19.6 C
New York
Sunday, April 14, 2024

The Error of Fighting a Public Health War With Medical Weapons

The cargo planes deployed; the trucks rolled. Hours after its approval by federal regulators, a vaccine against Covid-19 began moving across the country. The first shots in the United States plunged into the first shoulders barely a day later. Other countries—England, China, Russia—had already started administering vaccines too. It was a singular medical triumph, from the first known case of a novel, fatal infectious disease to vaccines against it in just about a year.


If that news made you cry—if the images of those trucks and those shots sparked strong emotion for you—that might be because of that triumph, but also because of what it took to get there. Time isn’t the only way to measure a span. Covid-19 killed more than 300,000 Americans, and a million more people in the rest of the world. Millions of people got sick, many of them severely, some of them with symptoms that linger for months. In the US, more people are getting sick and dying every day than at any other time during the pandemic. The triumph of medicine has followed a year of the failure of public health.

Not for lack of trying; don’t get me wrong. But public health depends on the public. If we fail it, it fails us. The virus SARS-CoV-2 is real, and it's bad. It’s a novel agent that infects the human respiratory system. Introduce that virus into a society that rigorously enforces and believes in the kind of difficult-but-basic measures that arrest its spread, you get deaths in the hundreds; drop it into a society that doesn’t do those things and you get deaths in the thousands. Drop it into a society that also suffers massive socioeconomic and racial inequities, with a political class trying to turn those inequities into unjustly held power, and you get deaths in the hundreds of thousands.

A pandemic is a social hack as much as a wetware dive. A virus is just a fleck of genetic polymer encased in a bubble of fat and protein. A disease is what happens when it gets into a body. A pandemic is what happens when it gets into the body politic.

It’s a classic challenge—a fight between the public health of a society and the medical choices of, well, you. Of a country of yous. The lifesaving public health advances of the 19th century—sanitation, sewage, nutrition—gave way to more technocratic and individualized medical interventions in the 20th. As the physician and public health expert John Knowles wrote in 1977, that meant everyone had an incentive to reach for expensive three-point shots to save their own lives, rather than work toward collectivist health overall, even though preventative measures like exercise, fluoride, nutrition, cleaner air, and access to primary care have more bang for the buck, society-wide. Knowles thought that there had to be a third way, that “the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health, a public duty if you will.” But it’d only work, Knowles wrote, if people had enough education and information, and if you gave food to poor people. Think of it as Universal Basic Health.

That’s not where we’re at. The fight is now more brightly lit than ever thanks to a pandemic and politics. Anyone can get Covid-19, but like the future, the disease and its consequences are unevenly distributed. Poor people and nonwhite people have borne the brunt of the disease, and because of disparities in the demographics most affected—thanks to a statistical property called overdispersion—it was still, somehow, possible for individual people to not see their connection to the greater whole. For months, the dynamics of the disease allowed some people to still think that Covid-19 is a problem over there, something that only kills brown people in blue cities. Somebody else’s problem. Any measures taken to fight it seemed, to them, to be worse than the disease.

Here’s the wild part, the most 2020 thing about 2020: That schism—that conflict between public health and private well-being, between personal liberties and communal gain—is as old as pandemics. The germ of the idea was, in fact, the idea of the germ.

In the mid-1800s, physicians and scientists were starting to come around to the long-gestating idea that diseases could be caused by wee, invisible critters that jumped from person to person—a “contagium animatum,” as 16th-century thinkers put it. They didn’t know what viruses or bacteria were, but they knew something was carrying illness.

The contagionists had their opposite number: scientists who in 1948 the researcher Edwin Ackerknecht famously called “anticontagionists.” Oh, they believed that some diseases spread by some agent, person-to-person. Smallpox and syphilis, maybe. Those were contagious. But they weren’t epidemics—yellow fever, cholera, or the plague, things that seemed to spread seasonally, or in specific places, or only among specific kinds of people. Nobody knew how. They didn’t know anything about food- and waterborne pathogens, about differences between viruses and bacteria, about surface-borne “fomites” that transmitted disease in some cases, while exhaled droplets and aerosols might in others. Absent any of that? Well, maybe it was something atmospheric—a cloud of illness, a miasma, maybe even the “filth” of poverty and pre-sanitation cities. (It’s telling that scientists are still fighting over the idea of an airborne contagium animatum, even today.)

But the anticontagionists knew one thing for sure. Those big three epidemics—with typhus thrown in sometimes, too—were the things that had, since the 14th century, caused governments to take population-scale measures to control them. That meant quarantines, travel restrictions, business closures—what today we might call lockdowns. And that made the anticontagionists nuts. They said that lockdowns, then as now, were bad for business; losses incurred as a result outweighed those caused by the epidemic itself. In the midst of the 19th century’s Industrial Revolution, anything that inhibited business was an inhibition of freedom itself. “Quarantines meant, to the rapidly growing class of merchants and industrialists, a source of losses, a limitation to expansion, a weapon of bureaucratic control that it was no longer willing to tolerate,” Ackerknecht wrote. “Contagionism would, through its associations with the old bureaucratic powers, be suspect to all liberals, trying to reduce state interference to a minimum. Anticontagionists were thus not simply scientists, they were reformers, fighting for the freedom of the individual and commerce against the shackles of despotism.”

Also, by saying that disease came from lack of sanitation and poor hygiene, the pro-filth contingent was sometimes quietly and sometimes loudly associating disease with ethnicity and socioeconomic status. It was immunological social Darwinism; if poor and nonwhite people got sick first, or more often, that proved to some “reformers” that those people made bad personal choices (rather than indicating a failure of the systems around them). In that light, identifying filth as the generator of epidemics paved the way for the hygiene movement, showed the moral and physical superiority of unpoor whites, and provided a rationale for “slum clearance” and residential zoning laws. Squint at redlining and you see not just the geography of racism but also a colonial cordon sanitaire.

To be fair, as one historian notes, the (paltry) science of miasmas did suggest that quarantines would actually make epidemic diseases worse, because they amplified the confinement and lousy conditions that spread the disease. And if you read “miasma” as “the conditions that make a disease spread,” well, that’s also the point I’m trying to make, so … yeah. These were good-faith scientific arguments that also happened to be politically motivated economic and philosophical ones, tinged by racism.

It’s easy to snicker at these obviously blinkered ancient physicians. Except some of the smartest scientists of the time were anticontagionists—the founders of biochemistry waged all-out war on Louis Pasteur’s insistence that fermentation was caused by invisible, helpful, teeny-tiny living things. And the idea has never really gone away. In the 1990s, credentialed scientists epistemically trespassed into the world of AIDS research to argue that it wasn’t caused by the human immunodeficiency virus (it is), but in fact by common viruses and drug use among gay men.

And what else are Covid-19 skeptics engaged in if not anticontagionism? The arguments—it’s a hoax, it’s no worse than the flu, it doesn’t abide by Koch’s postulates, masks can’t stop its spread, it only affects cities, the measures against it are unwarranted violations of liberty—are all familiar. None of these things is true, and the people making those arguments are just playing the hits.

This particular time loop broke the public health measures that could have saved tens of thousands of lives in 2020. They’ll be critical throughout most of 2021, as well. Vaccines won’t be widely available for months, and even when they are, the same people who don’t want to wear masks or give up holiday travel will also argue that getting vaccinated is a personal choice. But the fact is, if a big enough chunk of the population doesn’t believe in public health measures, and another chunk can’t follow them because of lack of societal support, then vaccinations are the only way to stop a pandemic—lots of people getting the shot and joining their immunity to the herd. (Which is a bummer when it turns out that 40 percent of Americans say they probably won’t get vaccinated, and just shy of half of them say no amount of new information would change their minds.)

Doing public health things is hard; it requires either personal discipline or government mandate. Lots of carrots, lots of sticks. That’s because, just as Thomas Knowles warned, Americans tend to believe that science and technology will always present a solution. We like gizmos and gadgets. That’s what drugs like vaccines are, really—magic solutions to big problems. And to be sure, sometimes the magic solutions work! We have data that confirms our bias: vaccines, antibiotics, antiretrovirals, immunotherapy, cardiovascular stents, painkillers, and ten thousand other expensive, complex, high-tech therapies. These medical gizmos may not have increased lifespans for everyone, but for the people with access and insurance, they’re always dangling out there, solutionist one-more-things. It’s moral hazard, but with drugs. If you think you’ll get a gizmo later, and you don’t believe keeping other people from getting sick is your problem, well … why bother? It’s a smart game-theory move to plan for other people to do the public health things.

That’s in one sense. But in another sense—in the sense of a deadly pandemic disease—your right to spew viral particles ends at my mucosal membranes. It’s a question of what we owe each other, even when we don’t see the connections clearly. We all tend to round small risks down to zero, forgetting that our fractional risks of exposure and transmission add up to huge ones for the “essential workers” who don’t have the option to huddle behind Zoom. Some people are disinclined to see past their own risk horizons. So we travel for holidays, eat and drink indoors where it’s legal, scoff at mask-wearing, attend indoor worship services (and loudly insist on our right to do so). So it goes.

What would have worked to bring people around? How do you make, in the construction of the economist Jared Bernstein, a YOYO (You’re on Your Own) into a WITT (We’re in This Together)? Would a Beyoncé–and–GeorgeClooney PSA have done it? More, better, clearer messages from government scientists? A $100 fine for not wearing a mask?

Maybe. Who knows? The federal government tried to get famous people to deliver public health messages, but the message wasn’t going to be clear new information. The feds wanted a sunny sense of all-is-wellness, even though all wasn’t. Like much of the federal response to Covid-19, this didn't come together. All-is-well wouldn’t have made sense if they were also fining people for misbehaving, so that didn’t happen. Nobody tested any of the public health interventions against Covid-19 the first time around, so nobody knew what would work, and nobody admitted it. President Donald Trump and his government saw political leverage in the personal freedom argument and the implicit racism of seeing Covid as a problem confined to cities and Democrats. To identify with Trump meant identifying with not wearing masks, with eating meals in restaurants, with going to indoor worship services, and with believing that diseases were things that happened to other kinds of people. The choice somehow became one between participating in collective anti-pandemic action or defending the American Way of Life.

National authorities abrogated that responsibility, so it fell to local public health officials. States and municipalities are usually in the lead of dealing with these issues, but they’re underwater. In the last 10 years, state departments of public health have seen budget cuts of 16 percent; in local departments it was 18 percent. That meant 38,000 fewer people working on those problems. And hyper-politicization made it worse; reporting from the Associated Press and Kaiser Health News found that at least 181 state and local public health officials have left their jobs in the past year because of harassment and threats from Trump-supporting Covid skeptics.

Public health became every bit the political weapon that the 19th-century anticontagionists feared it would—except it’s the 21st-century anticontagionists who are wielding it. The right-wing press managed to become unable to see a global pandemic. Sure, 1.3 million people are dead around the world, but as recently as September they were still writing that countermeasures in the US were a Democratic conspiracy to make President Trump look bad, and that liberals and the media would stop talking about it after the election. In response, let me just say: Hi.

To stop a pandemic, you don’t actually have to make every person immune. It’s only necessary to make each infected person slightly less likely to transmit the disease. That’s the whole game. You can do that with a vaccine, or by keeping people from contacting other people.

That’s a tough sell. Americans have trouble with second-order effects, and with believing that the future is as important as the present.

Covid-19 kills more old people than young people. It kills more Black and Latino people. Its targets of opportunity are people who contact more people—the health care workers who are fighting on the front lines of the pandemic, the essential workers who sustain the literal and economic infrastructure of society. And Covid-19 moves through communities in a jagged, bursty way—more isolated places get the disease later, but when they get it, they get it bad. (That’s what happened in Manaus, now the only place on earth that arguably reached herd immunity the hard way. In the early months of the pandemic, the city, nestled in the heart of the Brazilian rain forest, seemed safe. By spring, three quarters of the people there were infected; deaths peaked at 277 a day.)

People can spread the virus without having symptoms themselves. Some people only get a little sick, and others die. Some people don’t spread it much at all; other people in other situations spread it a lot. That makes it hard to know which people, specifically, it’d be best to make less infectious (with masks or quarantines or drugs or whatever)—and hard for any individual to believe they, personally, might be the risk. Absent good science showing which people spread a lot of the virus and which people don’t, or even who’s infected—and whoa, wow, has that data been absent—every intervention has to apply to everyone.

In 2020, at least one out of every 200 Americans got sick with Covid-19. One in 1,000 died of it. That’s probably an undercount. Yet the jagged statistics of the pandemic made it possible for just enough people to look at those numbers and say it wasn’t that bad—mild enough, in fact, that it required no changes in their behavior, and any suggestion otherwise was a violation of their rights.

This has always been a key question in both the legislation and jurisprudence on public health. It’s probably not right to force an individual person to do things science deems “healthy”; those ideas change over time, and that’s rightly seen as an unconstitutional invasion of privacy. You want to smoke cigarettes? Smoke. But lawmakers and judges have mostly agreed that societies can force people not to do things that harm other people—or to do things that, in some utilitarian sense, maximize the good. You want to smoke cigarettes in a crowded bar? Nope. You’re not allowed to drive your car too fast or let your factory spew toxic waste, either. Bad for others.

As always, the problem with utilitarianism is defining what’s actually good, though. Is it … money? Is public health more important than the global economy? How do you even do that math? Let’s say all the boring society-scale prevention stuff really does generate more health per dollar than fancy new drugs. “Even if it is true, it could only be acted upon by systematically ignoring the presently ill,” wrote the ethicist Daniel Callahan nearly 45 years ago. “They would have to be deprived of help as allocations were shifted away from them to those who would benefit in times to come. The argument can only rest on the highly problematic premise that the value of averting future suffering is greater than the value of relieving present pain.”

That’s what the circumstances of Covid-19 asked us to do—to accommodate some present pain to alleviate future suffering. And we failed. At nearly every crossroads, we took the wrong path. A few drugs turned out to help; many did not. Health care workers, through hard-won experience, found that cheap and commonly available medicines, combined with relatively simple care practices, made more difference to mortality than finicky, rare monoclonal antibodies and would-be antivirals. But we didn’t protect any of that knowledge. None of it matters if hospitals get overwhelmed by new cases and all of it gets rationed by overworked providers.

Good science and a bit of luck put vaccines on the table in slightly less than a year after the first human cases of Covid-19, a remarkable scientific achievement. It would have been no less remarkable if millions of people hadn’t gotten sick and hundreds of thousands hadn’t died in the meantime. That’s what the political weaponization of public health did: It killed a lot of people.

Related Articles

Latest Articles