Public Health in Times of Epidemics: The Good, the Bad, and the Ugly

By Karyn Pomerantz, May 7, 2020

The corona crisis, on top of so many others, shows how lethal capitalism is. Poverty and racism are the pre-existing conditions that inflate the rates of death and disability. For billions of people around the world, this disaster continues the misery at the hands of the 1%. It hopefully wakes up other people to the inequalities, negligence, and outright murder of global capitalism. 

How has public health responded to such inequities and pandemics? What can we learn from previous infectious disease outbreaks caused by smallpox, TB,  and cholera? When public health is good, it is very good, but when it is bad, many people die. When public health gets ugly, it destroys our lives and future security and aspirations. 

Public health today operationalizes the prevailing political ideology: personal responsibility, the philosophy that individuals make decisions about what to eat, where to live, how to work, or  whether to graduate, and then pay the consequences. Public health has blamed the individual for poor health habits and focused on educating people rather than dealing with systemic issues. Even now, when many talk about social determinants of disease, such as housing, racist police violence, immigration policy, and employment, actual interventions still focus on individual behavior.

This article identifies some of the qualities of successful and failed attempts to control epidemics with examples from selected countries since the late 19th Century.

Public Health: The Good

Community Mobilization

“... the conviction that ordinary people possess great strength and wisdom and when their initiative is given full play they can accomplish miracles… To mobilize the peasantry (in China, 1950s), it was necessary to explain to them the nature of the illness … they themselves worked out methods of defeating it” (Horn 1969).

Examples

China:

After the revolution in 1949, the Communist Party of China radically improved the health of workers and peasants; they eradicated diseases that ravaged Chinese people with infections, sterility, and addictions. Ten million people suffered from schistosomiasis, a parasitic worm infection that causes severe anemia, male infertility, and liver disease with a corresponding drop in birth rates and population.

In 1955, the Party launched a campaign against schistosomiasis that educated the public about how the disease spread and then mobilized millions of people to drain the waterways, and manually pick out the snails that carried the worms. This massive public involvement in primary prevention wiped out the disease at this time.

China also trained and mobilized teams of Chinese “barefoot doctors” to provide first aid and simple primary care in an ongoing way to peasants who had no medical care. This lasted until the 1980s, when China became a market economy.

Cuba:

Cuba trained enough doctors and nurses to staff neighborhood primary care clinics throughout the country. Today, there are enough Cuban doctors to serve in war torn and pandemic devastated areas around the world. In 1961, Cuba launched its Cuban Literacy Campaign that involved over 1,000,000 teachers and learners. In eight months, they raised literacy levels from 77% (with rural residents less likely to read) to over 96%.

US:

HIV activists in the US during the 1980s and 1990s developed sophisticated knowledge of the virus, medications, and harm reduction; the NIH under Fauci included them on its research study panels. They, in turn, led widespread educational programs for people with and without HIV often fighting the government to allow needle exchange programs and school based sex education.

During many disasters, such as Hurricane Katrina, ordinary people contributed life-saving support, but without the organization that could be provided by governmental leadership.  The Covid19 pandemic reveals the heroic efforts of volunteers to provide health education, food, mutual aid, and money, again with a lack of national leadership. Health workers, particularly nursing staff, retail workers, prison abolition advocates, and immigrant rights activists continue to build strikes, community protests, and other actions to demand health protection from employers and governments. 

Social Responsibility and Social Movements

Proponents of social responsibility locate the main causes and effects of epidemics in the social and physical environment instead of in individual behaviors. Public health practitioners who favor personal responsibility explanations will emphasize health education and create training and messages to teach the public how to eat healthy foods or exercise to boost their immune systems. Public health workers who adopt a social responsibility perspective engage in movements for social change. They may organize to alter immigration and carceral policies, improve living conditions, regulate worksites, and fight racist inequities. Such organizing is more likely to occur when there is a mass movement. A combination of social movements and health education can improve health outcomes.

Examples

US:                           

In the United States of the early 20th Century public health was influenced by the frequent militant rebellions. The Communist Party USA, the Socialist Party, and the Wobblies (the International Workers of the World) organized workers in mining, manufacturing, and transportation; led massive militant strikes, such as the Flint Auto factory occupation; and threatened the robber baron class of capitalists, the oil, railroad, and mining company owners, such as Rockefeller and Carnegie. The Depression of the 1930s catalyzed militant struggles against unemployment and evictions. Anti-racists fought lynchings and advocated freedom for the Scottsboro Boys who were falsely accused of rape and spent decades in prison even after their accuser recanted. Suffragists demanded the vote for women that they finally won in 1924, almost 150 years after the Constitution was written.

At the same time, public health adopted social interventions. Under the New York City Health Department’s leader, Herman Biggs, health workers concentrated on the unsanitary and dangerous conditions of the working class, enlarged by a large influx of poor immigrants from Europe. These public health activists and other reformers won better housing to replace the crowded, squalid tenements that bred TB and opposed the xenophobia directed against the new arrivals. Occupational health and safety became a focus of concern as employers exploited cheap labor, child workers, and immigrant garment workers.

“Muckrakers,” like Upton Sinclair, exposed deadly conditions at worksites, such as the Chicago slaughterhouses, and the Triangle Shirtwaist Company, notorious for the deaths of the women locked down in the sweatshop as a fire raged.

Social movements of the 1960s in the US contributed to improved health outcomes. The anti-racist civil rights movement helped desegregate hospitals and reduced infant and adult mortality. Feminists won better reproductive health care and changed the dynamics of communication and decision making between patients and doctors. Gay rights demands became more visible and paved the way for more significant reforms with the activism of people with AIDS and later with people who adopted non-binary gender roles. Disability activists secured legislation to end discrimination and physical obstacles for people with physical, psychiatric, and developmental differences.

Centralized Management, Leadership, and Enforcement

Reductions in disease transmission require strong central leadership and coordination as opposed to voluntary participation in vaccinations and quarantines. Epidemics cannot be controlled by spontaneous local mutual aid, and state or county level decisions to quarantine. Epidemic precautions cannot be understood or implemented when there are contradictory and unscientific messages. Enforcing quarantines, procuring supplies, requiring immunization, and disseminating recommendations require strong central science-based leadership while governments must guarantee food, money, safe housing, paid leave, and other necessities to allow people to protect themselves and communities without choosing between health and income.

Examples

USSR:

The Communist Party in the Soviet Union inherited massive health problems in 1917. Infant mortality claimed 250 babies out of 1000 live births; by 1970 that decreased to 20 out of 1000. Life expectancy increased approximately 30 years for men and women. The Soviet government used quarantines and “contagion clinics” to control infectious disease transmission; improved housing and nutrition; established many research institutes and medical schools; and produced more medications. The Sanitary and Epidemiological (SanEp) agencies, similar to the US CDC, worked on the national to the village level to monitor diseases and administer interventions, such as mandatory vaccinations. This centralized effort, along with many social reforms, accomplished a decrease in morbidity and mortality. Even anti-communist Russians later acknowledged that the system “offered stability … and protected us.” 

China:

The Party used extensive centralized educational programs to eliminate syphilis. It crushed the drug dealers who addicted millions. The Party legalized divorce and guaranteed jobs for sex workers, eliminating the spread of sexually transmitted infections. In hospitals, housekeepers joined the medical teams to offer information about patients’ lives, and physicians mopped floors in order for both groups to share the scut work and the patient care responsibilities.

US:

NYC made vaccines available for smallpox and diphtheria to limit transmission. TB raged, but quarantines dramatically reduced its mortality rates.  Biggs forced resisting TB patients into sanatoriums and developed a successful media campaign to convince people to vaccinate. He acknowledged the need for authoritarian control to protect the public’s health:

…the sanitary methods are sometimes autocratic, and the functions performed by sanitary authorities paternal in character…we are prepared to introduce and enforce…measures which might seem radical and arbitrary … for the public good…” (Garrett, p. 287).

Opposition has developed against strong enforcement measures when people are uneducated as to the source of health problems or were deeply suspicious of dictatorial regimes. In earlier times, people murdered vaccinators and doctors who treated plague, cholera, and smallpox, believing that health workers killed patients for their organs and to conduct experiments. More recently, health workers trying to treat Ebola or vaccinate against polio have been attacked. Even in the US, where science education is poor, many people oppose vaccinations.

Public health and enforcement agencies need to approach dissent without brutalizing people as Indian police did during the cholera outbreak in 1897 and today. Recently, thousands of Hindus and Moslems rebelled together against the violence of the enforcement even though they accepted the need to isolate. Governments must not only be trusted but ensure access to food, health care, and mental health support, and the elimination of rents and other critical expenses in order to implement distressful interventions. Enforcing public health with brutality and racial profiling further erodes trust in public health. 

As cited in the Black Agenda Report,

“The criticism of lockdown measures as “authoritarian” has been a convenient distraction from the fact that capitalism is truly an authoritarian menace of plunder and war which needed to be placed on lockdown and overthrown years ago.” 

Professional Roles 

Public health leaders in academia and practice adopt different roles over time. In the past when there were significant labor and social movements, public health played an activist role advocating for improvements in living and working conditions. Since then public health has devolved into a vocational, technical profession (Fairchild, 2010). Although there is increasing interest in expanding the role of public health and medicine to address the social determinants of health, there is little implementation. We can look to the past to honor and learn from some of these revolutionaries, Rudolf Virchow and Norman Bethune, who used their skills to serve the working class. 

Examples:

Multiple countries:

Rudolf Virchow (1821-1902), the founder of cellular pathology and social medicine, famously declared that “medicine is a social science, and politics is nothing more than medicine on a grand scale” and “doctors are the natural advocates of the poor and the social question falls to a large extent within their jurisdiction.”  As a scientist and revolutionary, he fought for reforms to benefit the working class. Sent to Upper Silesia (now part of Poland) to investigate a typhus epidemic, he reported on the brutal social and economic conditions of the population there, calling for radical, non-clinical improvements in living conditions and religious reforms, and rejected claims that there were biological differences in ethnic groups. He emphasized the need for universal free education, decent housing, the separation of church and state, infrastructure (roads), taxation of the rich, and changes in agricultural production. He joined the barricades in the 1848 uprisings against the monarchy and served in the German legislature to advocate for housing and radical policies. His influence lives today in the movement to address capitalist determinants of disease and neglect. 

Norman Bethune, a Canadian communist physician moved to China to serve the revolutionary Liberation Army. Eventually killed by a blood infection that occured while operating on a Red Army soldier in a Chinese cave, he represents health workers’ commitment to revolutionary change. In a speech, he called out the capitalists of his time:

  “… Such men as these must perish if the human race is to continue. There can be no permanent peace in the world while they live. Such an organization of human society that permits them to exist must be abolished. These men make the wounds” (Horn, p. 186).

Today, there are many public health scholars and activists leading the fight for equity. Camara Phyllis Jones, past president of the American Public Health Association, educator, and researcher, made fighting racism the central aim of her presidency and career. Her story telling helped people connect racism with poor health. Many other academics, such as Nancy Krieger and Arline Geronomis, published, researched, and spoke about the data that exposed the causes of racial and gender related health differences. 

Public Health: The Bad

Socioeconomic Factors

Supportive social and economic conditions can help prevent and lower the rates of infection. Housing, nutritious food, livable incomes, paid sick leave, safe working conditions, medical care, education, acceptance, respect, and antiracist policies promote health. As stated above, Progressive Era health sanitarians in NYC remediated slums, improved sanitation, and achieved better hygiene in hospitals. TB rates dropped dramatically until a resurgence in the 1990s after cuts in TB programs. 

However, as long as “capitalism is the virus,” most of the news is bad for the public’s health. The capitalists only invest in health when they need a population able to work, reproduce, and serve in the military. With so much unemployment, there are always people who need to work for any wage and can be replaced if they fight back.

Examples:

US:

As the antiracist and anti-poverty movements slowed down after the 1960s, the government slashed its investment in social programs. President Reagan declared that “government is the problem” as he pushed individual responsibility and lifestyle changes to improve health while eliminating the programs that could change lives.  The US continues to severely slash public health budgets. Although The Affordable Care Act (the ACA) in 2010 stipulated billions of dollars for the Prevention and Public Health Fund, its budget has since been stripped, leading to cuts in CDC funds for immunization, emergency preparedness, and global Ebola and Zika control programs. Over 700 CDC employees lost their jobs.

The proposed budget for 2021 includes continued cuts: 9% or $9.5 billion from Health and Human Services (HHS), 16% from CDC, and $3 billion from global health programs (IPS, 2020).  It allocates $11.5 billion for immigration suppression, including ICE, the wall, and family separation.

Capitalism rewards short term gains as seen in the “just in time” approach to supply chains that created severe shortfalls in protective gear and equipment to treat Covid19 patients – not a useful practice during a time of increasing and predictable epidemics. 

Meanwhile, the US Federal Government abdicated all responsibilities to control Covid19, disseminated lethal misinformation, and hoarded critical medical supplies. It willfully ignored the need for national level coordination by insisting that state and local governments make their own decisions about lockdowns and other containment practices. States ended up competing for medical supplies, often purchased from other countries.

Industrial and financial capitalists raked in money, reaping profits from increased sales, such as at Amazon and drug companies, and dividends from financial trading. Universities and think-tanks ran after Covid19 grant funds to research and publish data and models of coronavirus transmission and Covid19 mortality. While these contributions are valuable, universities siphon off a large percentage of the money for administrative costs.

In the business world, over 150 large companies took $600 billion in subsidies under the Payment Protection Program, a loan program for small businesses. Bankers then made $10 billion from the loan fees. Major capitalists like Jeff Bezos of Amazon and Eric Yuan of Zoom increased their obscene wealth by $1 billion, and the top 1% earned $308 billion in four weeks as over 26 million people lost their jobs and the federal minimum wage remained at $7.25 per hour. “Essential” or “disposable” workers, mostly black and Latin, face dangerous conditions. Many died at extremely disparate rates than people affluent enough to remain home, with a black:white death ratio of 2:1.

Public Health: the REALLY Ugly

Ideologies and Attitudes

Ideologies frame and justify the way society views and handles disease, such as attribution of disease to personal habits, individual rights versus community solidarity, how services and care are distributed, and the roles of government and employers.  

Examples

Racism creates poverty, stress, and intentional inequities that increases rates of disease as we see in the greatly disparate rates of Covid19 deaths and hospitalizations, and higher rates of unemployment among black and Latin US residents; black workers have suffered twice the rate of unemployment compared to white workers. 

Racist research greatly diminishes trust in public health initiatives – for good reasons. Historically, doctors have used enslaved black women to develop gynecological surgery (without anesthesia), and so-called scientists have created phony syndromes, such as drapetomania (escaping from slavery). In the 20th Century, psychologists have charged black people with inferior intelligence in order to justify discrimination. This year, two French scientists called for research on Covid19 in African countries (where it is hard for poor people to access or afford medical care). While research has benefited people in high income countries, black, Asian, and Latin people often don’t enjoy these life saving discoveries, such as HIV or hepatitis C medications.

Even when the government has instituted social programs, it has perpetuated racist discrimination by excluding black and Latin workers to appease the southern states’ racism. New Deal employment programs in the 1930s paid them less, and Johnson’s Social Security program in 1965 denied coverage to domestic and farm laborers who were primarily black and Mexican. Medicaid, insurance for the poor and many minorities, is often cut, while Medicare stays intact.

Xenophobia (fear and hatred of immigrants) deflects blame onto blameless people and incites violence against them. Racists have targeted Latin, Jewish, Moslem, Asian, black, and white Irish and Italian people with blame and violence over centuries of epidemics. They called European immigrants “race invaders,” accusing them of spreading filth and disease. Health reformers faced xenophobic residents in NYC as they mobilized against TB, weakening support for their recommendations. We see this today with Trump’s using the pandemic to close the southern border and attack China while assaults against Asians exceed 1000 incidents. Furthermore, scapegoating prevents people from uniting to demand the social changes necessary for everyone’s survival.

Anti-communism also affects responses to disease. The capitalists proselytize false ideas that we have democracy and individual choice. Therefore, individuals should be able to choose not to physically distance, vaccinate, or quarantine, acting so as to endanger the health of the public. In contrast, public health activists support the communist principle of serving the common good. Instead of uplifting the communist commitment to social responsibility and collectivity, capitalism reduces people’s poor conditions to the product of poor choices. US bosses fan anti-communism to condemn government programs, such as Medicaid, food stamps, and welfare benefits, as socialist handouts to the poor; many people construe public health as service to the poor and withhold their support for public health expenditures and programs. A woman at an “open up America” rally held a sign that said “Quarantines = Communism.”

USSR:

The break-up of the USSR dramatically reversed the health gains described above. Life expectancy fell three years in one year in the 1990s.The number of diphtheria, cholera, typhoid, hepatitis, and TB epidemics increased as did rates of substance abuse, suicide, and HIV. Young people using IV drugs accounted for the vast majority of HIV infections. Before 1996, HIV rates were low. By the end of 1998, 20-70% of IV drug users had HIV, robbing the society of young, productive people. 

Other health indicators, including mental illness, cardiovascular disease, intimate partner violence, and child abuse, worsened, and the birth rate dropped. Vaccination was voluntary giving rise to an anti-vaxxer movement and a drop in vaccination rates. Meanwhile, antibiotic resistance grew without any control of antibiotic use. A severe TB epidemic developed, especially within prisons. 

On top of losing all economic security, workers had to adopt an entirely different way of coping. The state now valued competition and entrepreneurship. In public health, it moved to a more market based system of privatizing health care, decentralizing public health governance, implementing health insurance and managed care, and limiting government involvement. An HIV researcher commented:

“From my point of view, it’s necessary to bring back socialism. This psychology of socialism is more acceptable for Russians…The sense of working for society is very important for young people” (Garrett, p. 223).

Sexist ideas justify women’s high representation in low paid jobs and domestic labor. It creates rigid gender roles and power relationships that contribute to personal violence and stereotyping. The oppression of women is particularly dangerous in times of sequestering when family conflicts often explode and women bear the majority of child care, home schooling and other quarantine related tasks while working.

The value of life in the context of decreased medical capacity has revived discussions of rationing care, determining whose lives are worth saving. Capitalism treats people as commodities, objects to be bought and sold to enrich the wealthy. Their value is measured in their ability to create profit. These decisions are murderous in a society saturated with disdain for seniors, people of color, and people with disabilities. In the 1930s, the Nazi government condemned elderly and mentally disabled people as “useless eaters,” people who consumed resources but didn’t produce anything, and killed many of them years before they established the genocidal killing centers.

Summary

The driving force of capitalism, profit, requires racism, imperialism, wars, and many other forms of oppression to suppress dissent, disunify the working class, and maintain power and wealth for a tiny minority. This brief overview of epidemic prevention and management shows the need for strong, supportive, centralized coordination and cooperation based on peoples’ knowledge that their government operates in their interest; economic security for the working class; health literacy; community responsibility; and multiracial, ethnic, and gender solidarity. 

It will take a militant political struggle to attain critical reforms, but we will need a revolution to overthrow the profit system before these dreams materialize. Organize and revolt: don’t let a pandemic go to waste!

References

Allan T. and Gordon S. The Scalpel, the Sword: the Story of Dr. Normann Bethune. Boston: Little Brown, 1952.

Baumgartner E. White House Hails Success of Disease Fighting Program and Plans Deep Cuts. NY: New York Times, March 13, 2018. https://www.nytimes.com/2018/03/13/us/politics/trump-ebola-disease-cuts-global-health-security-agenda.html

Fairchild A. The Exodus of Public Health. AJPH, 2010 January; 100(1): 54–63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791244/

Garrett L. Betrayal of Trust: The Collapse of Global Public Health. NY: Hyperion Press, 2000.

Haiphong D.  People’s War against COVID-19, Socialism Offers Victory while Capitalism Spells Defeat. Black Agenda Report, May 6, 2020. https://www.blackagendareport.com/peoples-war-against-covid-19-socialism-offers-victory-while-capitalism-spells-defeat

Horn J. Away with All Pests: an English Surgeon in People’s China, 1954-1969. NY: Monthly Review, 1969.

Institute for Policy Studies. Facing a Global Coronavirus Pandemic, Trump Keeps Militarizing America, Feb. 27, 2020. https://ips-dc.org/coronavirus-pandemic-trump-militarizing-america/

Selected authors to read on the social determinants of health and racism:

Richard David

Paul Farmer

Camara P. Jones

Richard Hofrichter

Ibram X. Kendi

Nancy Krieger

Thomas LaVeist

Keeanga-Yamahtta Taylor

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