The Costs of Prudentialism

Why our public-health institutions failed to stop Covid-19

New Jersey Governor Phil Murphy and Department of Health Commissioner Judy Persichilli visit the Essex County Vaccination Site on January 8, 2020 (Edwin J. Torres/ NJ Governor's Office)
New Jersey Governor Phil Murphy and Department of Health Commissioner Judy Persichilli visit the Essex County Vaccination Site on January 8, 2020 (Edwin J. Torres/ NJ Governor's Office)

The first few months of our coronavirus drama looked like a collective tragedy: American exceptionalism, a widely held belief that technology can always overcome even the most serious of material obstacles, and a false assumption that the federal government was looking out for the public, left the nation open to a disaster of terrible dimensions. And the latter part of 2020 looked like a murderous farce: people who by then knew that coronavirus is spread by aerosols nonetheless attended crowded parties and rallies without masks; gun-carrying terrorists planned to kidnap the governor of Michigan for her advocacy of virus-control policies; conspiracy theorists went to gatherings that were aimed to “prove” that coronavirus is a hoax, sometimes with deadly results.

The claim by the refusers, always, is that mask mandates, business and restaurant closures, and other coronavirus-slowing measures are violations of individual freedom—of rights that they imagine to be intrinsic to American identity. And on the other side, the claim is that those people who won’t wear masks and won’t keep their distance from others are making it worse for everyone by ignoring the “truth” or “the science.”

It’s particularly disturbing in the wake of the storming of the Capitol building last week by Americans who are gleefully immune to truth. I want to be careful not to make connections where there are none. But I do want to think about the way people act when confronted with truths that disturb them.

In 1982 and ’83, a dispute raged in the pages of the gay press. One side urged gay men to alter their sexual practices in order to survive what mainstream news outlets, if they covered it at all, were calling a homosexual “plague.” The practice of frequent, often anonymous liaisons with many partners was particularly condemned in a series of articles in the New York Native. Two respected members of New York’s gay community published a 48-page pamphlet, “How to Have Sex in an Epidemic,” detailing specific practices that gay men should modify or avoid. In San Francisco’s Bay Area Reporter, three well-known members of the gay movement there wrote that “unsafe sex is—quite literally—killing us.” The us here delineated not just a movement for gay rights, which was already recognizable, but a community.

But many gay men felt then that AIDS mustn’t be given too high a profile, lest adverse publicity taint the nascent community. Other voices echoed Edmund White’s suggestion from the days before AIDS that gay men’s sexually acquired infections might be worn as a “red badge of courage.” Gayness, the argument went, wasn’t just same-sex desire; it was an upending of the norms of heterosexual society. To take away the freedom offered by unbridled and fleeting sexual partnerships was to impose on the community exactly the sexual moralism whose expulsion was, to them, at the core of gay identity.

I bring up the events of 40 years ago because they are a reminder that the current divide about mask wearing in response to coronavirus is old news.

The matter of identity is deep. It has to be experienced, not just contemplated. For gay men who opposed sexual constraints in the early ’80s, the need to have some kind of tribal affiliation in a society that had thoroughly marginalized, even punished, same-sex desire was essential, existential. And therefore the charge given to the sex act by the dispute over how much and what kind of sex to have was a kind of demand: action (in that case, sexual) would forge a new consciousness—a true gay identity. I’m not championing abandon. After all, many of those men died for the sake of enacting this dialectical overcoming. But it’s a reminder that, for some, instruction is no match for identity.

Today, the people who refuse to wear masks or keep distance are deeply irresponsible. I wish they would toe the line, because the severity of our coronavirus outbreak would be blunted if they would. But I don’t dismiss them as mere crackpots, or as politically motivated renegades. There is a distinction between the people who can’t bring themselves to limit their freedom of movement for a virus that they can’t see, and the terrorists who broke into the Capitol building on January 6th.

The mask refuseniks are a reminder about something the country has taken for granted but really ought to discuss: the down-defining of public health into mere prudentialism.

When the debate broke out about gay sex in 1982, the cause of AIDS still wasn’t certain. But even when the human immunodeficiency virus was determined to be causative, in 1984, the public health armamentarium against AIDS remained limited. Attempts at developing a vaccine were unsuccessful. Drugs that reduce infectivity were more than a decade away. Debates over behavior, over advice about behavior, and about the meanings of behavior were inevitable.

But the institution of public health, an instrument of social engineering that had once built toilets and sewerage systems, inspected food for purity, fortified or supplemented foodstuffs with vitamins and minerals to stave off deficiency diseases, cleaned the air and water, and promoted universal prenatal care—an institution that was not only an advocate but also a builder of an inclusively protective society—was descending into a role of mere advice giver.

By the 1970s, immunizations were available against smallpox, polio, measles, mumps, rubella, diphtheria, tetanus, bacterial meningitis, and pertussis; others, against H. influenza type B, hepatitis B, human papillomavirus, pneumococcal pneumonia, and chicken pox became available in the 1980s and after. But where no vaccine could be offered, public health spoke of behavior. America’s medical and public health officers were full of advice, our federal health agencies had plenty of behavioral guidance, the Centers for Disease Control and Prevention began carrying out a regular nationwide Behavioral Risk Factor Surveillance program, but no social changes were engineered. The public health institutions no longer attempted to build anything to alleviate the social drivers of illness: poverty, lack of affordable housing, lack of universal medical care, or high medication costs.

The response to AIDS was the exemplar of prudentialism. Little else could be done, it might be argued. But other public health problems of the time—asthma, diabetes, obesity, hypertension, cardiovascular disease, firearm assault, opiate overdose, and a host of other conditions—might have been addressed by social reform, but were met, instead, largely with behavioral guidance. There were medicines, and there was advice. The framework of American medicine and public health had shifted away from remedying social ills to demanding personal propriety.

Into this scene came the new coronavirus, SARS-CoV2. The institutions that had once universalized threats to health and then shifted society to be able to meet them collectively—the U.S. Department of Health and Human Services, the U.S. Department of Defense’s health apparatus, state and local health departments, medical centers, schools of medicine and public health, professional societies, and health-oriented nonprofits—were mired in their own decades-long redefinition of public health as a matter merely of advising Americans on prudence and propriety.

In this context, and absent any magic bullet of a vaccine or effective chemoprophylaxis, the medical and public health apparatus of the United States did what it had become accustomed to: it told Americans how to act. First came school and business closings, then conflicting advice about mask wearing and confusing advice about decontaminating surfaces, then the social-distancing formula and clearer mask advice, rules of thumb about whom to see and for how long, travel suggestions, and what not to do for Thanksgiving.

On top of decades of prudential demands about sex, drinking, smoking, cancer screening, sugar-sweetened beverages, violence in the movies, opiate painkillers, and more, public health officials issued new demands for behavioral adjustment in regard to coronavirus. Given this larger context, I understand why some people received this approach not merely as a matter of wearing a mask but as a deeper insult. American health policy’s longstanding demands for conformity with prudential norms led some people, unsurprisingly, to resist. Because demands, especially governmental demands, are always met with some kind of resistance. Some Americans came to see resistance to demands for masks and distancing as a radical act of refusal, essential to consolidating an identity. If you say that America is based on freedom and yet that America demands conformity, you can’t expect that everyone will resolve the resulting identity conflict without inner turmoil or outward irritation.

What sort of society-reorganizing measures might an earnest public health system have taken when coronavirus came? It’s impossible to answer fully, because such a system has not been in place in this country for a half-century, maybe more. Therefore, a consciousness of medical and public health institutions as shapers of political and social realities is no longer at large. People can’t be expected to engage in the sort of morally inflected conversations that articulate values and norms, such as those that would prize the elimination of social distinctions and abolish inequities for the sake of inclusiveness, without such a consciousness. In Hubei Province, Chinese officials stopped all travel and locked everyone in their homes. By American standards, such an approach seems fantastical—dystopian. But in part that’s because the American public has either neglected or concertedly refused to have a collective conversation about the importance of health for all.

Could the tragedy and the later deadly farce of American coronavirus response been avoided? Perhaps. But it would have meant having collective agreements about how much we value health. Had that conversation happened, and had it led Americans to accept that everyone must have access to basic medical services, nutritious food, an adequate income, and a decent place to live, there might have been a response to coronavirus that wasn’t just a demand for fealty to mask-wearing and distancing guidelines. If people had to stay home, we all would have had homes to stay in, and there would have been financial support for everyone who wasn’t working. Funds would have been appropriated for dramatically ramping up ICU surge capacity in hospitals with a concomitant acceptance that some medical workers would be mandated to relocate temporarily to deal with emergent needs. In other words, America might have had a response closer to Germany’s or Norway’s. Not conferring immunity against high Covid-19 mortality on the whole country, by any means. But avoiding the catastrophe in which the United States still finds itself. And, importantly, also avoiding the current exacerbation of divisions among us.

But we didn’t do that. We had not had the conversation, so we could not have a sensible, and shared, response to coronavirus.

Those conversations are possible, but their premise is that the country isn’t, in fact, divided. The categories are neither neat nor binding. When the dispute over sexual practices and identity erupted in the gay press in the early days of AIDS, homosexuality had only recently been removed from the list of disorders in the psychiatric diagnostic manual, employment discrimination had been rampant and legal, the country still saw same-sex affection as abnormal. Forty years later, the sexual and gender categories are fuzzier and more plentiful. Gay people may marry. Discrimination goes on, but the divide isn’t as stark or the rhetoric as vitriolic. The national response to HIV/AIDS no longer demands a reckoning with personal identity.

The change in the social milieu about sexuality is worth examining as an example of how we might look at ourselves in the context of health. As with sexual identity and orientation, the conversation about health will have to seek legal and political fixtures to undermine the complacent adherence to an invidious social contract: equivalents of the Supreme Court opinions that finally overturned state laws against so-called sodomy and allowed gay marriage, and President Obama’s order to extend the 1964 Civil Rights Act protections to sexual minorities. With HIV/AIDS, that fracturing of the solidified mass of social assumptions was based on appeals to both freedom and love. With regard to the other ingredients of equality that prevent us from having sensible responses to coronavirus and will prevent us from having a sensible response to the next contagious disaster: that movement will have to question how to spend the $20 trillion gross domestic product, what medical care should cost and how it should be allocated, and how much tolerance we should have for some people to live in grinding poverty when there is so much money around. These are the questions that an earnest public health system would, and should, take up.

It is January 2021, and vaccines against coronavirus have arrived. I hope that federal and state officials can figure out how to make them available, a degree of management competence so far elusive, and that they turn out to work. I hope that, if the vaccines work, they are really made available to everyone. Which is to say, that it isn’t left solely to our capital-driven medical system, already overwhelmed in places with Covid-19 cases, to distribute vaccine.

My fear is that, true to the conventions of the past few decades, the availability of vaccine will leave unexamined the role our medical and public health institutions have played in their own decline as social forces. And that we will neglect to inquire about the role of the consequent down-defining of public health into mere prudentialism in those institutions’ impuissance. If public health is to return to its important role as social engineer, as an institution that makes life better for everyone, these are questions that must be addressed.

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Philip Alcabes trained as an infectious-disease epidemiologist and has been writing about health and illness for the Scholar since 2004. He is a professor of public health at Hunter College of the City University of New York. He is the author of Dread: How Fear and Fantasy Have Fueled Epidemics from the Black Death to Avian Flu, a history of epidemics as social phenomena.


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