by the Ebola outbreak in West Africa. The publication provided an array of examples, showing how norms and values shape development outcomes – from households enhanced saving to firms increasing productivity, communities reducing the prevalence of diseases, parents improving cognitive development in children, and consumers saving energy.
A year before the World Development Report came out, I was in Eastern Samar, a province in the Philippines located in the Eastern Visayas region. I was researching to design an economic recovery project from the devastating Super Typhoon Haiyan, locally known as Yolanda. I was speaking to a professor in one of the local universities. I still vividly remember what the professor shared with me.
“If you’re serious about supporting the community, you’ll need to change their mindset,” said emphatically the professor. What he meant was that before the typhoon, people relied heavily on coconut production which they considered a ‘gift from God’. Coconut, decimated by the typhoon, is a nut-bearing palm tree that requires an average of six to ten years to produce the first fruit but can take 15 to 20 years to reach peak production. It’d take a lot of effort to convince the communities to change their livelihoods.
For the project, while addressing other root causes for shifting the livelihood source of the community (the ‘what’ question), it was also important to work on the rationale of the shift (the ‘why’ question) by sensitizing the community members. Looking back, the professor was spot on as we showed in our recent blog of revisiting the work in the Philippines.
And that’s not all. The impact of norms and values is more pronounced in gender equality. Overall, progress has been uneven as women move away from basic areas into enhanced ones, where gaps tend to be wider. One of the critical mediating factors is social norms and values. The work by UNDP showed that women seemed to make greater and faster progress in cases where their empowerment or social power is lower (basic capabilities). On the contrary, they face a ‘glass ceiling’ where they have greater responsibility, political leadership, and social payoffs in markets, social life, and politics (enhanced capabilities).
Perceptions of what others are doing and the information available guide individuals’ behaviors for vaccination – meaning stories over statistics have the power to sway actions beyond simple mandates. In my work, we use the inclusive systems approach – also known as Market Systems Development (MSD) approach. Using the approach, we try to understand why systems (e.g., education, health, governance) underperform. For this, we go beyond what is visible (e.g., services like training, financing) and try to analyze the role of informal norms and values.
However, I feel that two areas need improvement. The first is the need to have a firm grip on what constitutes social norms and values. The other is how to translate social norms and values into intervention design and measure their contributions to development objectives. Beyond writings such as Bowling Alone, my favorite reading at grad school, strong cases showing the role of social norms and values in sustainable and scalable development are limited.
I hope the unpleasant and tragic experience we’re currently facing offers us lessons to become more adaptive, resilient, and innovative. Wishing you a fulfilling, joyful, and healthy 2022.