Plague Revisited

three decades ago, social research hosted a conference at the New School on plagues. My presentation was limited, centering on perceptions of risk and social responses. How has our response to the novel coronavirus incorporated what has been learned from previous experience?

My earlier presentation (see p. 305, this issue) mentions how definitions change. Webster's Medical Desk Dictionary (1986) defined plague as an epidemic disease causing a high rate of mortality. We now have a more expansive view of plagues, not limited to problems of high mortality, and we talk about plagues of violence, diabetes, and obesity. As Albert Schweitzer observed, suffering is a greater burden than death itself.

Our perceptions of risk are influenced by how much control we believe we have. Many of us tolerate high risks in rock climbing, fast driving, drug use, or smoking because we are in control of placing ourselves at such risk. But we often protest even small or debatable risks, such as those of fluoridation, if we feel we have no control over the exposure. The initial fear of COVID-19 was consistent with the view that we had little control, and the need for some control even drove toilet paper sales. The impact of hand washing and physical distancing has given individuals some power and has perhaps changed the perspectives of risk.

Important events in the history of plagues include the movement from fatalistic acceptance to action. Hand washing, water chlorination, vaccines, and malaria prophylaxis are examples of action. Tools were important, but they required the development of systems to be impactful.

For instance, the Salk vaccine was declared effective in 1955, but there was no system for the purchase, distribution, and use of the vaccine. The first secretary of the US Department of Health, Education, and Welfare, Oveta Culp Hobby, opposed socialized medicine; therefore, there was no government plan. Public pushback was so great that President Eisenhower directed her to develop a program. Her plan was to seek an appropriation to buy vaccines for poor children. Senator Lister Hill declared there should be equity and passed a bill providing federal support to provide the polio vaccine for all children. The problem was not left to states; instead, the federal government took the lead. That program persists to this day.

Many of the lessons of past plagues have continued to be useful even with new agents not previously recognized. Since the Social Research conference took place, approximately one new infectious agent a year has been recognized. Some, such as Ebola, have high fatality rates but are limited in geographic distribution; human cases disappear for months or years. Others, such as Lassa fever, appear to have high case fatality rates initially, only to reveal that many people have evidence of past infections without life-threatening illness. Some, such as Zika or SARS, demonstrate person-to-person spread but do not spread worldwide.

Response has been hampered by a deficit of materials, workers, and plans. On various occasions, the US government has declared there will be a strengthening of the public health structure so that counties, states, and the federal government will be ready for the next problem. In every case, resources and support evaporated after the immediate problem subsided.

Michael Osterholm pointed out years ago (in a personal communication) that airport fire departments are funded every year even if they go decades between emergencies. That doesn't happen with the public health infrastructure … but it should.

The Ebola outbreak in West Africa started in 2014 and caused great fear as it spread into urban areas for the first time. Global health workers believed that this event would finally strengthen public health programs going forward. The Obama administration organized a massive response and created the National Security Council pandemic directorate to ensure the existence of an office in the White House ready to respond to the next pandemic. The office was eliminated in 2018, demonstrating resistance to using the lessons of the past.

These newly recognized emerging infections frequently involve an animal host and a vector, or both; yet curiously, the public health community has not integrated human and animal surveillance...