Eighty-four million Americans remain unvaccinated against COVID-19. Nearly no one has knocked on their doors to explain why a vaccine is a good idea. Even at this late date, now is a good time to start.
As with COVID testing, thousands of newly hired community health workers are needed to hit the streets and back roads to convince people that vaccines are safe and necessary. Daily conversations, some over the course of many weeks, are needed to turn millions of skeptics or the disconnected into participants. This would be the kind of program the Biden administration proposed, if still in an inadequate form, for contact tracing before the inauguration and never pursued after.
Certainly, the ongoing bloodbath — only inches deep but wide as a lake — isn’t just a matter of the present administration. Trump’s vindictive inaction helped kill half a million Americans the first year of the outbreak. Biden’s smug insufficiency, however, will likely add another half a million by spring. But more pointedly, it’s as much a matter of the U.S.’s structural decline that produced the holes in our public health coverage. Beginning nearly 50 years ago, public health was increasingly abandoned or monetized under the neoliberal program.
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Public health spending clearly saves lives. Ten years ago, health policy analysts Glen Mays and Sharla Smith found that U.S. mortality rates from preventable deaths — including infant mortality and cardiovascular disease, diabetes and cancer — fell between 1.1 to 6.9 percent for every 10 percent increase in local public health spending.
Yet this crucial spending has dropped. In 2018, the Trust for America’s Health reported on the effective decline of public health funding.
The report described the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Program as the only federal program that supports state and local health departments to prepare for and respond to emergencies. Except for one-time bumps for the Ebola and Zika outbreaks, core emergency preparedness funding had been cut by more than one-third (from $940 million in 2002 to $667 million in 2017).
The report went on to identify precipitous declines in public health funding at the state level. Thirty one states cut their public health budgets from FY 2015-2016 to FY 2016-2017, with spending lower that year than in 2008. The budget cuts during the Great Recession were never restored.
The impact was felt at the local level, too. Local health departments cut 55,000 staff in the decade following the Recession. By this system’s logic, an acute emergency is also grounds for such cuts. Thousands of health staff were furloughed during the COVID outbreak — cuts attributed in part to declines in more lucrative elective surgeries. One in five health workers have left their jobs during the pandemic.
The Trust for America report went on to describe the incoming disasters for which the U.S. appeared unprepared in 2018. They sound like headlines of the past year: weather disasters; flooding; wildfires; extreme drought; hurricanes; infectious disease outbreaks; and deaths of despair due to factors including racial disparities, opioids, and regional disparities that continue to drive distrust of government.
Trust for America placed particular focus on pandemics and the need to fully fund the Pandemic and All-Hazards Preparedness Act, the Hospital Preparedness Program, the Project BioShield Act and PHEP.
The report recommended increasing funding for public health at all levels of jurisdiction — federal, state and local. It called for preserving the Prevention and Public Health Fund, increasing funding to prepare for public health emergencies and pandemics, establishing a standing public health emergency response fund, and surge funding during an emergency to avoid the delays that were apparent in the Ebola outbreak, the swine flu pandemic, Hurricane Sandy and the Zika virus outbreak.
Trust for America concluded with a recommendation for a national resilience strategy to combat diseases of despair, for preventing chronic disease, and for expanding high-impact interventions across communities.
While it is important to consider recommendations for increased funding and preparedness, it’s also crucial to take a step back and consider the system under which these suggestions are being made. Trust for America’s recommendations were wrapped in the worst of language and precepts. The report accepted the class character of the state. Public health is a means of cleaning up messes that capitalist production produces. Public health outcomes were pitched in terms of returns on investment.
All terrible. And yet, in the present context, such recommendations are radical, if only in pushing back against the damage of an empire at the end of its cycle of capital accumulation, organized around helping billionaires squeeze what’s left of the commons and turning decades of social infrastructure back into bunker money.
Anti-Public Health — at Home and Abroad
We find an analogous fallacy in U.S. COVID policy abroad. While the Biden administration has taken a stance in favor of waiving TRIPS rules against vaccine generics for COVID, tech billionaire and philanthrocapitalist Bill Gates, funding WHO efforts, effectively sets U.S. foreign policy on the matter.
Gates declared in April that:
there are only so many vaccine factories in the world and people are very serious about the safety of vaccines. And so moving something that had never been done, moving a vaccine from, say, a J&J factory into a factory in India, that, it’s novel, it’s only because of our grants and our expertise that can happen at all. The thing that’s holding things back in this case is not intellectual property, there’s not like some idle vaccine factory with regulatory approval that makes magically safe vaccines.
The reality is something different. Last month AccessIBSA and Médecins Sans Frontières identified 120 companies in Africa, Asia and Latin America with the likely capacity to produce mRNA vaccines. Human Rights Watch reported:
“Global vaccine production forecasts suggesting there will soon be enough Covid-19 vaccines for the world are misleading,” said Aruna Kashyap, associate business and human rights director at Human Rights Watch. “The US and German governments should press for wider technology transfers and not let companies dictate where and how lifesaving vaccines and treatments reach much of the world as the virus mutates.”
Two months earlier, The New York Times had investigated the possibility:
“You cannot go hire people who know how to make mRNA: Those people don’t exist,” the chief executive of Moderna, Stéphane Bancel, told analysts.
But public health experts in both rich and poor countries argue that expanding production to the regions most in need is not only possible, it is essential for safeguarding the world against dangerous variants of the virus and ending the pandemic.
Setting up mRNA manufacturing operations in other countries should start immediately, said Tom Frieden, the former director of the Centers for Disease Control and Prevention in the United States, adding: “They are our insurance policy against variants and production failure” and “absolutely can be produced in a variety of settings.”
Both at home and abroad, pharmaceutical industry apologists propose nothing can be conceived, much less pursued, unless the largest companies make billions in profit. Our men of the year are to be treated as no less than gods with rocket wings. Few of the respectable establishment have described, much less denounced, the fallacy.
Others have been much more truculent in their commentary, connecting increasing wealth concentration with COVID failures:
- Economic historian Matthias Schmelzer started one Twitter thread early December: “The global concentration of capital is extreme: The richest 10% own around 60-80% of wealth, the poorest half less than 5%, according to just published World Inequality Report.”
- Americans For Tax Fairness reported: “America’s billionaires got $1 TRILLION richer in 2021, a 25% gain in collective wealth that will go largely untaxed.”
- Union organizer Jack Califano encapsulated the damage of such an arrangement: “COVID has been a perfect illustration of how our government now works. In a crisis, it will provide benefits, but only the absolute minimum it determines necessary to protect the system from political upheaval. And then, as soon as stability is restored, it will take them away.”
The Pandemic ThinkTank has taken up the core matter in similarly direct terms. In a report it released in November, the ad hoc group — comprised of a social psychiatrist, disease ecologist, medical anthropologist, epidemiologist, critical care physician and county official — unpacked the origins of the COVID trap that the U.S. placed itself in and offered a plan of escape other than “go to work.”
The team described how social systems set the ways epidemics spread, the damage that accrued in the American system of disease control long before SARS-2 showed up, the history of successful public health efforts before that destruction, and what a working public health system looks like:
Several lessons emerge from the COVID-19 pandemic and frame our approach to planning for the next pandemic.
First, there are three ‘partners’ in this enterprise: the government, the public health establishment, and the communities. Each partner has an important role to play in ensuring that we learn these lessons and can meet the next challenge with a better chance at survival. But there is an underlying issue of excess power held by the American oligopoly and the politicians allied with them. They profit in power and wealth from the array of policies David Harvey (2019) labeled ‘accumulation by dispossession’.
Any serious examination of pandemic threat must confront the danger contained in such one-sided power. Part of the way in which the oligopoly has gained and maintained power is by undermining communities and destroying their organizations. While this is good for short-term profit, it poses an enormous threat to long-term survival. Rebuilding community power is an essential part of epidemic control.
Rebellion as Intervention
So, there are minds stateside who understand both disease and the country in ways the establishment that rejects their counsel does not. In contrast to the president’s chief medical advisor Anthony Fauci and a CDC that repeatedly places commerce and empire before people, Pandemic ThinkTank explicitly counsels a rebel alliance:
Local health departments must, in many municipalities and counties, foment revolution.
This, like most revolutions, must occur in secret and with interactions with community groups in places like neighborhood bars, playgrounds, houses of worship, and barbershops/beauty salons.
In order to bring communities into condition for improved public health and for pandemic prevention and response, the health department must have the social and political muscle to pressure the elected executive into reforming the relevant agencies.
The health departments themselves must feel the pressure of empowered communities to establish egalitarian planning councils that will produce plans acceptable to and supportable by the various elements that form the local communities.
Unlike the COVID Collaborative of establishment epidemiologists who, like the CDC, push a more individualistic approach to public health, we can see why the Pandemic ThinkTank holds no direct line to the president. Indeed, ultimately, it’s going to take everyday people from beyond the Beltway to help bend epidemiology back into a science for the people.
Younger epidemiologists are taking on that spirit, turning on Biden and their better-connected colleagues in confrontational terms for which most journeymen are punished:
- Perhaps with the COVID Collaborative and ex-Harvard epidemiologist and now chief science officer at the eMed diagnostic company Michael Mina in mind, Columbia University’s Seth Prins tweeted: “Turns out lots of blue check public health experts moonlight as pandemic profiteers.”
- Ellie Murray, of Boston University’s School of Public Health, tweeted: “Honestly baffled by people who claim the COVID plan put in place by the president of the united states, ‘leader of the free world’, was so fragile that an assistant professor tweeting on her coffee breaks could undermine it, & that *isnt* somehow worse than the plan just failing?”
- Justin Feldman, a social epidemiologist at the Harvard FXB Center for Health & Human Rights, who wrote his own critique of Biden’s COVID year, followed up: “There’s ‘a lot to unpack’ about how the only substantive criticism the media has been willing to pursue wrt Biden’s pandemic response is failing to make a consumer product (rapid tests) available to individuals.”
- From abroad, Botswanan doctor Letlhogonolo Tlhabano weighed in: “I’m an intensivist and have been taking care of COVID patients since this pandemic begun, and the new AHA guidelines are idiotic. We’re not martyrs. The CDC guidelines are also motivated by the need to protect capital, and not necessarily by any science. We’re on our own.”
- Science organizer and biochemist Lucky Tran commented: “We are not ‘learning to live with COVID’. When we give up on protecting our healthcare systems, workers, the immunocompromised, and the vulnerable, in reality we are ‘surrendering to COVID.’”
- It really speaks to the tenor of our times when March for Science retweets Black radical Bree Newsome on the out-of-pocket costs of COVID testing.
I tried warning people about Biden’s pandemic-related policies before the inauguration, twice, and wrote a book titled Dead Epidemiologists, underscoring the mortally wounded thinking of even some of the field’s best and brightest practitioners.
The advocacy work of these younger scientists, however, may signal that our ugly future also offers hope. A more recent invitation to my millennial colleagues that we had a world to win reminded me of the generation-appropriate Marx t-shirt I’m getting my kid for his birthday: “You’re A Wizard, Harry.”
Of course, I don’t have all the answers on how we’ll get through this shit show — to use the technical term. I’m always learning alongside this new generation.
I experienced a bout of my own booster hesitancy, born out of the ethical quandary in which Gates trapped us all. Why a third inoculation for me when much of the world hasn’t gotten stuck a single shot? The utter shame of it, with the appropriate symptoms of a red face and shortness of breath. I finally concluded that being alive allowed me to use what little power and platform I had to argue for a different public health order the world over.
For ending a pharmaceutical industry focused on commoditizing health and reinvesting in a public health organized around our shared commons here and abroad is the only way out of this pandemic in any short order. Otherwise, we are left to letting the virus burn out on its own by something like 2025, as early models projected. The Black Plague in Europe eventually ended after eight years. Unless we act now to restore an active, on-the-ground public health mobilization helping people block-by-block and farm-by-farm, we will be forced to assimilate the possibility that we are to suffer a pandemic of a similar duration.