Thinking in a Pandemic

The Crisis of Science and Policy in the Age of COVID-19

Boston Review

• Publisher: Verso
• Year: 2020
• ISBN:
  9781839763137
• Topic: Politics & International Relations
• Subtopic: Essays in Politics & International Relations
• Index: Politics & International Relations

We are living in the midst of the greatest public health crisis of our time.Confronting the many challenges of this moment-from the medical to the economic, the social to the political-demands all the moral and deliberative clarity we can muster. Bringing together coverage of the unfolding pandemic from the critically acclaimed Boston Review, this collection explores the history and social legacies of pandemics, explores the place of science in popular culture and policy-making, and interrogates the ways in which science and health have been politicized. Thinking in a Pandemic collects the latest arguments from doctors and epidemiologists, philosophers and economists, legal scholars and historians, activists and citizens, as they think not just through this moment but beyond it.While much remains uncertain, our responsibility to public reason is sure. Now, more than ever, we affirm the power of collective reasoning and imagination to create a healthier and more just world.Contributors include: Alex de Waal, David S Jones, Stefan Helmreich, Jeremy Greene, Dora Vargha, Jonathan Fuller, Marc Lipsitch, John Ioannidis, Trisha Greenhalgh, Sarah Burgard, Lucie Kalousova, Cailin O'Connoer, James Owen Weatherall, Natalie Dean.

PANDEMIC
HISTORY

Science,
Politics,
Society

New Pathogen, Old Politics

Alex de Waal

April 3, 2020

There is a saying among epidemiologists: “If you’ve seen one pandemic, you’ve seen one pandemic.” Echoing this trade wisdom in an interview two weeks ago, Bruce Aylward, the assistant director of the World Health Organization (WHO), pointed out that each new pandemic follows its own logic, and those who rely on past experiences to draw conclusions for public health will make mistakes. With each new pandemic, it is tempting to scour history books for parallels and lessons learned. But as many have stressed, the wisdom to be gained is often greatly exaggerated.

Still, it is possible to steer a course between the Scylla of historical blindness and the Charybdis of hasty generalization. In her book about the Black Death of 1348, A Distant Mirror (1978), historian Barbara Tuchman confines her remarks on the present to a few oblique lines in the preface. “If one insists upon a lesson from history,” she writes, it is, as the French medievalist Edouard Perroy contended, that “certain ways of behavior, certain reactions against fate, throw mutual light upon each other.” My working premise is that although the pathogen may be new, the logic of social response is not, and it is here that we can see historical continuities. An especially telling case study—still an object of fascination and controversy among historians of health and disease—is the devastating outbreak of cholera in Hamburg at the end of the nineteenth century, the subject of Richard Evans’s superbly researched Death in Hamburg (1987).

On the morning of August 24, 1892, Robert Koch arrived at Hamburg railway station from his laboratory in Berlin. Germany’s most famous medical scientist, he was already credited with discovering the anthrax disease cycle and the bacillus that causes tuberculosis. In the 1880s he had traveled to Egypt and India, where he succeeded in isolating the bacterium responsible for cholera, and on his return to Berlin, he was feted by Kaiser Wilhelm, invested with the Order of the Crown, and put in charge of protecting the empire from epidemics of infectious diseases.

Nine days before Koch’s train arrived in Hamburg, a doctor in the neighboring town of Altona had been called to see a stricken construction worker, whose job included inspecting the sewage works. He was suffering from acute vomiting and diarrhea; the diagnosis was cholera. In the first sign of the lethal controversy that was just beginning to erupt, the physician’s superior medical officer refused to accept the diagnosis. From August 16 to 23, the daily count of cases grew exponentially to more than 300; over the following 6 weeks, some 10,000 residents of Hamburg perished. Like a forest fire racing through dry tinder, the epidemic burned itself out in October, an ending helped by the efforts of Koch and his team.

As we now know, those deaths were totally preventable. The immediate cause of death was Vibrio cholerae, but the city authorities were accomplices to mass mortality, having long resisted spending public money on public health and fearing that a declaration of cholera—with the quarantine and isolation sure to follow—would bring their trading city to a halt. In Altona, just outside Hamburg’s jurisdiction, there were few infections; in Hamburg’s sister port of Bremen, a self-administering former Hanseatic League city-state, there were just six cases, half of them recent arrivals from Hamburg. Hamburg suffered alone that year.

In their pitch and consequence, these events have the narrative structure and moral tensions of a theatrical tragedy. Besides the cholera vibrio itself, which takes the shape of a comma (like its typographical counterpart, potentially catastrophic if inserted at a crucial juncture), the dramatis personae are Koch, chemist and hygienist Max von Pettenkofer, physician-anthropologist Rudolf Virchow, and a chorus of the afflicted themselves and some of their revolutionary spokesmen. There are five subplots. Science contends with superstition and fatalism; the new germ theory of disease disputes with so-called ecological or local conjunctural theories; militarized centralizing bureaucracy spars with liberal capitalism; the anthropocentric “epidemic narrative” that promises a return to the safety of life-as-normal wrestles with the logic of evolution operating on different timescales from the microscopic to the macro-ecological; and last, an open, democratic society questions its limits.

As we will see, some that is old is new again.

Cholera: The Nineteenth Century’s Most Fearsome Pandemic

Until the early nineteenth century, cholera was endemic to the Ganges Delta in Bengal, but it appears not to have been found elsewhere. The causative bacillus lives in warm water and multiplies in the human intestine, transmitted by fecal contamination. That was cholera’s macro-ecology: all it needed was to survive in just a few shallow wells during each dry season, with every annual flood spreading the germ far and wide.

Along with the great famine of the 1770s, one of the lethal gifts of the English East India Company was opening up routes whereby cholera could spread far more widely, colonizing new places as a kind of biological blowback. British investment in widespread irrigation to grow cotton created the perfect ecology in which the vibrio could find multiple local reserves—irrigation ditches and canals, reservoirs, wells, water tanks—and become endemic. In 1854 English physician John Snow elegantly demonstrated that the infection was waterborne. He showed this through an epidemiological study still heralded in textbooks today: after painstakingly plotting cases on a London street map, he asked each affected household where it obtained its drinking water, tracing the source to a single contaminated pump on Bow Street.

According to legend, Snow asked the local alderman to remove the handle on the pump, and new cases promptly ceased. In fact, as Snow himself admitted, the epidemic was already subsiding by that time, but he had made his point: the dominant “miasma” explanation—that the disease was caused by locally generated impure air—had a competitor theory that had the virtues of being simple and provable. In the same year that Snow was mapping the outbreak, Florentine microbiologist Filippo Pacini described the bacillus, which he had extracted from the autopsies of victims. But Pacini had no powerful political apparatus behind him to endorse and broadcast his breakthrough, and medical studies were not sufficiently systematic for the correct conclusion to be drawn. Thus the paradigm shift was not automatic. Rather, advocates of the miasma theory refined their arguments, contending that complicated local interactions of soil, air, and personal characteristics accounted for the vagaries of the disease. Prominent among the exponents of these views was indefatigable chemist, hygienist, and health reformer Max von Pettenhofer, whom we shall encounter in Hamburg shortly.

Cholera first reached Europe in 1830, causing mass mortality, panic, and unrest. The vibrio produces particularly nasty symptoms in its human host: once it enters the intestine, its ideal microecology, it multiplies exponentially and drives out the resident microbiota within just a few hours. The stricken body loses control of its functions, lapses into fits of uncontrollable vomiting, diarrhea, and muscle spasms, and turns blue and bloated. Catastrophic dehydration then causes death in about half of those infected.

For the emergent bourgeoisie in Europe, the manner of cholera’s attack was no less terrifying than the prospect of mortality: an individual could be stricken at dinner, or in a tramcar, causing revulsion and terror among his or her companions. Just as disturbing to the authorities were “cholera riots” in which peasants and the inhabitants of the newly expanding, grossly unsanitary industrial cities attacked landlords, city authorities, and in some cases physicians, accusing them of using the disease as a pretext for driving them out of their homes and seizing their property. Sometimes the poor even blamed the rich for having introduced the disease for that very purpose.

Subsequent cholera pandemics coincided with the 1848 uprisings throughout Europe—with localized outbreaks for a decade, including the one that prompted Snow’s investigation—and the wars of the 1860s. In 1891 famine struck Russia, prompting a wave of migration by hundreds of thousands of people one or two economic steps up from the starving peasantry. The following year, the tsar expelled the Jews from Moscow and the vibrio traveled westward with both groups. Those tired, poor, huddled masses dreamed of the United States, and the Hamburg–America shipping company was the most traveled route to the New World. German health authorities registered the cases as the migrants moved; many were stopped at the border, but some passed through undetected. The epidemic warning lights were blinking red.

Medical and Ecological Controversies, Then and Now

Cholera is a pantomime villain in this drama: stealthy, sudden, and lethal. At the time of the Hamburg epidemic, there was still much controversy about its etiology. Was it a contaminant invader? Did it emerge when there was a special configuration of local conditions? Thirty years after Snow and Pacini, and eight years after Koch isolated the vibrio, there still wasn’t medical unanimity. Hamburg was to change that.

Scientific method was itself developing alongside medical discoveries, and Koch was in the vanguard of both. “Koch’s postulates,” as we now call them, were criteria for determining whether the agent of a disease had indeed been correctly identified. According to the postulates, the microbiologist had first to identify the suspected microbe in all infected individuals; then it should be grown in culture; third he had to use the microbe to infect an experimental host and observe it sicken with similar symptoms; and finally isolate the same microbe in the sick or deceased animal. The experiment had to be repeatable. Ironically, Koch’s identification of the cholera vibrio did not fulfill his own criteria; despite his best efforts, he could not induce cholera in an animal host. It only affects humans. There were also plenty of who, why, and where questions left unanswered about outbreaks—enough material for skeptics to make the case that the germ theory was, at minimum, incomplete.

The cholera controversies of the 1880s and 1890s were, nonetheless, the first conducted under the dawning light of the new microbiology. So-called “anti-contagionists” and “localists” argued that there surely had to be other conducive factors such as the weather, the soil, or the temperament of the individual patient. Radicals asked, why was it that the proletariat were always hardest hit? (Studies of disease patterns show that this wasn’t always the case, but it was true often enough to serve as grist for social reform agendas.)

In the case of COVID-19 today, the mysteries are fewer, the scientific method is more robust, and the speed with which controversies are resolved is many times faster. The lapse between identifying a new disease and knowing its pathogen is closer to five days than five decades. The virus was isolated within a few days of the first cases and its entire genome was sequenced and available online two weeks later. We have the benefits of testing and tracing and massive computational power in charting epidemiological scenarios. Still, much remains uncertain, and epidemiologists continue to revise their understanding of the case fatality rate and vulnerability factors. We do not know whether COVID-19 will infect 20 percent, 40 percent, or 70 percent of the population. It is important to parse our ignorance, separating out what risk is calculable now, what risk will be calculated when we have better data, and what is profoundly uncertain because it cannot be captured by data gathering.

Consider an example. In their influential modeling of possible trajectories and the impact of “non-pharmacological interventions” (NPIs, by which they mean policies such as quarantine or social distancing), Neil Fergusson and colleagues at Imperial College London include the following caveats:

It is important to note at the outset that given SARS-CoV-2 is a newly emergent virus, much remains to be understood about its transmission. In addition, the impact of many of the NPIs detailed here depends critically on how people respond to their introduction, which is highly likely to vary between countries and even communities. Last, it is highly likely that there would be significant spontaneous changes in population behaviour even in the absence of government-mandated interventions.

There are two caveats here, and they should be treated differently. The first is that the basic data for sound epidemiology are not yet known, but better approximations are constantly becoming available. This is an exercise in better calculation of risk. The second caveat, which Fergusson divides into two, is that outcomes will depend upon how people respond, both to official policies and because of other changing beliefs. Health behavior is harder to measure than epidemiological constants. The point is that the social component of the trajectory of the epidemic is uncertain in a way the medical component is not: although the margins can be narrowed, the risk really cannot be quantified. In a series of blog posts examining the intersection of health, environment, and politics, scholar of science and technology policy Andy Stirling explains “the crucial distinction between ‘uncertainty’ and ‘risk.’ A risk is what results from a structured calculation that must necessarily reflect a particular view. An ‘uncertainty’ is what these risk calculations might leave out.” Health behavior is just one part of this.

Another element of uncertainty is that epidemics are inflection points in evolution across different scales from the microbial to the planetary. Pathogens evolve; microbes populate the microbiomes of animals and plants, the soil and the water; remnants of viruses are found in our DNA. For bacteria and viruses, the boundaries of the human self hold no meaning, and the more that we discover about the viral remnants in our DNA and the richness of our microbiomes, the more we are compelled to acknowledge that point of view. The vicious nineteenth-century strains of cholera retained their prior strategy of rapidity and lethality, killing about half of the humans they colonized. In the mid-twentieth century, the “El Tor” strain evolved a new strategy of lower virulence. This is a common adaptive trajectory for pathogens, which prosper by treating their hosts as symbiotes instead of wantonly destroying them. The first pandemic of any new pathogen is, for the human population, usually the worst—so it was for bubonic plague in Asia and Europe, smallpox and measles in the Americas, and cholera. It is no solace to Homo sapiens facing COVID-19 today.

Ecosystems change too. Most of the new pathogens that infect humans are zoonotic: they jump the species barrier, from wild monkeys or bats, or from domesticated chickens or pigs. This has always been the case. But in the past, a zoonotic pathogen might infect a band of hunter-gatherers; today, thanks to a globalized, deeply interconnected world, a single local outbreak can become a pandemic in a few weeks. Another new factor is the proximity of humans to domestic animals and factory farms. The 90 percent of nonhuman terrestrial vertebrate biomass on the planet husbanded for our consumption lives—if we can call it living—in ecosystems such as feedlots that have no precedent. These are perfect incubators for new zoonoses, especially for avian influenza, which can evolve first in chickens, then jump to pig populations that act as a kind of pathogenic evolutionary accelerator, and finally make the leap to humans. In turn, each new human–pathogen dyad alters the ecology of global public health and disease: our built environment changes (in the nineteenth century with the introduction of municipal water supplies, for example); our biochemical environment changes (supplementing animal feed with antibiotics, for example); and our health behaviors change. Meanwhile, climate change is altering the ecologies of infectious diseases in ways that we cannot predict. The post-pandemic world is a changed ecosystem.

Though a great deal of headway has been made into the study of these complex environmental factors, the uncertainties they introduce are left out of epidemiological models narrowly focused on predicting numbers of cases and deaths. The standard “epidemic narrative” consists of a stable “normality” threatened by the intrusion of a novel, alien pathogenic threat, followed by an epidemic and an epidemic response (of variable proficiency) and ends with a return to the status quo ante. That neat storyline simply isn’t going to happen. In turn, in Hamburg 140 years ago and across the world today, what is “left out” depends on where you stand.

How Liberals Failed to Prevent Epidemics

So much for the microbial protagonist. Let’s turn now to the three human characters in our retelling of the Hamburg tragedy.

First on stage is the dominating and ultimately tragic figure of Max von Pettenkofer (1818–1901)—almost unknown today, but 130 years ago at the height of his professional fame as Germany’s preeminent chemist. He championed medical research, advocated clean air and urban sanitation, and mentored dozens of students. In the comic book version of our Hamburg story, though, all these achievements count for naught: he is instead the villain whose obstinate pride, reprised by his acolytes who dominated Hamburg’s medical policies, failed the people of that city twice over. Their biggest shortcoming was failing to prepare for waterborne diseases and refusing to order the construction of filtration plants to treat the city’s drinking water so that people were drinking water piped straight from the river Elbe to storage tanks, and from there to their homes. As water levels dropped in the dry, hot summer of 1892, contaminants were washed by the tides and currents from riverside towns and from the barges that plied the waterway. Filtering through sand efficiently removes Vibrio cholerae. Other cities did it; Hamburg did not.

Why did Hamburg authorities take this stance? Despite the centralizing ambitions of the Prussian state, and the uniform color of its territories on the political map of Europe, the administration of Germany was not yet unified. Hamburg, the second-largest city and its richest port, still retained the legacy of self-government from its membership in the Hanseatic League. The city was run by its own senate and zealously guarded its powers to make independent policy decisions, especially in matters of trade. Indeed, Hamburg was the most “English” city in Germany, governed by an assembly of its citizens—by its constitution, a small and privileged group of property owners; by its social history, an oligarchy of traders and lawyers. They disliked and distrusted th...

Table of contents

• Cover Page
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• Editor’s Note
• Pandemic History
• Pandemic Philosophy
• Pandemic Policy
• Contributors