COVID-19 & Epoch of Incredulity

by Ans Irfan, MD, MPH, FRSPH

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.” ―Charles Dickens, A Tale of Two Cities

COVID-19 has exposed many of the fissures, hypocrisies, and inequities in our society. Among many other things, it has also highlighted public health’s failure to offer human rights-based solutions to the pandemic that center equity and  inherently prioritize sanctity of human life over profits wrapped in false pragmatism. The current pandemic is costing Americans over 3,000 lives a day on average. To put things into perspective, that is roughly 20 Boeing 737 passenger jets crashing each day. It is also more Americans dying — from a preventable cause —  every day than  those who died on 9/11. As we mark the somber anniversary of the pandemic, US society, especially the public health intelligentsia, should remember that these  400,000+ deaths were preventable.

State-sanctioned Sacrifices: Socially Vulnerable & Workers

There is a profound disregard for the lives of socially vulnerable — especially Black, Indigenous, and People of Color (BIPOC) — communities in our country. Be it the kids in cagesincarcerated — often thanks to the racist criminal legal system — people, or workers, there seems to be a consistent apathy, if not contentment, with the status quo. Given the United States’ violent history of genocide, enslavement, and persistent, baked-in structural racism in our social and health policies, it is not surprising that most people dying due to COVID-19 are socially vulnerable, predominantly Black, Indigenous, and Brown people. Black people are 2.3 times, Indigenous people are 2.2 times, Latinx people are 2.5 times, and Pacific Islanders are 2.5 times more likely to have died (age-adjusted mortality rate) than whites due to COVID-19, according to the APM Research Lab.

Similar trends in preventable deaths are seen among children as well. According to the data reported by the Centers for Disease Control and Prevention, nearly 75% of deaths in under 21 years of age are among BIPOC communities. The COVKID Project also shows corroborating evidence and mortality differentials among children depending on reported race as a proxy for racism causing the said differentials. 

These tragic disparities are also true across workers where existing research shows that racialized minority workers are the most impacted by the pandemic. This becomes even more critical given that BIPOC, especially Black workers, are overrepresented in the essential workforce. In certain essential worker categories, BIPOC people make more than 50% of the essential workforce.

It is critical to characterize this viciously disproportionate burden of mortality and morbidity from an equity lens to ensure that policymakers or public health intelligentsia making arguments about failed, piecemeal approaches are aware of the human toll and acknowledgment of blatant disregard of human life — especially the fact that lives being sacrificed due to governmental inaction are non-white.

America’s Favorite Panacea: Individualism

One of the biggest challenges that public health in the United States faces is a culture rooted in individualism regardless of human or economic costs. Often weaponized by politicians to push austerity-based neoliberal — defined as “post-Cold War, post-welfare state model of social order that celebrates unhindered markets as the most effective means of achieving economic growth and public welfare” — policies that are detrimental to population health and equity goals, especially socially vulnerable people. This is reflected in economic, social, healthcare, and public health policies. The response to the pandemic has been a perpetuation of our unhealthy obsession with individualistic interventions rooted in the flawed economic theory of neoliberalism — vehemently supported across the political spectrum — and abdication of any social responsibilities to protect those made vulnerable through many systems of oppression.

Public health is complicit insofar as few other fields talk as much about equity and justice as public health, and yet we fall short of aggressively and unequivocally arguing for human-rights based strategies that put people before profits. Public health inherently fringes upon ‘individual rights.’ Yet, we shy away from these difficult discussions and ethical analysis that would help us ground our interventions in the moral values of equity and justice. This failure to translate our evidence into bold policy solutions results in neoliberal, individualistic solutions that either do not work or are simply not applicable to those most vulnerable in our society.

For instance, solutions such as mask mandates and social distancing are fine and dandy on paper but we must acknowledge that these are geared towards those who have the adaptive capacity, power, and privilege to follow these guidelines. Most poor people and workers simply do not have a choice but to get exposed to a deadly virus because of governmental inaction. This is equally applicable to arguments for opening schools, without first creating an environment necessary for safe opening, that lacks nuances and does not center workers (teachers) who will get exposed and potentially lose their lives.

Vaccination as the be-all and end-all is another — obvious — solution proposed time and time again while continuing to sacrifice thousands of lives a day. It has its merits and we should absolutely be pushing for equitable allocation and vaccinating those most socially vulnerable. In practice, however, according to the CDC, vaccinated proportion among those groups most impacted by the pandemic has been abysmal with a 5.4% for Black and 2% for American Indian or Alaskan Native, and less than 1% Native Hawaiian or Pacific Islander populations. This is also an example of public health and healthcare systems’ failure to earn Black Americans’ trust eroded due to the centuries-old but persistent racism, abuse, and neglect, and another example of trickle-down structural racism which failed to account for all the evidence, recommendations, and alarm bells from the BIPOC communities since the beginning of the pandemic. Moreover, with the new strains of COVID-19 reaching the community spread levels and preliminary data suggesting limited cross-strain immunity, masks and social distancing — interventions that rely on individuals — without proper social support will simply not work. Public health ‘experts’ need to take stock when we talk about our proposed interventions and think carefully about whether conformity to a neoliberal approach aligns with core tenets of public health: equity and justice.

Sea Change that Wasn’t: One Mask to Double Masking

As the new strains get discovered and spread, the US response continues to be masks and social distancing. Nearly half a million lives lost, yet the urgency of aggressive action is absent in our governmental response. The governmental response to this once-in-a-life-time challenge has been disappointingly demure. The current administration has continued the previous administration’s policies of a blatant disregard for human life and bipartisan consensus to do the bare minimum that allows politicians to stay in power through rhetoric alone: primarily whataboutism. The current administration’s plan — primarily focusing on mask mandates and testing — falls short of any bold public health prevention measures needed to meet the moment. The public health community spent the past four years — rightfully — critiquing and criticizing the previous administration for its incompetence and failure to control the pandemic. To maintain our credibility as a field, it is public health experts’ responsibility to hold the current administration accountable for its inaction despite controlling Congress and the White House. Speaking truth to power when political or socially expedient is just a façade. We must transcend the cults of personalities and partisanship and reckon with our failure to understand political economy and hold our elected leaders accountable as a result — or risk losing any moral ground to critique those in power.

Public Health’s Mythological Knight in Shining Armor: Science Communication

Another challenge that has been highlighted in COVID-19 discourse is the role of science communications. Science communication has its place, but for the most  part, it is geared towards individual behavior change by those who have the capacity and privilege to do so. Its failure to acknowledge structural factors and a lack of systematic support needed to actually engage in the communicated behavior is its Achilles’ heel. We have tried this — and failed — with climate change communications, where often the focus stays on the actions an individual can take without challenging the systems that make it impossible to engage in the  recommended behavior. At the very least, we ought to acknowledge the shortfalls of science communication and take this opportunity to advocate for bold policies and programs that will help people stay alive. We cannot #SciComm our way out of this pandemic.

Sins of Omission

There is no such thing as a neutral stance. A neutral stance is always supporting the status quo. Status quo that has cost us nearly half a million lives and still counting. Stating the obvious with a sense of discovery and failing to provide bold solutions needed to tackle the root causes of the identified problems is a disservice to the communities we serve. Public health experts are very good at characterizing the problem and its magnitude but then fail to offer a remedy needed for the said  problem that goes beyond the symptomatic treatment. This trend is seen time and time again from climate change to COVID-19, where there is all the talk of structural issues being the driving factors behind these challenges but the solutions offered are mostly individual-based strategies like recycling and masks, respectively. Often, these are wrapped in distorted, self-absolving explanations rooted in neoliberalism, incrementalism, and even false notions of practicality. We need to find our moral groundings and offer drastic, bold, innovative solutions that are needed to meet these monumental challenges. We must critically analyze an issue and then ask ourselves whether or not we are just offering symptomatic treatment or an actual solution to the root causes. Instead of offering symptomatic treatment that further glamorizes failed individualistic strategies, public health should offer bold solutions that focus on creating conditions necessary to control the pandemic and save lives.

Where do we go from here?

Problem is not — it has never been — a lack of solutions. It is a lack of imagination, conformity, commitment to upholding the status quo, and a lack of political will. Will the pandemic eventually ‘conclude’ with current strategies? Yes. At what cost? Nearly half a million lives lost over just a year provide some insight into that cost. We have been trying individualistic strategies such as masking and social distancing mandates with broad public support for these measures. Yet, these have failed to contain the pandemic at the tune of hundreds and thousands of lives and trillions of dollars. Moreover, these interventions fail to account for those who are most socially vulnerable and simply do not have a choice but to be exposed and risk their lives because of a governmental failure to create a safer society. To be very clear, mask mandates, physical (social) distancing, and vaccination are absolutely critical public health interventions. However, these alone are far from enough given the thousands of preventable deaths each day that are tolerated by our politicians as collateral damage. 

To effectively curtail this pandemic, we should support and advocate for a short-term, national shelter-in-place policy that will provide people with generous economic support — enough to survive the global crisis and not to be conflated by the crumbs being offered so far — by the federal government and restrict all nonessential activity. This is the only evidence-based, upstream public health strategy to proactively control the current pandemic. Beyond a moral imperative, the current administration has made claims about infusing equity into the COVID-19 response and challenging systemic racism. This can only be achieved by centering the most socially vulnerable populations in our social and public health policy responses. In the end, it is a question of power and privilege. Many Americans, including many in the public health intelligentsia, with certain privileges such as race, class, economic security, the luxury of remote working, and so forth have the privilege to support ineffective individualistic interventions because it does not affect them. Hence, they play Martin Luther King’s “white moderate who is more devoted to ‘order’ than to justice” role in upholding the status quo that is sacrificing thousands of lives daily. Sadly, this also seems to be the de facto stance of the current administration. Those at the margins of the society lack the social capital and the power to change a system demanding sacrifices. Our moral obligation as public health scientists is to advocate on behalf of communities we serve without capitulating to people in power regardless of their political affiliations. 

“The plantation and the ghetto were created by those who had power, both to confine those who had no power and to perpetuate their powerlessness. Now the problem of transforming the ghetto, therefore, is a problem of power, a confrontation between the forces of power demanding change and the forces of power dedicated to the preserving of the status quo.” —Martin Luther King, Jr (1967)

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Ans Irfan, MD, MPH, FRSPH

Ans Irfan, MD, MPH, FRSPH, is a public health practitioner, faculty member, and the Director of the Climate & Health Equity Practice Fellowship at George Washington University. He is a fellow with the Robert Wood Johnson Foundation Health Policy Research Scholars program. Select recent projects include: COVID-19 & Black transit workers health; farmworkers health equity; the intersection of theology and public health; traffic wardens and climate adaptation in Pakistan; evaluation of physicians’ training on climate change and health; global and occupational health equity. He can be contacted at Twitter: @PHScientist