COVID-19: Lest We Forget That We Always Forget

New Zealand closed its borders yesterday. The Land of the Long White Cloud called its sons and daughters home, latching its door shut behind them like a parent ushering their children across the threshold as the day darkens. In a world of porous borders, it’s strange to be reminded that each of us belongs in a place.

There’s some comfort in it, some security in laying down roots and staking a claim to a piece of land. It gives you a kind of assurance—or is it insurance? As if, when everything goes to hell, you can sink yourself in your own sweet mud, a frog seeing out the winter. But there is a flipside to the bargain. A country quite literally is its people; it cannot live unless its people survive. That connection is what makes public health a matter of national security.

And so, the nations of the world debate what can be done and what should be done to curtail the spread of COVID-19. The world has broken apart into its constituent pieces, each one coming to its own conclusion. As of now, it’s unclear which countries have been bold enough to walk the tightrope successfully and which have made missteps. What is beyond doubt is that when you put all those puzzle pieces together, we as a global community are not prepared for pandemics. And if past performance is the best predictor of future behaviour, I’m afraid that there is no reason to expect that to change.

In his seminal work, The Plague, Albert Camus wrote:

The people of the town were no more guilty than anyone else, they merely forgot to be modest and thought that everything was still possible for them, which implied that pestilence was impossible. They continued with business, with making arrangements for travel and holding opinions. Why should they have thought about the plague, which negates the future, negates journeys and debate? They considered themselves free and no one will ever be free as long as there is plague, pestilence and famine [1].

Camus lays out the problem clearly: part of living is ignoring the fact that we will die. That’s natural, even essential. It does not merit blame, only acknowledgement. But a side effect of this defence strategy, which protects us so well from distress, is that we lower our guard and leave ourselves vulnerable to attacks from other quarters.

The result, as it relates to pandemics, is a cycle of increased funding followed by relative neglect [2]. A disease emerges and spreads and we are afraid, and where our fear is, so goes funding. Then time passes and we forget, because forgetting lets us go on with our lives. Less fear, less funding.

This is not new. Following the Ebola epidemic of 2013-2016 (remember that?), there were calls for increased, sustained funding for pandemic preparedness [3], as professionals felt that the crisis highlighted gaps in our defences. But it is hard to stay focused on what seems like a possible threat when there are so many real and present dangers and only so many dollars to go around.

It’s true that over the short-term (1-4 years or so, the length of an elected official’s term in office), the threat of disease is merely possible. But over longer periods, say, a decade, an outbreak becomes a near certainty. I was born in 1987. In my lifetime, there have been at least 3 pandemics (AIDS (ongoing); H1N1influenza (2009-2010); and COVID-19), as well as several serious epidemics, including SARS and Zika virus. And yet, even with all this warning, the world wasn’t ready. All around us, governments, schools and businesses are developing plans on the fly. Lessons have not been learned because the fear doesn’t last. As recently as 2018 (just two years after an Ebola epidemic), President Trump dissolved the White House National Security Council Directorate for Global Health Security and Biodefense, one of the bodies in charge of pandemic preparedness at the federal level [4].

Rahm Emanuel famously said that we should “never let a serious crisis go to waste” [5], urging action when fear is the freshest in our minds. Abiding by that advice means taking definitive, long-term steps now to stave off the next pandemic. But how can we break the cycle and ensure that a boost in funding now doesn’t fall prey to later cuts? The only way is to place humans one step removed from the equation. Nations need to set aside a generous fund for pandemic preparedness in perpetuity with the appropriate checks and balances, eliminating annual budget debates. Spending should be scrutinized, but the allocation should be accepted as a given. That is the only way to insulate pandemic preparedness from the whims of lawmakers in less troubled times.

We need to establish a system that will shoulder the burden of remembering our fear. And we need to do it when we are most afraid. Because, lest we forget, we always forget.

References
1. Camus, Albert. The Plague. Penguin Modern Classics, London, England, p.30-31.

2. Yong E. The deadly panic-neglect cycle in pandemic funding. The Atlantic 24 October 2017. Accessed on 15 March 2020. Available at: https://www.theatlantic.com/science/archive/2017/10/panic-neglect-pandemic-funding/543696/

3. Burkle FM. Global health security demands a strong international health regulations treaty and leadership from a highly resourced World Health Organization. Disaster Medicine and Public Health Preparedness 9(5):568-580.

4. Cameron B. I ran the White House pandemic office. Trump closed it. The Washington Post 14 March 2020. Accessed 15 March 2020. Available at: https://www.washingtonpost.com/outlook/nsc-pandemic-office-trump-closed/2020/03/13/a70de09c-6491-11ea-acca-80c22bbee96f_story.html?fbclid=IwAR0TFwUNNFGx6U9zyQiK0MHwGKmj8abG-BusDcQbH-Wp5IHYuW82yA7U5ZU

5. Wikiquote. Rahm Emanuel. Wikipedia. Accessed on 15 March 2020. Available at: https://en.wikiquote.org/wiki/Rahm_Emanuel

Disease and Poverty: The Hidden Cost of Being Poor

We tend to think of disease as sort of natural disaster, like a kind of biological tsunami. While that’s true to an extent (some amount of disease is unavoidable), this view is dangerous because it suggests that no one is to blame for disease outbreaks, and that they cannot be prevented. And that—to put it mildly— is a bunch of hogwash.

In health, as in everything, the game is rigged in favor of the rich. It turns out that it’s not just the big top-down social structures that empower the wealthy. Inequality affects everything, right down to our immune system, stacking the deck from the ground up. The socioeconomic class you were born into directly relates to your chances of survival. That’s true not just in the near-term, meaning whether or not you survive childhood, but throughout your life.

The meek’s inheritance

Poverty is one of the greatest (arguably the greatest) causes of illness and premature death around the world. Poverty is a public health double whammy: it leaves people more vulnerable to disease by depriving them of adequate food, water, shelter, and support, and it prevents people from accessing healthcare when they do fall ill1,7. Living in poverty keeps people from getting educated, making them more likely to participate in risky health behaviors like smoking, because they do not understand the danger. It also limits choice. For example, the poor often have limited access to healthy food options, leaving them more likely to eat calorie-dense, high-fat food that deteriorates their health7.

Not only can being poor prevent you from getting medical attention, getting treated can also make you poor. The poor often cannot afford healthcare, if it’s available at all. But the expense can also cause an economically secure family to fall into poverty, which then leaves them more likely to get sick in the future, creating a terrible cycle. It’s easy to see how this happens. Healthcare expenses add up quick, from the cost of medicine to the wages lost due to sickness. These costs can spell disaster. The severe illness or death of the main breadwinner can be financially catastrophic for the household, and may permanently impoverish the remaining family members7.

As with everything, deep economic misfortune is not shared equally. The world’s poorest citizens are concentrated in areas that have been historically exploited and disenfranchised, including sub-Saharan Africa and eastern and southern Asia5. In high-income countries, a legacy of racism and xenophobia have left minorities much more likely to live in poverty. For example, in America, 45.8% of young black children (under age six) live in poverty, compared to 14.5% of young white children3. The global burden of social and health inequality falls particularly hard on women, aided by gender inequality2,7. Worldwide, women suffer from a higher rate of disease than men, especially very poor women7.

disease and poverty
What a weight to carry.

Live poor, die young

The World Health Organization estimates that 45% of the global disease burden is caused by diseases of poverty5. That’s right, the connection between poverty and illness is so powerful that there is an entire group of diseases defined by the association: diseases of poverty. These include HIV/AIDS, tuberculosis (TB), malaria, and the so-called neglected tropical diseases, like dengue, rabies, and Chagas disease2.

These conditions take a massive toll, measured in the millions and billions. Of the 2.7 billion people living in poverty around the world, more than 1 billion suffer from neglected tropical diseases1. In 2010, HIV/AIDS killed 1.5 million people, TB killed 1.2 million, and malaria killed 1.17 million. In 2012, 91% of the deaths from malaria occurred in Africa, and 86% involved children under the age of five2.

The conditions of poverty itself also give rise to a suite of deadly conditions. These include malnutrition, diarrheal diseases (which claim a staggering 1.8 million lives per year), and respiratory infections due to air pollution.

Chronic diseases, like cancer, cardiovascular disease and diabetes, also disproportionately affect the poor. The poor are more at risk of getting a chronic disease, and of dying from it early. This inequality is often most striking in high-income countries like the United States. These conditions can last for decades, and require long-term care, which can greatly increase their cost and exacerbate the negative poverty-healthcare cycle I talked about earlier7.

What is especially tragic about these conditions is that most of them can be prevented with established approaches or treated with existing medicines2,5. They should not happen. But, as discussed above, healthcare and health education are often not available to those who need it most.

The lasting effects of poverty

Poverty in childhood affects health for a lifetime, even if you stop being poor. The conditions common to poverty, like malnutrition, can have lasting effects like impaired growth or cognitive development2. However, it’s more than that. All else being equal, children who are raised in poverty still have a greater risk of developing health problems later in life than those who are not. These include many diseases that are common in America: heart disease, stroke, and some cancers4.

Scientists have not determined what drives this; some have speculated that the conditions of poverty prime the immune system for later illness4. For now, it’s clear that even if you somehow claw your way out of poverty, you may still suffer its costs.

The toll of history

Disease does not happen in a vacuum. It is a symptom of historical inequality and structural violence, including racism, sexism and xenophobia1, and it is often the direct result of poverty. Until those of us in positions of relative privilege take responsibility and address these underlying causes, the world will not be free of the enormous burden created by preventable illness and death. And—make no mistake—we will all be to blame.

References

  1. Alsan, MM, M Westerhaus, M Herce, K Nakashima, and PE Farmer. 2011. Poverty, global health and infectious disease: lessons from Haiti and Rwanda. Infectious Disease Clinical North America, 25:611-622.
  2. Bhutta, ZA, J Sommerfeld, ZS Lassi, RA Salam, and JK Das. 2014. Global burden, distribution, and interventions for infectious diseases of poverty. Infectious Diseases of Poverty, 3:21.
  3. Economic Policy Institute. 2012. The State of Working America: Key facts. Washington, DC. Economic Policy Institute. 13 December 2016. http://stateofworkingamerica.org/fact-sheets/poverty/
  4. Miller, GE, and E Chen. 2013. The biological residue of childhood poverty. Child Development Perspectives, 7:67-73.
  5. Stevens, P. 2004. Diseases of poverty and the 10/90 gap. International Policy Network.
  6. Sumner, A. 2012. Where do the poor live? World Development, 40:865-877.
  7. World Health Organization. Chronic diseases and poverty. Web. 8 December 2016. http://www.who.int/chp/chronic_disease_report/part2_ch2/en/

Image Credit

Julie, D. File DSC00930 Burma Shan State Table Land Heavy Transportation on the Path to Indein. Creative Commons. 13 December 2016. https://commons.wikimedia.org/wiki/File:DSC00930_Burma_Shan_State_Table_Land_Heavy_Transportation_on_the_Path_to_Indein_(4679157162).jpg