‘No wise man has a Policy,’ said the Viceroy. ‘A Policy is the blackmail levied on the Fool by the Unforeseen. I am not the former, and I do not believe in the latter.’
- Rudyard Kipling, "A Germ-Destroyer" (1887)
Reader, I failed to take a break. In the months since my last post, which I naïvely envisioned as an exorcism of COVID-19 obsessions, three significant developments have kept me (and many others) glued to a steady stream of news and tweets: the onset of a massive winter wave across the northern hemisphere; the approval of two mRNA vaccines, hailed as the beginning of the end of the pandemic; and the emergence of potentially more transmissible variants in the UK and South Africa, which sparked renewed global panic reminiscent of March. Now that my leave is almost over (with very little real work to show for it), I will try once again to move on by reflecting on these developments in relation the suppression vs. mitigation spectrum described earlier and by looking ahead to the future.
My thesis is simple: everything has changed and nothing has changed. In other words, the many contradictions unleashed by the virus and the unprecedented response to it have only deepened.
I. The Wave
The winter wave was already on the horizon in October, but the speed and scale with which it took hold was surprising (in many countries and regions far exceeding the spring). The already shaky correlation with various non-pharmaceutical interventions (NPIs), from hard lockdowns to voluntary guidelines to aggressive test-trace-isolate infrastructures, has grown weaker. South Korea, the poster child for the latter approach, is being hit hard. Meanwhile, Sweden's apparent success over the summer has been exposed as a mirage and Anders Tegnell has exited stage right. I won't go farther down this road since country comparisons are useless and counterproductive, little more than a political parlor game. The more interesting question to ask is about hindsight. Does this "prove" that, like endemic coronaviruses, SARS-CoV-2 is intrinsically seasonal? And even if it isn't, how should we assess public health messaging over the summer when cases stayed low in many countries and US states?
It now seems obvious, as Zeynep Tufekci points out, that people should have been encouraged in no uncertain terms to take advantage of the warm weather and go outdoors as much as possible (including properly distanced socializing and, I would add, schooling), as well as take care of medical appointments and other needs in anticipation of a more difficult time ahead. Instead, officials turned the dial up to 11 in the spring, down to maybe 8 or 9 in the summer, and then quickly back up to 11 in the winter. Meanwhile, pandemic fatigue predictably increased in a linear fashion. Each passing day spent cut off from family and friends, or struggling to balance precarious work and childcare, eroded people's resilience. Whenever scientific experts and political leaders warned about the dangers of surges, spikes, and a "dark winter" ahead, I asked myself when it was ever advisable to go outside or do anything - if not now. At a particular time of year or case rate? According to government rules (which allowed, for example, indoor dining), epidemiological considerations (a specific case rate or R number), or personal risk assessments? The lack of a long-term strategy and failures of communication pushed public trust well past the breaking point at the worst possible moment.
For steadfast mitigators like Julia Marcus, Stefan Baral, and Monica Gandhi, the steep rise in cases is all the more reason to promote empathetic, nuanced, and resource-based messaging rather than heavy-handed restrictions and toxic shaming. For hardcore suppressors, the latest wave provides yet more evidence of governmental and individual failures to "control" the virus and do the "right thing" in limiting social interactions, respectively. The response can only be more restrictions, more shaming, and even the deliberate promotion of fear (more on this later).
What would I do, to move briefly from critique to prescription? Start with two basic premises, inspired by Baral's mantra of "resources before restrictions:" 1) don't impose any restrictions that you can't/won't enforce (Taiwan-style border controls and testing at airports - sure, vague "stay-at-home" orders like in California - no) and 2) that you can't/won't pay for (business closures without furloughs, quarantine without paid leave or facilities). Or, following the old Marxian chestnut, "From each according to his ability [distance as much as you can given your living conditions/financial constraints and other considerations, including mental health], to each according to his needs [more resources to high-risk and vulnerable populations, from nursing homes to essential workers, and safer socialization options for everyone]." Instead we have, "Follow these confusing and constantly changing rules indefinitely or you're a bad person, and maybe you'll get a stimulus check soon."
II. The Variant
The identification of reportedly more transmissible variants in the UK and South Africa dropped like a bombshell in late December - a plot twist fit for the penultimate episode of the season. Perhaps due to the symbolism of a "cancelled Christmas," the news captured the public imagination much more than the D614G mutation in the summer or the Danish minks in the autumn. A familiar state of all-encompassing panic ensued, with sudden border closures and supply chain disruptions (exacerbated by Brexit) creating new apocalyptic scenarios. Would mitigation measures (being outdoors, wearing masks, socially distancing) even work anymore? If the variant was up to 70% more transmissible (a disputed number based on preliminary epidemiological data), would this mean longer and harder lockdowns - for "many months," as Health Secretary Matt Hancock bleakly warned? Rumors began to circulate that the variant produced more severe disease in children and young people (yet another silver lining gone, this time really no more school!). Antibody and vaccine escape, an ever-present possibility with viral mutations, is just around the corner as the next big threat.
Should it be confirmed, a more transmissible (if not more pathogenic) virus takes us right back to square one. We are in March again, facing a big unknown. The variant is already all over southeast England, as SARS-CoV-2 was in Wuhan and northern Italy. We can safely assume it is also in many other places and will continue to spread. What to do?
It's worth revisiting the crucial issue of how and why existing pandemic preparedness plans were swiftly abandoned in March. None of the NPIs that became public health orthodoxy overnight, from business and school shutdowns to universal masking and contact tracing, were recommended by the WHO in 2019. Indeed, there was a rock-solid consensus against such measures. Suppressors celebrate the triumph of a proactive SARS/MERS model over a passive "influenza model," but provide no systematic justification beyond anecdotal success stories of highly disparate countries (Taiwan, New Zealand, Vietnam, maybe South Korea). If pressed, they might point to certain aspects that make SARS-CoV-2 both easier and more imperative to contain: higher dispersion (k) through superspreader events, a longer disease course leading to greater hospitalizations and mortality/morbidity, etc. Such claims do not stand up to rigorous scrutiny. Hospitalizations and deaths were obvious areas of concern (H1N1 in 2009 may have been a bust, but the 1968-69 H3N2 pandemic was comparable in severity to the present one). Still, the transmissibility of the virus plus the collateral damage and uncertain benefit of NPIs sufficed to close the case. It may have been a good bet for Taiwan and South Korea to treat a novel coronavirus like SARS or MERS in the beginning. And SARS-CoV-2 did appear much easier to control than anticipated - though we have no historical examples of sustained, large-scale attempts at suppressing pandemic influenza for comparison. I suspect it was this paradoxically "optimistic" realization that lay behind the mysterious abandonment of "flatten the curve" and the about-face of experts like Michael Osterholm (see also previous post). How else to explain Dr. Tedros's remarkable statement on March 9 that this "would be the first pandemic in history that could be controlled"?
To clarify the contradiction, the higher the R, the less like SARS or MERS the virus becomes. Yet rather than cast doubt on the feasibility of the suppression strategy, the mere existence of these variants supplies self-evident proof that more suppression is needed. If less virus circulates, there are fewer opportunities to mutate - a reassuringly obvious conclusion. But we don't yet know how the variants arose (it may have taken just one immunocompromised host, not unlike the original spillover), why they spread more quickly (higher viral load? more efficient ACE2 receptor binding?), and what their consequences will be. If/when the next big change comes along (antibody or vaccine escape, increased pathogenicity), the cycle will surely repeat - a Groundhog Day-style nightmare of rolling lockdowns accompanied by the same exhausting debates.
The pandemic discourse rests on an almost philosophical conundrum about how to act in a crisis. Think of public health officials as teachers, intermediary figures of authority who have been trained for years to promote student learning by providing information, assuming the burden of communicating it in the most compelling way, offering support and guidance, and relying on persuasion rather than coercion. But what if test scores suddenly acquired urgency, say because of a state ultimatum that the school will lose funding or that certain students must pass or be expelled? Would this justify abandoning all previous lesson plans and adopting a different set of tools, including mandated homework hours, invasive surveillance technology, or public shaming (dunce caps)? And if other schools in the district seem to improve their practice test scores by using some of these methods, should you follow suit? How much do the resources of the school or the characteristics of the student population matter? You only have until the end of the academic year - the clock is ticking. How can you tell what "works"? Do you carry on as usual, intensify existing practices, or adopt new ones? There are no easy or obvious answers.
III. The Vaccine
The triumphant arrival of vaccines, the alpha and omega of this pandemic year (developed in January, approved in December) provides an important clue to the choices we've made. The vaccine is more than a "silver bullet" or "technological fix." It constitutes an entire techno-utopian horizon of possibility. It is the original sin of the pandemic response, underpinning both Trumpian selective apathy (carry on as usual because the vaccine is on the way, the government will spend as much money as it takes on Operation Warp Speed - but not PPE or paid leave) and lockdown absolutism (just stay inside for a few more months because "the cavalry is coming" - an apt metaphor given American militarism and frontier mythology). The temporality of the pandemic (remember the constant refrain of "12-18 months"?) has been almost entirely dictated by the vaccine, creating unrealistic expectations of a neat resolution that are sure to be frustrated.
The ethics, politics, and logistics of vaccine distribution will take center stage over the next few months, and will be as fiercely contested as the suppression vs. mitigation debate. Everyone agrees that older adults (65+) and essential workers should be prioritized, though not necessarily in that order. However these categories are spliced, the differential impact of the disease comes into stark relief and contrast with the indiscriminate approach of lockdowns and mass testing. If preventing deaths by age stratification is the guiding principle, why did nursing homes and their workers not get absolute first claim on resources (PPE, paid leave, quarantine hotels, testing kits) from the start? If equity or reducing community transmission are the main criteria, shouldn't prisoners, farm laborers, and other vulnerable populations move right to the front of the line? The latter thought exercise reveals, once again, why outwardly "progressive" public health goals are incompatible with a neoliberal capitalist system. There are many other ways in which vaccines could theoretically be distributed (randomly/by lottery, through markets/the price mechanism, first come-first serve, cronyism and "connections" etc.). The combination of the ones we adopt will say something about the kind of society we live in. There are no easy or obvious answers.
One book that helped me make sense of these dynamics in a longer term historical context is Vaccine Nation by Elena Conis (Chicago, 2014). Conis argues that the availability of vaccines has fundamentally changed how diseases have been framed by scientific experts, governments, and the public. In the mid- to late 1960s, measles and mumps went from routine childhood afflictions to deadly enemies with a litany of horrific complications. Whereas widespread panic over polio in the 1950s had created an organic demand for the Salk and Sabin vaccines, the public was much less sold on the necessity of inoculation against these milder diseases. The impulse to eradicate them was culturally produced in an era of "high modernist" (James Scott's words) overconfidence in the power of science and the federal government to gain mastery over nature. Success against smallpox in the Third World, through a combination of vaccination and targeted field epidemiology, fueled the fantasy.
In turn, a growing anti-vaccination movement in the 1970s and 80s drew on environmentalism (specifically revelations of the hidden damage wrought by asbestos, tobacco, and DDT) and second-wave feminism to build a critique of vaccination as unnatural - a mirror image of the official disease discourse. Whereas the public health establishment spread alarm about the complications of measles and mumps, skeptics amplified the side effects of vaccines (both real and exaggerated). They also promoted "natural immunity" through infection as superior to "artificial" vaccine-induced immunity. Whereas vaccination campaigns relied on gendered notions of mothers' responsibility to inoculate their children and protect society at large, skeptics insisted on mothers' responsibility to make the best decisions to protect their children. The media contributed to further polarization in the 1990s and 2000s by reducing the complex issue of vaccination to a moralistic conflict between "science" and "anti-vaxxers," shaming skeptics (stereotypically, middle-class white women) as "selfish" killers and obscuring other reasons for the stubborn persistence of preventable disease (poverty, inequality, access to housing and healthcare).
The parallels with COVID-19 are suggestive. Concern about possible long-term side effects from "rushed" vaccines using "unproven" mRNA technology mirrors anxieties over "long COVID" from above (used as a justification for lockdowns) and below (shared in social media forums by victims, most of them women, who feel ignored and dismissed). The WHO's rewriting of the definition of "herd immunity" to exclude previous infection mirrors vaccine skeptics' unwavering belief in the superiority of "natural" immunity. Shaming has become routinized and weaponized, with a sharper edge in terms of age, class, and race. The impulse to increase compliance with restrictions and vaccine uptake by stoking fear of the disease is rooted in decades of public health practice.
In the political arena, Conis shows how vaccines have repeatedly been imagined as a "great equalizer" in a profoundly unequal and broken healthcare system. Both the Carter and Clinton administrations embarked on mass immunization drives as a substitute for, or shortcut to, structural reforms. The shocking disconnect between the discourse of "overwhelmed hospitals" and the lack of progress on Medicare for All is as American as apple pie and as old as bell bottomed jeans. The pandemic response reinscribes the logic of austerity and personal responsibility under the cloak of communal solidarity and shared sacrifice.
There is one crucial departure. Unlike past diseases, whether endemic or pandemic, COVID-19 was framed as vaccine preventable well before vaccines were actually available. This, too, explains the early consensus that it could be controlled. Fantasies of eradication are always culturally produced. As sociologist Harish Naraindas has written, the fight against smallpox in the early 1970s shifted to an "offensive strategy of ‘search and destroy’ whose purpose was to ferret out Agent Pox," informed by the Vietnam War. In eastern India, where the steel town of Jamshedpur emerged as the focal point of the last major outbreak, it overlapped with ongoing state and corporate incursions into the lands and bodies of indigenous people. In 2020, COVID suppression has been made thinkable by the enhanced carceral and surveillance powers of states and corporations, even as their abilities to provide resources and deliver care have been hollowed out.
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