New Pandemics, Old Politics. Alex de Waal

Acknowledgements

      This book began life as a compilation of reflections provisionally entitled ‘Critical Thinking in a Pandemic’, which became an essay in the 3 April 2020 online issue of Boston Review, entitled ‘New Pathogen, Old Politics’ (http://bostonreview.net/science-nature/alex-de-waal-new-patho-gen-old-politics). The Boston Review editors, Deb Chasman and Matt Lord, were indulgent, encouraging, and usefully critical. I have drawn on comments and critique from colleagues, students, and former students, including Lisa Avery, Bridget Conley, Sarah Detzner, Ella Duncan, Sulmaan Khan, Jared Miller, Aditya Sarkar, and Ben Spatz, as well as Louise Knight and Inès Boxman at Polity Press and anonymous reviewers.

1 Following the Science, Following the Script

      A pandemic pathogen is scary and strange. It is new to medical science and society and it is everywhere. At the critical early moment of a pandemic, much of the advice of doctors and epidemiologists will be vague and some will be wrong. Those who know their subject best will have the deepest uncertainties. No expert can say when and how the pandemic will end. There isn’t even an agreed definition of ‘pandemic’ – an arcane but revealing absence.

      Public leaders pay homage to ‘following the science’ but they actually follow a script. It’s a storyline with a reassuring ending. It goes something like this:

       We are at war against an invisible enemy. While our doctors and nurses combat the disease at the frontline in hospitals, while our scientists seek the cures and vaccines in their laboratories, the population must make sacrifices on the home front. We should trust our government while we forgo liberties and livelihoods. The pandemic will end with a medical magic bullet that vanquishes the pathogen. Then we will return to our way of life and be safe.

This is the basic outline of a war story. It’s also a tale of conquest of the microbial world and a charter for emergency rule that sets aside human rights and civil liberties. ‘War on disease’ is not a harmless metaphor. It suppresses critical thinking. It focuses our worries on a singular germ as our enemy, forgetting about other things – such as devastated ecologies and an inequitable society – that are no less pathogenic. And its comforting ending is false – even if the discovery of a vaccine or therapy means that leaders feel entitled to declare ‘victory’.

      This book is about this gargantuan and harmful error. It is about how and why the ‘war on disease’ script was written and how it guides our thinking and shapes our institutions in ways that we may not realize. When we most need a narrative to make sense of a devastating pandemic, the ‘war on disease’ not only fails, but also stops us recognizing our failures. This book is also about some very different visions. Scientists, social activists, and public health experts have other analyses and narratives – rigorous, practical, democratic, holistic – that we should pursue. The Covid-19 pandemic and crisis is showing us that the ‘war on disease’ is at best humdrum and at worst dangerous, and that these alternatives are urgent.

      The ‘war on disease’ script is like the sheaf of documents in a desk drawer seldom opened. It consists of a handful of different scripts, pictures, and reminders. Some are Chinese, most are European or American. Also in the drawer are other images for disease outbreaks: a journey, an imbalance in the cosmos, a crime investigation, a storm, and a forest fire.¹

In an emergency, we think fast and intuitively. To change the metaphor, being caught by a pandemic is like being caught in a storm when hiking in the mountains: suddenly the clouds roll in, darkness descends, rain lashes down, and the stones become slippery. We can’t stay where we are, and we can’t wait for the storm to clear to look around and find the best way down – we want to find a way to safety right away. There’s a handrail: we grasp onto it because it keeps us steady. This handrail is our intuition, built from metaphors, storylines, images, and memories of what worked in the past. It’s more than just a thesaurus, it’s actually how we think – and so it usually goes unexamined. In the moment of greatest turmoil, fear, and uncertainty, it’s reassuring. The handrail makes each step feel safe, and we assure ourselves that we can look at the map later on. That map will show us some other directions we might have taken, had we stopped to orient ourselves more carefully. We may regret that we didn’t pause for a few moments to consider those other paths.

Following the Science

Experts on pandemics like the storm metaphor. The influential health scientist Michael Osterholm has compared an influenza pandemic to a blizzard and coronavirus to a hurricane.² In 2007, the United States Federal Government published a preparedness plan that adapted the five-level tropical storm classification scale for use in responding to epidemics (where a ‘category 5’ is the most destructive).³ It grades national-level disease outbreaks in terms of fatalities. According to its rankings, Covid-19 in 2020 would be category 2 (that is, an order of magnitude less severe than some of the diseases anticipated.) The scale may be a useful prop for getting politicians to take notice, but it reproduces an elementary mistake. A pandemic isn’t just a disease outbreak or epidemic multiplied to pan-continental size. Scale is important, for sure, but there’s a qualitative aspect as well. The World Health Organization (WHO) stirred controversy in 2009 when it quietly changed its definition of an influenza pandemic. The previous definition was ‘when a new influenza virus appears against which the human population has no immunity, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness’. The revised one cut out the words ‘enormous numbers of deaths and illness’.⁴ A pandemic that doesn’t cause massive human suffering might seem odd to the layperson, but the virologists’ particular concern is the newness of the pathogen and not how many people it sickens and kills. The novel coronavirus that causes Covid-19 is exactly such a candidate. Its closest relative is severe acute respiratory syndrome (SARS), which emerged in 2002, and it has some epidemiological similarities to influenza, but Covid-19 possesses characteristics all of its own.

      For doctors, microbiologists, and epidemiologists, what matters in the storm isn’t so much the wind but the darkness: we can’t see our way. There’s a trope among crisis epidemiologists: if you’ve seen one pandemic, you’ve seen just one pandemic.⁵ The health metrics expert Chris Murray described constructing his model for Covid-19 as ‘forecasting the weather while trying to build the forecasting tools’.⁶ Perhaps we should adapt the storm metaphor to capture the fact that each pandemic isn’t just a hurricane, it’s a new kind of weather condition. Margaret Chan, Director General of the WHO in 2009, observed ‘the virus writes the rules’.⁷ Those rules govern how the disease is transmitted, which people are symptomatic and which are contagious and when, and what the microbe does to the human body and brain. It can take years to figure them out. In the case of the novel coronavirus, science has moved with unprecedented speed, but it is still lagging behind the epidemic curve. What we do during that lag is what’s most important.

We like to think that biomedical scientists can provide authoritative certainty. As a pandemic hits, that isn’t so. They are confident that their research methods will provide answers, but they don’t have them yet. A new pathogen is an off-model event and models don’t (by definition) predict them. In these events, it’s the narrative that counts.⁸ Scientists also have difficulty in explaining what their uncertainties mean to the public. In turn, every doubt or debate feeds the appetite of denialists, conspiracists, and pseudo-scientists, such as anti-vaxxers. In America, changes in advice to the public from the Centers for Disease Control and Prevention (CDC) in the early days of Covid-19 – initially advising against stopping incoming travellers from Europe and China⁹ – have been repeatedly brought up by far-right pundits purportedly to show that public health authorities can’t be trusted. Public health spokespeople and science journalists find that debating denialists registers somewhere between irritation and enraged despair. The difficulty is that the history of medicine includes