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.