The history of epidemic infections is a story of reaction, not prediction. For the past century or so, that reaction has primarily been a quest for a technical fix. This isn’t a bad idea: a technical response, when found, can make life better, at least for some. Think of polio immunization; DDT spraying against malaria, yellow fever, and dengue; pre-exposure prophylaxis (PrEP) and post-infection combination therapy for HIV/AIDS; measles vaccine; human papillomavirus vaccine (which prevents cervical cancer); and so forth. In a world that craves safety, the technical solution is irresistible. For the novel coronavirus outbreak, the search for a technical solution will go on. But there are three reasons why that quest can’t be the only response and shouldn’t be the main one.
First, for viral infection, there are no perfect technical fixes. Smallpox might be the one exception: smallpox virus was eradicated from the globe in 1978 by an international case-finding and immunization effort, using a highly effective and long-lasting vaccine, against a virus that infects humans but not animals. Most vaccines are less effective (influenza vaccine, for instance) or confer immunity that isn’t necessarily long lasting (such as mumps vaccine, part of the vaccine that includes measles and rubella). For many viruses, including HIV and herpes simplex, an effective preventive vaccine remains elusive, even after years of research. In other cases, such as Ebola, the vaccine protects against specific known strains, but since Ebola outbreaks in humans always originate from contact with animals, the vaccine will have to be modified if new animal strains enter the human population (that’s what happened with COVID-19.
There are fixes other than immunization, but these have problems, too. Pharmaceutical prevention, like PrEP against HIV infection, generally only works if it is used consistently and continuously. Immune system enhancement, meant to boost the host’s self-protective capacity, can backfire and facilitate pathogenesis for some viral infections, including dengue, HIV, influenza, and possibly coronaviruses. Treatments with antiviral drugs are under investigation for COVID-19—the drug Remdesivir is in clinical trials now. But antiviral medications come with potential adverse effects that require medical monitoring, which require continuous access to medical care and, therefore, the capacity to pay for medical care. Plus, no one medication works for all cases of infection.
From a public health perspective, the worst feature of the fixation on technics is that each solution has to be invented post hoc. With viruses, the pursuit of the technical fix is a constant game of catch-up.
Second, the technical approach does nothing about the social and political conditions that promote illness. The main ones are well known: poverty, hunger, and lack of sanitation. But technical innovation tends to disguise fatal deficits in policymaking and health practice. Viruses that come from animals have been a feature of public health for decades—cross-species “traffic,” as the virologist-epidemiologist Stephen Morse calls it. It was the route by which many notorious human threats appeared, including HIV/AIDS, hepatitis C, Ebola, West Nile, both prior international coronavirus outbreaks (i.e., SARS and MERS), plus all influenza viruses. Yet the illegal wildlife trade that inarguably exacerbates this traffic has not been stamped out—it has only increased. Already by 2016, this trade was worth an estimated $23 billion and it has likely become even more lucrative since then. No powerful interests are threatened by the illegal trade in animals. The tens of thousands of human deaths from outbreaks of viral diseases in the past two decades have not been sufficient to persuade anyone to walk away from a business that lucrative, or to convince governments to create and enforce effective regulations. Whether tens (or hundreds) of thousands of deaths from COVID-19 will provide the requisite incentive remains to be seen.
Third, investment in the technical approach suppresses the most consequential fact about infectious illness: the wealthy protect themselves; the suffering is done by the poor. Technics does nothing about the grossly unequal distribution of resources, and usually distract attention away from it. Examples are abundant. Effective means of both preventing HIV infection and of treating an infected person so as to reduce his or her infectivity have dramatically lowered incidence and mortality rates in the United States over the past 20-odd years. Yet, HIV still infects one to two million people worldwide each year, almost all in poor countries. Liver cancer, almost always caused by hepatitis virus infection, kills 700,000 people a year globally. Measles, entirely vaccine-preventable, kills more than 100,000 a year, mostly children. The garden-variety flu causes 250,000 to half-a-million deaths globally, year in and year out. We all live with viruses; the poor die from them. Even in the United States now, it’s the poor who are disproportionally affected by coronavirus. The alacrity with which the wealthy seek and embrace technical fixes serves to protect the powerful. The others just go on dying.
There are no technical responses to the new coronavirus (the catching up is still catching up). Social distancing is the strategy that policymakers have paid lip service to, but what they have enacted is better termed social-class distancing. The current outbreak is already proving to be twice as lethal to black and Hispanic Americans as it is to whites—undoubtedly because poorer Americans are less likely to be able to self-isolate if they live in crowded dwellings, and they are more likely to work in a service role that is deemed essential, such as home health care or food delivery. The federal government has declined to follow the course of action of the UK and some European governments, insuring a high percentage of workers’ salaries so as to avoid job loss. To date, more than 16 million Americans have lost their jobs. Many find it impossible even to file unemployment claims, let alone receive compensation. One and a half million Americans who formerly had health insurance as a benefit of employment have already lost their insurance. My colleagues David Himmelstein and Stephanie Woolhandler, experts on health-care financing, predict that an additional five million or more people will lose their health insurance soon. In other words, the poor may die so that we who are able to shelter at home may continue to be safe.
This outbreak is not a war—but the carnage has exactly the form of a war, the least powerful sacrificed first and most. Jails and prisons, perfect incubators for the rapid spread of infection, have already been the site of deaths—a chilling perversion of the criminal-justice system. A young man jailed only for a minor parole violation at Rikers Island in New York City died last week of coronavirus, as did a man detained—not even convicted of a crime—in Cook County Jail in Chicago. As of last week, eight convicts serving time in federal prisons had died from COVID-19, as had 23 residents of New York homeless shelters. The declared need for layers of protection against both the viral threat and crime is a rationale for inhumanity toward the powerless.
The way things are going, this coronavirus pandemic could be forge a new kind of servitude, a sensibility that the threat of viral infection is paramount and that only technology can provide deliverance. Technology that, inevitably, will be available to some but not to all. An article in The New Yorker reports that David Ho (a brilliant scientist, one of the architects of combination therapy for HIV infection) is now working on treatments for coronavirus infections in future pandemics because, Ho says, “an outbreak due to this virus or some other virus will surely come back.” Brian Bird, a virologist at UC Davis, says that “the only certain thing is that the next [pandemic] will certainly come.” Books by David Quammen and Benjamin Wallace-Wells also talk about the inevitability of further pandemics, especially because of climate change.
Here we are at the crux of a dialectics of epidemic history. Are epidemics past and present a valid indicator of the future? If so, is there a moral obligation to marshal what techniques can be invented so as to guard against the (supposedly certain) advent of a new global threat? But isn’t the future by definition unknowable? How can we know that what we know is sufficient?
But if the United States invests in the medico-technics to deal with the theoretical (foreseeable) threat—a coronavirus vaccine, intensive surveillance of humans’ movements, biosensing for fevers, etc.—who will decide how it will be deployed? And who will decide what happens to those people who are, inevitably, left out? If the past foretells the future, surely, then, the injustices of the past will also be repeated. If the response is technical, who will keep an eye on the technicians?
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