Epidemics are powerful agents of change

Is it true that some clouds have silver linings? When it comes to epidemics, the answer is yes. With a few notable exceptions, epidemic infectious diseases, even as they caused suffering and death, have enhanced government’s ability to control future outbreaks and protect the public’s health.

The traditional examples of positive and long-term public health responses are yellow fever and cholera. These two diseases brought intermittent terror and death to U.S. cities in the 18th and 19th centuries. They also successfully stirred cities to spend money for needed, yet expensive, projects to tame the unsanitary urban environment, which was thought to cause disease, such as sewerage and water-supply systems and garbage disposal works. Without the high degree of fear engendered by the sudden onset of epidemics (as opposed to endemic diseases such as tuberculosis), lethargic city governments would never have spent such large sums of money on projects of such magnitude. Epidemics also increased the power of public officials to control infectious diseases by allowing them to forcibly place patients deemed dangerous to the public health in isolation hospitals. It took the shock of epidemics to force the changes.

This power was not always used positively. During a smallpox epidemic in Milwaukee in 1894, for example, health officials forcibly seized children from their mothers’ arms in the immigrant sections of the city while allowing middle-class, native-born families to harbor their sick children in their own homes. 

Coercion under such unfair conditions led to month-long rioting in the streets and the impeachment of the health commissioner. A confluence of ethnic-group mutual mistrust and political party competition building on this mistrust led to the diminution of health department powers and budgets that lasted for years.

In 1947, when smallpox threatened New York, the health commissioner embarked on a public information campaign that combined isolation of cases with free vaccination for all New Yorkers. Frequent and honest multilingual messaging and equity in vaccine distribution, with help from the U.S. Public Health Service, led to public trust and a just and effective intervention. People waited patiently in long lines that wound around city streets, and within weeks, 6,350,000 city residents were vaccinated and the epidemic averted. 

The history of epidemics teaches us two important lessons. First, because epidemics elicit fear and focus the public’s mind, they can energize government actions. But second, those governmental actions can elicit ethnic, class, and racial strife as “others” are identified as carriers of infection, as in the Milwaukee example or when gays and Haitians were blamed for HIV/AIDS. A movement to promote public health benefit must take advantage of the first lesson and address the second. Fairness and public trust, as the New York smallpox example demonstrates, are the indispensable conditions for developing robust public health institutions.

During the past few decades, despite SARS, MERS, and H1N1 scares, our government has neglected public health, forgetting the devastation that epidemics wreaked in the past. COVID-19 has exposed cracks in our public health system that cannot manage disease testing or even provide protective gear for health workers.

As with past outbreaks, the coronavirus epidemic exposes opposing social and political forces. COVID-19 has produced a public health crisis in the United States, which is ripe for positive reform, but it has also produced some of the finger pointing toward Asians that could signal insidious inequities. If historical precedent holds, we have a chance to use this crisis for sweeping changes in public health institutions. We must seize this opportunity to mount a concerted effort to use the public’s fears and the focus generated by them to promote new, fair, and just investments in public health programs. As we work to create robust and equitable public health, we could find a silver lining.