The COVID-19 public health emergency facing the world is the worst in living memory. It is changing everyday life in an immediate and stark fashion not seen, arguably, since the Second World War. The, perhaps unhelpful, metaphor of ‘war’ is being used to evoke our attempts at mastering the attacking virus. In the worst-hit country, Italy, those on the frontline of health care are describing the situation as ‘being like a battlefield’. The UK’s government has rallied a monetary battle cry of ‘we will give whatever it takes’. President Macron of France, along with other leaders, has hailed COVID-19 as ‘the enemy’ to be defeated. Like the imprints left by war on societies, this virus may, or may not, fundamentally and forever change us. How will we respond?
To explore the implications and possible responses, the Deep Transitions Research founder, Professor Johan Schot from Utrecht University Centre for Global Challenges and Deep Transitions Research Fellow, Dr Bipashyee Ghosh, from the Science Policy Research Unit at the University of Sussex Business School, take a look at the pandemic through the microscope of the Deep Transitions framework, with an interview from Geraldine Bloomfield, to discuss the effect the virus may have in bringing about a more rapid Second Deep Transition, in other words, a sustainability revolution.
Can we can think of COVID-19 as a ‘Landscape Shock’ within the Deep Transitions framework? How rare are they? How do they impact?
Dr Ghosh: “While Covid-19 is indeed a global landscape shock, the cause and effect of this shock can be traced back to fairly localized events and triggers. For example, this particular shock is exaggerated by – mass population movements; the absence of a global pandemic response team (as explained by Bill Gates in this TED talk); and lack of preparedness of most countries including particularly those in Europe to tackle this epidemic.”
Professor Schot: “Yes, it is a Landscape shock. In the Deep Transitions framework, the Landscape is our social, technical and ecological environment which surrounds us and sustains us. The Landscape is our context, which we cannot easily influence, at least not in the short-term. Of course, over the long term we have contributed heavily to the construction of our landscape. Urbanization, climate change, individualization, digital transformation, hyper-modernity and globalization are all developments within the landscape. We have changed our Landscape in such a way, and so dramatically since the Industrial Revolution and the start of the First Deep Transition, that viruses causing infectious diseases have become more easily transferable from animals to humans. Landscape changes put pressures on the way we live, and we have to adapt. Landscapes, also produce shocks. Such shocks appear as if they come suddenly, but they can have long lead-in times, and have indeed been building up – like the COVID-19 crisis.
COVID-19 is part of a longer history of pathogens threatening human development, think of SARS, MERS, Ebola, Mexican flu, swine flu and Hong Kong flu, and much earlier in the 20th Century the Spanish flu. There is this deeper history. Pandemics do not happen very often, but they are not rare either, and they will not go away. Humans are under constant assault, particularly in modern societies where transmission is much easier due to the concentrations of people in urban cities, international connectivity and globalization.
The important questions are, how do we respond to the pandemic and what impact it will have? It is clear that COVID-19 has become disruptive to the economy, our mobility and to all everyday life – closing schools; forcing home-working; closing borders; travel bans; social distancing and isolation – yet disruption is not the main predictor of its impact on human development. The main thing to look at is, whether the world is ready to let the pandemic have a broader, long lasting impact on how we might choose to live our lives collectively.
In Deep Transition terms, this will be about the nature of the socio-technical systems that we have for healthcare, food, mobility, water, communication, as well as our governance structures, and what alternatives we see emerging and developing. Previous niche-thinking activities and ideas, such as avoiding airplane travel, may become the new societal rule. Investments in the healthcare system may be redirected to help cope with pandemics, developing vaccines and more local production of masks but we may also have to explore the relationship between health and our life-styles, our food practices (such as eating meat) and mobility practices.”
Dr Ghosh: “Exactly my point. This lack of preparedness also shows that there is a lack of vision and learning in our current systems. Covid-19 is a shock because of the lack of resilience in our healthcare systems, which in turn, is because such resilience was perhaps not prioritised globally. This is also the case for the climate emergency. One important learning from this pandemic, is to be able to distinguish between avoidable and unavoidable shocks, and how deeper changes in governance systems, as well as scientific institutions, may help in mitigation of a crisis before (ex-ante) it hits the lives of innocent people.”
With the pandemic’s effects, how may we see pathways and directionality for the Second-Deep Transition being influenced?
Professor Schot: “In the Deep Transition framework the economy and society are shaped by a set of socio-technical systems that make life possible, as we discussed, these are health, food, mobility, housing etc. These systems have developed in specific directions over the past 250 years, since the Industrial Revolution, we have seen a direction in systems that has a great dependency on fossil fuels (coal, oil and gas), has linear production (extract, use, dispose), land grabbing and exploitation of natural resources. This type of production, distribution and consumption means we use nature as a sink. Our hyper globalization; rampant, mass consumption, for example of meat and the effects of this, show that these directions are not sustainable. They have caused climate change, dramatic loss of biodiversity, massive resource depletion, and now a rising in inequality – not just in income but access to basic needs. We have a looming future where the rich secure their access and resources, while the poor, and even the middle class, will struggle to survive.
We need a massive redirection of our systems towards a low-carbon and circular economy, based on a better balance between local and global production, new systems of peer-to-peer consumption, a sharing economy, and the development of new type of services (and commons) to replace mass production, for example, not more automobiles, but mobility as a service. I talked to James Anderson, one of the largest investors in TESLA, about this in a recent Deep Transition podcast.
Will this huge, fundamental change happen because of COVID-19? The system response is to go into crisis mode, and then back to normal. However, hopefully this is not the entire answer. It does depend on how we respond to this crisis, if we see niches spring up, if assumptions are questioned and if longer term behavioural change occurs.”
Dr Ghosh: “It is hard to speculate the long-term impact of this landscape shock. However, we are observing a rapid shift in our routines and practices. While practices like working from home and reductions in commuting are promising for pollution mitigation and a better work-life balance, there are other trends like fake news about the virus and its remedy, and the increased use of private cars as a substitute for using mass transit, that may have long-term negative impacts on society and the environment. The key question is whether the new practices, that generate positive impact, can be continued over the longer term when the shock disappears. After all, ‘cancel everything’ can’t be a motto for the longer term, but perhaps cancelling the commute to work to attend just one face-to-face meeting that could be conducted online instead, may become the norm. ”
Transitions theory believes that it is rules, patterns and behaviours that dictate change, rather than for example, rationality or ideology. We often think of these as being extremely hard to change but what is this crisis telling us about that?
Dr Ghosh: “What makes the Covid-19 situation interesting for transition scholars is that the rate of infection of the virus is almost entirely dependent on individual and social behaviours. One of the most important measures recommended to prevent the spread of the virus is ‘wash your hands!’ This apparently trivial individual act of day-to-day hygiene is now considered an essential and mandatory rule, imposed by the government and experts directly, implicated in mitigating a global pandemic. In addition, official guidance like ‘stay at home’ and social distancing demands difficult social adjustments . It will have a deep-rooted impact on how people perceive their roles, choices and ultimately power and responsibilities in the face of a global crisis.”
Professor Schot: “The big question is whether the response to COVID-19 will influence the rules and routines that guide our behaviors. Let me explain. Systems are built by people, and the behaviour of people is driven by rules or institutions. These are behavioral rules about what to do, as well as beliefs and values. People use these rules to guide what they do. They can reflect on them and deviate from them, however, in most instances they follow them. This is because rules are not individual, they are collective and they are embedded in the systems that we have created. Following a set of rules is easier because we are socialized to use them, and others expect us to use them.
For example, for academics, flying is part of our lives. International air travel is embedded in the way we work – going to conferences, meeting each other, doing field work in other places. We also hold a general belief that face-to-face contact is necessary. However, in fact building communities of practices and networks of scholars working together is part of our value and rule system. Not flying would really harm prospects for an academic career. Even academics who work on sustainable development, sustain a very polluting academic working style, and find it very difficult to change. New types of behaviors often emerge in niches. These are environments where other conditions exist or are produced by specific actors. Here actors show new types of behaviours. For example, if one university were to forbid flying, because of particular local circumstances with the leadership of a particular set of people, this would be a niche, but the question then becomes, how to scale this up and make it the normal behavior or rule? This is often very difficult. It is more likely that this university would find it hard to attract good academics and students because of the incumbent expectation around frequent global airline travel that comes with the academic, and also business, world.
A crisis like COVID-19 does two things. First, it opens up more space for alternative niche practices. They become more relevant and may have a better chance to sustain themselves. Crises, and landscape shocks like this, can thus have a bigger impact when they empower existing niches and accelerate them. Second, a crisis can help to question dominant rules, behaviors and systems. Individuals and organizations that believe in using existing rules may begin to reflect and question their assumptions and framings for behavior. This is what is called Second Order Learning and it is where a transformation occurs. As an example, we may look again at flying as a central cog in an academic life, which we believe is necessary. Perhaps this will be more greatly questioned? Not only in academia but also beyond in other sectors. For example, in food production. Why do we need food products from all over the world? Why not use more locally produced food? Why not reduce our meat consumption? I realize we will always need products from other parts of the world, but at the moment, we fish octopus in Mexico, bring it to Spain to add value (which involves adding plastics, olive oil etc) and then transport in back to Mexico to sell it to hotels. What is the rationale behind this?!
COVID-19 may end strident globalization as we know it today. In our Deep Transition research, Phil Johnstone and Caitriona MacLeish have explored the impact of World War I and II, of course not yet comparable with COVID-19. Here, they have developed the concept of imprinting. This is a widely used term in biology and psychology referring to a process in which humans are exposed to a severe threat, which then influences behaviour long after the particular period of time has ended. COVID-19 may imprint enough people and consumers in such a way that they become convinced a different type of behavior is necessary. This may lead to massive investment in renewable energy, forestation, and new digital infrastructures to enable more circular, sustainable production and consumption patterns.
These investments could be part of a recovery and reconstruction package after COVID-19 is over. In Deep Transition research, building upon the work of Carlota Perez (in her 2002 book, Technological Revolutions and Financial Capital) we put emphasis on the importance of public and private investments becoming productive again, focused on long term benefits for the society, and not just short-term benefits for the happy, elite few. This did happen after WW II, and it may happen again. Within the Deep Transition research programme, The University of Utrecht Centre for Global Challenges together with the Science Policy Research Unit (SPRU) at the University of Sussex are planning to build up a coalition or Panel of private and public investors who will develop and help implement a new investment philosophy aimed at nurturing a Second Deep Transition which aims for a Sustainable World.”
Why do you think the climate emergency has not had the same effect on policy, economic and communities even though it threatens as many lives? Is it because it is seen as an external, abstract threat and not a deeply personal one?
Professor Schot: “The Climate emergency has been a slow and hidden killer, not a shock. It is a trend at the landscape level, that has opened up space for new developments, such as the massive development of renewables. Shocks relating to the climate emergency have begun to happen. Think about the burning forests in Australia, and we will see more of them in coming years. We are entering a world where shocks will become more common, the earth is speaking back to us, and we will have to respond with transforming our world. This is the strapline to the UN Agenda 2030, which set out the 17 Sustainable Development Goals. They represent a new development paradigm that requires a reformed Capitalism. As to address them, the business-as-usual approach just will not work. We need a new type of economy and society, building on the new principles and rules of the Second Deep Transitions, which transform our systems to low carbon with a reduction in the use of resources, part of a circular economy with fairer distribution, access and ownership of resources.”
Dr Ghosh: “I agree with Johan. Landscape shocks like a global pandemic and landscape trends like climate change have very different impact on system change. But yes, many recent initiatives to tackle climate change as well as recent climate-change led events and disasters have more of a ‘shock factor’. Shocks force regimes to open up and change in different ways. But whether a transition will happen also depends on availability and acceptance of alternatives to fill the gap. Now is the time to invest in innovations (both technological and social) that will create fair and sustainable regimes.”
Should we reframe and break down the climate emergency into more personal public health emergencies to get action?
Professor Schot: “I believe this will happen, because the climate emergency will impact on the health system. The current crisis shows that the healthcare system is not prepared for these shocks due to current investment patterns which mainly aim for solving the problems of the richer countries. Even within these there is an unequal access to healthcare, both in these richer countries, and across the world in general. Certain countries are far more vulnerable than others. Think about what will happen when COVID-19 comes to highly populated urban areas with low quality housing in India, Brazil and other parts of the world. It also shows that we have to take responsibility for our own health by changing our lifestyles. Yet we also have to rely on experts and our governments for the research and answers on how to do this. It is not just an individual responsibility.
But can we and should we trust the experts? Rebuilding the relationship of trust with experts, without delegating to them all the responsibility for individual behavior, and finding new ways of participating in knowledge production is an important ingredient for the transformation we need. In the academic world, this is about transdisciplinary research, which integrates various types of knowledge and experiences. Universities are experimenting with this type of knowledge production, but they can do a lot more. It is about working directly with other key actors too, such as policymakers, much like the Deep Transition sister project, the Transformative Innovation Policy Consortium (TIPC) which co-creates knowledge around how we can enact and implement policy that transforms.”
What adaptations are there for system change in transport, health, education from COVID-19? How would these be termed in the DT thinking?
Dr Ghosh: “Many systems will adapt with the creation of new rules and meta-rules (this is when a rule applies across multiple systems). So for example, with social distancing and self-isolation as the key recommended strategy to tackle this virus, the current crisis has a substantial impact on public transport systems. The International Association of Public Transport has issued guidelines for public transport operators to support their businesses while mitigating the risks. These guidelines range from cleanliness protocols, reduced services, staff awareness and minimising contact as immediate measures. Many of these are immediate responses to a crisis, however initiatives like TFL’s ‘new cleaning regime’ has more potential to stay. Social distancing and public hygiene are the two main ‘metarules’ that multiple systems are embracing in the wake of this new global crisis. We will see many more.”
Professor Schot: “Yes, there are many types of systems changes. I have already talked about education, we need to rebuild our university system, integrate education, and research and rethink what is termed, impact work. Universities need to become focused on solving problems, this does not mean there is no space for basic research. On the contrary, asking questions about specific fundamental problems calls for basic research. I would challenge universities to involve students in this journey, instead of teaching them standardized text book knowledge in a factory model. Universities need to open up to society, and involve societal actors in the knowledge production journey like with the Deep Transitions research project and our investment bank funder, and as with TIPC, mentioned earlier, work directly with policymakers. This would transform the university system.
Transport needs a complete radical overhaul and COVID-19 may assist with moving us in that direction! We need to reduce flying; change our working and leisure styles; and reduce ownership of cars (although this is something a pandemic may increase due to isolating). We must integrate our public transportation – biking and walking in an integrated mobility system, served by new type of actors who organize mobility for us, enabled by all the new digital tools and apps at our disposal. It is crucially important that the data is not owned by a few companies, but by ourselves, and that profits and benefits are not owned by the few.
Further, the healthcare system needs to become more focused on underlying causes of some of our diseases such as obesity and diabetes. These diseases also generate a vulnerability for dying from a virus like COVID-19. Health is related to food, mobility, life-style, housing, employment, social connection. We need a healthcare system with research, which allows all of us to understand and take responsibility for our health. We need to integrate physical health, mental health, and social care, to ensure it is accessible for all.”
After being lambasted and belittled, science and experts are now back in positions of trust and responsibility. How might this play out longer-term?
Professor Schot: “Yes, there is a battle around the value of expertise happening. This has deep roots in the development of technocracy, as a separate mode of decision-making. Technocracy is delegation of power to experts – in that, they know what they are doing and are making the decisions. Many socio-technical systems have been built on this. Choices have been made without much consultation with and input of a wider public. This has led to a crisis in the public trust of expertise, as well as a strong postmodern criticism that all knowledge is socially constructed, and thus not necessarily true.
It is clear that rebuilding our socio-technical systems in a sustainable direction, the Second Deep Transition, needs the knowledge and inputs of all actors, the public and experts. Experts have a specific role to play, since the situation demands expert knowledge about complex relationships and developments, such as behaviour of viruses, as well as climate change and loss of biodiversity for example. This knowledge needs to be trusted, not only because this is the view of many experts, but also because it is embedded in a new relationship between experts and the public. This is a relationship of mutual learning.
However, it does not mean we need to accept everything experts say. In the new required modes of interaction between experts and the wider public, experts can be questioned, and they need to take on board concerns and knowledge of citizens. Meanwhile, citizens need to engage with what experts say and sometimes accept uncertainty, ambiguity and complexity. As a society we need to experiment, and certain things may fail. We also have to accept a plurality of perspectives.
We do not know for sure what is the best way of managing COVID-19. Various countries also follow different trajectories, these could be seen as experiments. We will have to accept that (within limits, because certain experiments may be off-limits following what medical experts say), and we must engage in a debate with reflections, and a learning process, so we improve our capabilities.
For a Second Deep Transition towards sustainability to occur, we need a new mode of knowledge production and what it means to be an expert, and a citizen. There needs to be a much more interactive and more experimental mode. The COVID-19 crisis may open up a space to begin building this mode.”
Dr Ghosh: “While the trust in science is a really good sign, we must also communicate that scientific knowledge is plural and contextual. This means that governments need to be very careful about screening one type of scientist/ scientific output as governance and decision-making tool. Especially situations like this, where the virus is novel with no vaccine available and no consensus on the source of the virus. This calls for more openness to diverse expertise. In such unprecedented times, what is most important is the coordination across expert communities and mutual learning, among not just the medical and biological sciences, but also social and environmental sciences.”
Accountable, transparent communication from government is now essential and being enacted after a long absence. How else will this effect governance?
Dr Ghosh: “It is indeed true that in overcoming this crisis, governments and governance systems all around the world have to put exemplary efforts to restore and renew the systems in the economies. From interventions around the world, one can see the welfare state playing a major role in creating safety nets and showing ‘capacity for compassion’ for workers in all sectors in many western democracies. These steps are indeed welcome from governments and help restore public trust in them. However, we believe that governments have a bigger role to play than reacting to a crisis and offering cash incentives. They need to invest in the preparedness for the next crisis. One can also see, surveillance is used as a tool to mitigate the crisis in parts of Asia and elsewhere. The fact that application of such tools proves to be so powerful has implications for future governance. Post crisis, whether the promises are kept and democracies are protected will determine what long term impact this crisis may have on vulnerable people.”
Professor Schot: “Shocks such as COVID-19 cannot be solved by the government, or the market. This way of thinking has been central to much of the debate, and a core feature of the First Deep Transition. Over the last two centuries societal problems have been solved by re-embedding the market in society through government action. This was the Great Transformation that Polanyi talked about. Now we need a new re-embedding process, in nature, first of all, but also in new type of relationships between all actors, including the ones between local, national and international ones, as well as between market, civil society, knowledge and government. Asking the question, more government or more market, is thus not adequate anymore. We need new type of governance arrangements, which do not build on this dichotomy. It is not clear yet what type of governance arrangements can be put in place, so also in this case we need experiments, perhaps we can speak of experimental governance. What is clear is that in this process of experimentation we need to empower the citizen, and in fact all actors to take up a shared responsibility. Governance needs to be built around common courses, and common good, owned and governed by a range of actors, and with checks and balances, to avoid exploitation of the least powerful people. They need to have a voice and be able to question the powerful, otherwise we may get a Second Deep Transition in which the elite lives in a green and clean environment at the expense of many others, violating their human rights.”
There has been an emphasis on readdressing social injustice, for example, how do we look after vulnerable workers or those in the gig economy, and we have seen promises of spending that we have not seen in two generations. What will this crisis do for traditional, neoliberal thinking?
Dr Ghosh: “This is an intriguing question. On one hand I think the gig economy employment model has rules (i.e. standards, expectations and values) that are quite stabilised and mutually aligned to be uprooted by the shock of a global pandemic. Will platforms cease to exist? Will the digital economy be any less influential? I don’t think so. On the other hand, I also think how the imprints of the new rules emerging from this shock (eg. a recession, new modes of working etc) might affect the new generation of workforce and the culture and contracts of work.”
Professor Schot: “It will hopefully destroy neoliberal thinking since it is clear that the market will not solve the crisis. And yes we need more government intervention and public investment, but not in a top-down manner with a traditional interventionist planning approach. We are ending a period of belief in the power of the market. Yet we should not make the mistake that we then think that the government interventions can address the crises. This is a false solution. As I discussed earlier, it needs common actions. We need new platforms and institutions working together. They are neither government nor market. For example, people in the gig economy may form new mutual sick funds, crowdfunded and run by themselves. This is already happening. This development can be underwritten by the state, but should not be taken over (for example, through a national insurance, replacing all these small funds).”
Finally, what will be the most powerful result of this crisis do you predict?
Professor Schot: “People will have new experiences. They will begin to believe things can be done differently. Lifestyle changes need experimentation, and this crisis can become a collective experiment in how to change the way we live and work. This will not happen across the board since many dominant actors including many citizens want to return to normal life after the crisis is over. However, niches containing new types of behaviour may have been empowered, accelerated, will be more stable and in a better position to sustain themselves. Investment may also flow into new directions. My hope is that the Second Deep Transition, of which the seeds are already with us, may get a new push, contributing to the transformation of our world agenda, building a new landscape that will surround, support and sustain us all. The work of the Transformative Innovation Policy Consortium is more important than ever, since the members are experimenting which new approaches for nurturing these seeds of the Second Deep Transitions.”
Dr Ghosh: “I am an optimist, and perhaps from privilege, to see the positives in this situation. I think the forced slowing down of lives (for some professions) has given us a moment to rethink the choices we make in life, to reconnect with family, and most importantly, reflect on what our routines are worth. The fact that at least some people will take this period to find their lost balance between work and life, to re-evaluate the costs and benefits of what we do, and realise the real sources of happiness – is the most powerful and incredible result that we can ever hope for from a crisis like this. I hope this crisis will pass but that the reflections will stay.”
References, notes and further reading
International Resource Panel. Read the comprehensive analysis by Mark Swilling
The Age of Sustainability. Just Transitions in a Complex World
Comment provided by Dick van Lente in response – added 24/06/20
I would like to respond to this interview, because I am very impressed with it, and I hope that pointing out a few weaknesses, as I see them, may help strengthen this approach further.
I like the interview because of its holistic, ecological approach (‘landscape’, ‘systems’), which connects the current health crisis with economic practices, inequality structures, forms of governance, education, the natural environment, and more; its historically informed depth, which contrasts the ‘second deep transition’ with the previous one, that started with the industrial revolution, which shaped our current responses; and its underlying optimism, which seems to come from an entrepreneurial, adventurous, and courageous spirit.
I have two issues that I think need elaboration: the question of power, and definitions and practices of health care.
1. Power In your analysis, the covid crisis is part of a landscape that is partly natural, partly created by humans: the virus is a natural phenomenon, its spread is due to people living close to animals and their diseases which used to be more isolated, to crowded cities, and to the explosion of world-wide travel during the last decades. The human part of the landscape consists of systems for food production, transport and so on, and people’s behaviour is determined by rules and institutions which are part of those systems. So far, so good. However, we should add that within this whole intricate network, people have different interests and hugely different levels of power. This means that they differ greatly in their ability to assert their interests (personally or collectively). One implication is that the current crisis is not only a big experiment from which we may learn better ways ‘to live our lives together’, as you say, it is also a game in which the strong and clever tend to win. We can already see this happening. Pharma companies are in a race to develop a vaccine, and will take good care that they make a lot of money for their managers and stock holders (while probably advertising their services to human health). Big companies that have evaded taxes for decades now claim tax money, arguing that they are essential for the economy. Companies like Google will be happy to create tracing apps, because tracing people for their own profit is their core business, and the health scare will give them new opportunities. In other words, the ‘massive redirection of our systems’, making them more sustainable, will require either the cooperation or defiance of these enormous powers. The basic problem is that big companies are after profits, not sustainability or the well-being of people. For example, how are you going to convince them to give their employees contracts, rather than hire and dump them, which is so much cheaper? How are you going to convince governments to allow nurses and teachers a better salary when they can hire them cheaply? Yes, it has happened before that governments directed the flow of money towards long-term goals and the benefits of the many: responding to the economic crisis of the 30s and WWII (Piketty). The question is whether the current crisis can have the same effect. To answer that question, we need a closer look at power relations than I find in this text.
Let me add that this is a very common problem in texts on social reform. One simple indicator is the use of the word ‘we’, as in ‘how we respond to this crisis.’ Look up any sentence containing ‘we’, and you see that it usually obscures power relations. You always have to ask: who will do this, and cui bono? Adding the power question to this text could start from there.
2. Health, care, and niches
The way the covid crisis is dealt with is based on current insights in health. From what I know (I am not an expert in medical history) this framework of understanding has its origins in the late nineteenth century, with the emergence of bacteriology (I borrow much of the following from David Rosner, ‘Twentieth-century medicine’ in R.W. Bulliet, The Columbia History of the Twentieth Century; and Marcia Angell on drug companies).
In the nineteenth century, until the arrival of the germ theory (Koch, Pasteur etc), illness was seen as emerging from personal characteristics (including lifestyle) interacting with a specific environment. Restoring health meant restoring the balance between the individual and her environment, which required a personal approach (taking into consideration diet, exercise and so on). The theory of germs (first bacteria, then viruses) brought a revolution. Illness was now seen as caused by a specific germ, irrespective of personal or environmental conditions. Restoring health meant killing the germ. The language became one of war (and it still is). Laboratories became the core institutions, and they were hugely successful in determining more bacilli and viruses and inventing a range of medicines. Here are the origins of Big Pharma, which now is, with the tech companies, among the mightiest powers in the world.
In the meantime public health institutions (clean water supply, sewerage, stimulating sports and so on) continued, but they did not have the same priority. Also, older forms of therapy, such as herbal medicine and homeopathy, were marginalized, although they too continue to thrive in niches (as you call them). As Big Pharma companies are not after health but after profits, their research focusses on illnesses of rich people, who can pay fantastic prices for cancer cures etc. Basic, low tech health care and preventive medicine in poor countries (water, cleanliness etc), that could save millions of lives, is neglected. So are, to take an example from our western society, personally based approaches to diabetes (diet, exercise) which are often more effective than pills, although they require more time and effort. You have said similar things, so no need to elaborate.
But there are two points that I think do need more attention. First, our health system is clearly not geared towards health, strange as this sounds. If it were, why are food producers allowed to advertise and sell junk food to our children, causing overweight and diabetes? Why are people forced to participate in a stressful gig economy, which undermines their health? Why is air pollution allowed to increase? (is it true that the death rate in China decreased thanks to cleaner skies and in spite of corona?). No, the current health system serves mainly to prolong lives, no matter the quality of those lives. It thrives on our fear of death, and it is a hugely profitable deal for producers of medical equipment and drugs. If ‘we’ want a society which works towards health for all its citizens, we have to take on not only the food industry and medical firms, but also the common expectation that doctors will save your life no matter the costs and the consequences. Is it possible to shift the emphasis from cure to prevention? The current epidemic kills a lot of people with conditions such as diabetes and lung disease, which are related to lifestyle and environment, and are therefore susceptible to change.
Second: no paradigm of thought and practice lasts forever, for all have their limitations, although it is hard to see them when you are in them. That is one reason why niches are so important, as you have been arguing so forcefully for a long time. This is important in the field of health care too. I hear homeopaths have already successfully treated many covid patients. Maybe other alternative practices may have similar results. They often operate from a perspective on human health and nature that has been displaced since the nineteenth century and that may deserve a new hearing. I hope these results are recorded, so that they can be compared to the forms of treatment that are current now. If the comparison is favourable to the alternatives, they should be encouraged. They offer a more holistic (and immensely cheaper!) way of dealing with health problems. Therefore it is very regrettable that in many countries these alternative practices are demonized by some organizations, and more or less suppressed by governments.
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