Each society determines its own death rate.
Over a century ago, Hermann Biggs, M.D., the Commissioner of New York City Department of Health and a Bellevue Hospital Medical College Graduate in 1883, wrote that “public health is purchasable,” as he fought the epidemics of cholera, tuberculosis, typhus, and diphtheria, combining aggressive public health measures with the transformative scientific discoveries of the late 19th century.
In this moment, it is useful to look back into history to understand how previous epidemics have harnessed political will. The Sanitarian movement of the 18th century, led by Edwin Chatwick, saw some of the first public health reforms, passed in coordination with the state, for clean water and other public improvements. With the identification of the tuberculosis germ as a cause of disease in 1882, Nobelist Robert Koch launched the scientific era of bacteriology. Biggs was both a medical pathologist and Sanitarian who recognized the urgency of harnessing political will to support the smartest public health measures, based on the best scientific knowledge to combat the lethal bacteria-causing epidemics. He knew the social pathologies of poverty, lack of access to health care, tenement housing, racial and gender inequalities, endemic corruption, lack of environmental regulations and so on would stymie any control efforts. Germs were actually the last step in the complex line of disease causation and death.
Biggs applied bacteriologic tests to monitor milk, food, and the city’s water supply in the first public health department laboratories. Doctors were required to report all new cases of tuberculosis to the Health Department, which many of them initially resisted. These cases and their contacts were assigned to teams of community health care workers fluent in the melting pot of languages and cultural differences. Quarantine was enforced and centers were created to isolate patients. If necessary, food was provided. The city allocated special funds so that the poor could access public health resources for vaccines and anti-toxins.
Biggs also brought new scientific technologies from Europe to control diseases. “Antitoxin horses” on an upstate farm in Otisville, for example, were bled on a regular basis to extract the serum that would be used to treat children with diphtheria. These were later commercialized and sold domestically and internationally. He used his connections with Tammany Hall, the ruling political party of New York at the time, to accomplish his public health goals along with relentless education of lay organizations and medical institutions. He knew that active volunteer citizen’s groups could counter entrenched interests.
Biggs’ deep insight was that political processes and priorities determine the death rate of a population. It’s a decision—not providing health care to everyone, gutting clean food, air, and water standards as the planet burns, watching the zip codes with the highest rates of poverty and greatest concentrations of Black Americans and Latinos align with the highest death rates. These are deliberate decisions. Not preparing for pandemics, even when we know they’re coming—that’s a decision. Leaving our frontline workers directly exposed to the lethal virus is a decision. The Covid-19 pandemic has put in stark relief the collateral damage of our nation’s deepest divisions and competing value systems.
Some of this political malpractice has a long tail. The fierce, bipartisan, decades-long battles over expanding health care coverage for all lays bare a value system of gross inequality based on class, racial, misogynist, and homophobic prejudice. Ronald Reagan chose to ignore the HIV virus—like Covid-19, another spillover zoonotic illness that spreads from animals to humans—that went on to kill 33 million people globally. Within recent memory, we have learned a great deal about pandemics in the era of globalization, thanks in large part to the CDC and international networks of collaboration. The responses to SARS and Ebola, though imperfect, showed that timely, coordinated, international interventions could control spillover infections. Pandemic epidemiologists have repeatedly warned that the next viral outbreak would likely be respiratory and, therefore, spread like wildfire. Their alert systems have gone off from the World Health Organization to DARPA, from Bill Gates to Hollywood.
These lessons, however, have been flagrantly disregarded by Donald Trump.
If societies determine their own death rates, then it is evident that more people are dying from Covid-19 in the U.S. than need to be. The U.S. now has more fatalities than any country on earth, the direct result of many bad decisions.
Reshuffling priorities under Donald Trump has contributed to this crisis magnified by inattention. Trump joined the ‘doubter’ community decades ago—birtherism, anti-vaxxers and anti-global warming proponents who actually contribute to this pandemic. His need to create new facts to fit his political goals fuels his attack on the scientific communities—from the weather service, Center for Disease Control, Environmental Protection Agency and beyond. He eliminated the pandemic advisor from the National Security Council and dissolved the scientific committee that oversaw pandemics. People with no scientific expertise, such as Pence and Kushner, were put in charge of decision-making. The Trump administration then chose to ignore early warnings of the oncoming outbreak stemming from a variety of sources, opting instead to listen to finance and corporate leaders’ misplaced emphasis on saving the economy over human life, which culminated in putting both in very high peril.
The loss of vital weeks of a clear and coordinated federal effort crippled attempts to provide adequate resources and support: poisoned relations with China slowed US efforts to get a sample of the virus to create a vaccine and secure supply chains. Trump’s resistance to mandate that private vendors develop testing to scale and supply PPE and ventilators created enormous confusion and delays. Moreover, by kicking decisions down to the governors, Trump created a free for all, with 50 different and competing responses.
Herman Biggs knew that endemic epidemics required an intense and long-term political approach that needed to be blended with the best public health practices and newly developed scientific products and protocols like quarantine, timely isolation (now social distancing), testing, and vaccine development. We have had to learn and relearn these lessons from Biggs and his predecessors, but our modern era has seen spectacular success with polio vaccine and smallpox eradication. The irony is that misinformation, inattention, and chronic underfunding of public health measures ends up costing far more, not just in lives but in money. However, the relatively simple prevention measures are being largely ignored.
Covid-19 highlights our political and structural fault lines. The slow response and the lack of unified leadership are killing people. By the way, it has left the economy in shambles. The US used to lead the world in public health, and now we lead the world in Covid-19 cases? The Trump Presidency will be judged guilty of political malpractice and should be held accountable for excess deaths and suffering. After all, as Biggs would have pointed out, it was Trump’s decision.
—New York City, May 1, 2020
Eric Manheimer M.D. was Medical Director of Bellevue Hospital from 1997-2012. He is the author of Twelve Patients: Life and Death at Bellevue Hospital, now the basis for the television series “New Amsterdam.”