We must not ignore the benefits of local initiatives that are already connected to the recruitment base

As the number of covid-19 cases across the UK is on the rise, suggesting a potential second wave, the government is under pressure to implement plans to identify cases of covid-19. The centralisation of track and trace initiatives, which are taking place on a national rather than local scale, is problematic. If the aim is to cut transmission chains and spot local outbreaks, then we should not ignore the benefits of local initiatives that are already connected to the recruitment base. Problems are amplified if we consider the difficulties of capturing people who have already been deemed “hard-to-reach” by other government initiatives. These “hard-to-reach” people include those isolated due to age or poverty, migrants and asylum-seekers, rough sleepers, and transient populations who might not have the most productive relationship with many facets of the state.

There are already good examples of local initiatives that could be built upon to help reach those who get left out of many public health initiatives.

In the summer of 2019, we conducted a short pilot study for Cancer Research UK, tracking down what we termed “Elusive Risks.” We went to a diverse part of East England to explore practices and perceptions of cancer prevention among generally “hard-to-reach” populations underrepresented in cancer clinical trials and other public health initiatives. Drawing on anthropological approaches, the aim of our project was to explore people’s own reasons for not participating in national cancer prevention schemes.

We sought out and met with people who lived without a permanent residence, or were affected by long-term disabilities, and others who were working on short, part-time contracts or in seasonal work. We also approached local initiatives that brought together people affected by severe mental health issues, migrants with weak or no safety-nets, rough sleepers meeting in day-centres, or people trying to recover from drug and alcohol addictions. Despite the diversity of their daily challenges, we found that most of the participants were, in their own terms, having to live one day at a time. Social exclusion, stigma, or poverty meant that their lives were most frequently focused on immediate needs to ensure survival. Participants put effort into doing things they felt they could affect—including distancing themselves from people they perceived to be dangerous or who might add to the challenges of their lives. In some contexts, this included self-distancing from healthcare professionals, who, although well intentioned, were unknown to them and therefore could not be trusted. 

Being strangers ourselves, we found that getting to know people whom we might call “super-locals” was the key to enabling study participation. These super-locals knew the apparently “‘hard-to-reach” people intimately—not as ciphers of social problems, but as real people—and understood their concerns. Super-locals were people who not only lived in the area and worked as managers of various community hubs, they had also had their own first-hand experience of the issues affecting specific segments of these populations. They encountered, as peers, those who were invisible in other contexts and knew that some apparently “hard-to-reach” people were in fact easy to reach under the right conditions. So-called hard-to-reach people were already participating, for example, in some wellbeing activities, initiatives perceived by organisers and service-users as “neutral” and “safe” spaces.

Fast forward a few months and the pandemic poses a public health risk for all of us, but for none more so than those already identified as “vulnerable” or “off the grid” before the pandemic started. The messages popping up in media outlets urging people to wash their hands, stay at home, and not mix with other households seem unrelated to the everyday realities of many of those whom we met, nor was there any likelihood that such messages could be heeded without a place to sleep that night, or food to eat. It should not be assumed that they owned a mobile phone that would enable their location to be tracked, an approach that could increase the very sense of institutional surveillance that many actively resist.

Public health campaigns often contain personal exhortations to responsibility and solidarity, implying that the risks of which they speak have a self-evident priority and can readily be taken on board. Such campaigns might benefit from consulting the expertise of the “super-locals” to understand first what any publicised “risk” might mean, and what acting on it might entail. 

We know the pandemic is aggravating persistent social inequalities in the UK; now is the time to really listen to those who are already least visible and least supported in existing systems. We exclude local experts at our peril.

Ignacia Arteaga is a postdoctoral researcher and affiliated lecturer at the Department of Social Anthropology, University of Cambridge.

Kelly Fagan Robinson is a teaching associate and subject manager for Medical Anthropology in the Health Medicine and Society MPhil at the University of Cambridge.

Maryon McDonald is fellow in Social Anthropology at Robinson College, Cambridge, and has long taught and researched in the field of medical anthropology.

Competing interests: None declared.