was the least unexpected pandemic in history. Scientific and institutional preparations narrowed the uncertainties of a new pathogen to a span that should have been readily manageable. And indeed the development of vaccines in record time is testament to scientific expertise backed by public money. The best-laid plans were confounded, however. It turned out that the main agent of radical uncertainty was not a new and inscrutable microbe. Instead it was Anglo-American political leaders whose doctrine of disrupting institutions, including science, made the pandemic ungovernable. At a cost of hundreds of thousands of dead and millions impoverished, this has had the modest virtue of showing that the ‘war on disease’ is a humdrum script that cannot guide political action.
Towards Democratic, Ecological Public Health
I would have liked to have drafted a new playbook for emancipatory public health in the Anthropocene, but this book concludes with something more modest: an appeal that it’s necessary to talk about this. There are hopeful openings, such as ‘One Health’, which unifies public health with animal health and environmental sustainability, and ‘people’s science’ approaches to disease control. At the moment, however, these remain minority agendas.
For now, people who work for democracy, human rights, liberal education, environmental sustainability, and similar goals – citizens, activists, elected officials, and the like – are bewildered as a pandemic arrives. They shouldn’t be. For English-speakers at least, their problem begins because the English language doesn’t give them a firm mental grip on the crisis. Our vocabulary is deficient.
The point of etymological origin is the word ‘epidemic’. This was first used by Hippocrates 2,500 years ago. In classical Athens, an ‘epidemic’ referred to an episode of sicknesses among the people. The people (‘demos’) was not today’s ‘population’, it was restricted to free male citizens. Sicknesses included all diseases occurring at the time. In the 14th century, ‘epidemic’ got attached to named diseases, especially plague. Often used interchangeably with the noun ‘epidemy’, in the early 19th century, ‘pandemic’ was used for a geographically magnified epidemic. Cholera was its archetype. At first, it had a sibling ‘pandemy’ as well. With the demise of ‘epidemy’ and ‘pandemy’, the English language lost the distinction between a societal crisis and a much higher number of cases than normal of a disease.14 ‘Pandemic’ is best used as an adjective, to qualify a disease – thus, ‘pandemic influenza’ or ‘pandemic Covid-19’. Were these old words to be revived, speaking of the ‘Covid-19 pandemy’ would make it clear that we’re referring to the entire societal crisis. This crisis includes all the other health problems that worsen when hospitals are overwhelmed by cases of one disease, along with the psychological distress, the losses of livelihoods, and strains on communities. The concept ‘pandemy’ could also be stretched to include ecological and societal pathologies that cause pandemics. I won’t use the word ‘pandemy’ in the chapters that follow, but it will remain in the background and I will return to it in the final chapter.
Democrats and social activists don’t have many tools to steady them in the pandemic storm. They can look to historians’ accounts of past pandemies (here the word doesn’t sound so quaint), but each one of those is so distinct, and the context in which they struck is so different, that there doesn’t appear to be much of current relevance. Reading Boccaccio on the plague in Italy, or Daniel Defoe’s account of the London plague, or reconstructing the devastations of small-pox in 16th-century Mexico, provides a stock of anecdotes and intriguing echoes but not much more. This book is also a history, but my guiding principle is that each pandemic is a shock and disruption of its own distinct kind. Insofar as there’s a pattern, it’s in the political response.
We can turn to social medicine and its analysis of inequalities in health care provision and health outcomes, and the importance of socially engaged and culturally sensitive public health.15 Each pandemic reveals inequalities in health, housing, income, and political access. HIV/AIDS shone a light on other injustices: discrimination, stigma, sexual and gender-based violence and exploitation, and repressive policing. With Covid-19, selective vaccine provision may soon become the greatest ever inequality in health care history. Social medicine also illuminates the frightening levels of public distrust in medical expertise. For too long, health experts and authorities took public compliance for granted. Today, ‘trust me, I’m a doctor’ no longer convinces. Minorities and formerly colonized peoples have had good reasons to distrust the official health apparatus, which too often treated them with contempt. Western publics are growing suspicious of medical authorities, to the extent that mass vaccination – the single greatest success of public health – is in serious peril. Vaccination prevents epidemics when it delivers herd immunity, which is usually achieved when about two-thirds of the population have natural or acquired immunity. Vaccine distrust means that America and some other countries may not be able to reach that threshold for Covid-19. Most health scientists just want these problems to go away: the facts alone should suffice to convince. In her book on this subject, Stuck, Heidi Larson takes a different view. She provocatively observes that ‘vaccine rumors are here to stay, but that is not a bad thing’.16 That’s because medical scientists are compelled to join the public debate – a debate that will need to include questioning the role of immunological technology in the Anthropocene. Expedited comprehensive immunization is akin to building higher seawalls to protect coasts from the rising oceans: inescapable but limited.
The citizen science movement has been hugely accelerated by Covid-19. Never before have so many people become epidemiologically numerate so quickly. But this hasn’t kept pace with a fast-raging pandemic. The most encouraging examples of activists setting an agenda for pandemic response are from HIV/AIDS – which I will discuss in chapter 4 – but that was a slow-burn pandemic and it took several years for the affected communities to organize and make their case, and for the health authorities to listen. In the case of Ebola in west Africa – discussed in chapter 5 – the mutual learning was much quicker and the anthropologist Paul Richards observes that the epidemic was overcome when ‘communities learnt to think like epidemiologists, and epidemiologists to think like communities’.17 This is a crucial example of public health as a people’s science, and Richards encouragingly observes that it can happen rapidly.
Joint learning by epidemiologists and the public runs into several problems with the ‘war on disease’. The first is that war leaders give orders and expect obedience.
The second is that control instruments demand discipline. For contagious diseases, it’s a brute fact that measures such as stopping travel and screening or quarantining travellers, and rigorous surveillance of individuals’ activities, can stop transmission. In European history, building and legitimizing that apparatus of control was part of creating the state.18 Human rights law allows for emergency public health to overrule civil and political rights.19 The tensions between disease containment and personal freedoms are real, but are easily exaggerated and politicized, especially when narratives of control and fear chime with authoritarianism and xenophobia. Measures to control infectious diseases don’t need to be coercive and comprehensive. The opposite is true: they work best when they are consensual and precise – the two go together because contagion control is best done locally by ordinary people. The most encouraging examples of joint learning by communities and epidemiologists are in the global south or among minorities.
This points to a third problem with the ‘war on disease’: its imperial lineage. Rich countries typically don’t have the humility to accept lessons from former colonies. An African slave introduced smallpox inoculation to North America in 1720 but his contribution isn’t widely known and his real name isn’t known at all. Recent Ebola outbreaks were overcome by African people’s science, and one of the saddest episodes in Covid-19 policy is that African countries have not valued that experience and have instead regressed to copying centrally planned European lockdowns, which are hopelessly ill suited to their circumstances.
