Can the Pandemic Really Change our World?

In May of 2020, just a couple of months into the pandemic, I reflected in these pages on what the pandemic (and our response to it) was revealing about the links between how our society is organized and our health. Many of these “revelations” (often facts of which we have long been aware) have become even clearer over time, showing how health and disease are driven by economic and social systems that go well beyond access to medical care. I also reflected on how the pandemic appeared to be opening the way for unprecedented actions (e.g. payments to individuals, reductions in travel, a different use of public spaces, questioning of sick leave policies) challenging “business as usual” in ways that could suggest that a different way of living together is possible. In this, I fear I was too optimistic, though the pandemic is still not over, and in some areas perhaps, just perhaps, the door has not yet fully closed.

There is no doubt that the pandemic has made starkly visible the impact on health of social and racial inequities, as illustrated now by myriads of reports demonstrating striking differences in COVID-19 incidence rates and mortality by social class and race. These facts (reproduced and illustrated over and over again in the media), together with a reinvigorated social movement against racism triggered by the murder of George Floyd, have resulted in unprecedented attention to the systemic factors that drive health inequities. Whether this will result in a successful challenge to the biomedical understanding of health that still permeates not only health research and health policy, but also much of the public’s perceptions about the key drivers of health remains to be seen. The challenge is to change the paradigm underlying how we think about the drivers of ill-health and what can be done about them in ways that go beyond this pandemic, and that will persist even after biomedicine finds ways to stop COVID-19, which I am confident it will in time, even if this means that the disease will persist endemically in some social groups.

From the very beginning, the response to the pandemic in the United States was characterized by a striking absence of national coordination, and by a remarkable and (to me at least) surprising inability, despite this being a country with premier public health research, to collect and process the basic information needed to guide actions. Sadly, this remains largely true today. Despite recent guidance on various pandemic-related topics issued by the Centers for Disease Control (CDC), the actions implemented to control the pandemic (e.g. masking, distancing, gatherings, school reopenings, vaccination requirements) have varied and continue to vary significantly across jurisdictions driven by a combination of political, economic and public health considerations with often little rationality. And even 18 months into the pandemic, we have struggled to compile the data or even to simply mount the systems that would allow us to properly characterize basic facts like accurate counts of deaths attributable to COVID-19 by various sociodemographic characteristics, or more recently, whether immunity resulting from vaccination has or has not waned over time, information which is critical to determine whether vaccine boosters are in fact needed. The failure of a national coordinated strategy has many causes, including specific political circumstances and a historical lack of investment in public health infrastructures, but is fundamentally rooted in the difficulty of implementing coordinated collective action in the context of systems that inherently work against an integrated, rational response.

But, it is also true that over the last year the pandemic has also revealed opportunities for social and collective action that previously seemed impossible, while also illustrating the fundamental challenges we face in creating the types of social change needed to effectively improve population health. On one hand, the pandemic has motivated and allowed actions that illustrate our ability to overcome perceived barriers to change when a crisis demands it, but it has also vividly illustrated the constraining effects of systemic forces, how the dynamics of our social and economic system often countervail and prevent real sustained change. In the United States, the example of payments to individuals (including stimulus checks and expanded unemployment benefits) and the moratorium on evictions are two examples of social interventions that would have been perceived as impossible before the pandemic. And yet they both happened and, unsurprisingly, had measurable beneficial social impacts as well as likely health impacts that will extend well beyond the pandemic itself. The vast expansion of government aid programs during the pandemic (many of which were pre-existing ideas that were applied or expanded) resulted in a dramatic decline in poverty to half of what it was pre-pandemic.¹ The impacts of this poverty reduction on health are hard to quantify and are likely to be complex but decades of research linking poverty to myriad health outcomes suggests that the effects of sustained poverty reduction on health are likely to be substantial.

In another example of unprecedented actions, early in the pandemic, the CDC called for a moratorium on evictions that was further extended in August 2021. What is remarkable is not only the national call for a moratorium, but the fact that this was led by a health agency, the CDC, and justified on health ground—i.e. the CDC recommended an eviction moratorium just as it recommends screening for high blood pressure or vaccination (in a further, not entirely unexpected, twist the US Supreme Court subsequently ruled that CDC had exceeded its authority).² In calling for an eviction moratorium, the CDC explicitly recognized the links between housing and health. Admittedly, both payments to individuals and the eviction moratorium were motivated by the wish to stop the transmission of a highly contagious disease that was threatening rich as well as poor and, most importantly, that threatened the economic functioning of our society—and even under these circumstances both have been questioned and challenged. Of course, because these interventions were conceived as temporary actions, the impact of their elimination on mental and physical health, and not just COVID-19, is something that we are likely to see over the next few months. Notably, and reflecting the many contradictory effects of the pandemic, the protection of public health has not always resulted in policies to protect the most vulnerable: Title 42 and the authority of the CDC have been used to expel immigrants at the border with the justification that they could be carrying the virus, and has led to the expulsion of close to 1 million migrants,³ including most recently, thousands of Haitian immigrants who were fleeing a country ravaged by extreme poverty, political chaos, and a terrible earthquake.

The pandemic has also interacted with and often reinforced existing social problems. Many reports have documented increases in domestic violence ⁴ during the pandemic. In the United States the purchase of guns soared during the year 2020, ⁵ even among persons who had never owned a gun before, and likely contributed to and reinforced recent stark increases in gun violence ⁶ across US cities. The pandemic has also highlighted poor conditions at work ⁷ including inadequate safety standards and limited sick leave for many workers. And recently, the pandemic appears to have emboldened worker demands, as reflected in growing numbers of strikes among US workers.⁸ Environmental impacts have been mixed: on one hand dramatic reductions in air pollution and greenhouse gas emissions during the lockdown phases demonstrated even to skeptics that human activities have major environmental consequences, but on the other hand paranoia about transmission through contaminated surfaces brought back plastics⁹ and single-use containers in daily life as never before. These effects, of course, are not the result of the pandemic on its own, but rather of the pandemic interacting with pre-existing systemic factors like the availability of guns for purchase and an industry interested in promoting its single-use products.

Yet another example of how the pandemic has interacted with existing systems is the failure to distribute vaccines in a way that is not only fair but also rational if our goal is to stop disease transmission. On October 13, 2021, 63% of the residents of high-income countries had been vaccinated with at least one dose, compared to only 4% in low-income countries. ¹⁰ COVAX, a platform which was to make vaccines available to lower-income countries, has failed miserably:¹¹ it struggled to obtain doses and also to deliver them effectively. Calls by the World Health Organization¹² to prioritize vaccine allocation to countries with limited vaccine coverage over boosters (of debated effectiveness) in higher income countries have been blatantly ignored. Meanwhile, the profits of pharmaceutical companies that produce what are perceived to be the “best” vaccines have soared¹³, and they have launched campaigns to accelerate the approval of boosters shots which will mean even larger profits.¹⁴ Calls to share patented knowledge and technology so that vaccines can be manufactured in the Global South have also gone unheeded,¹⁵ despite recognition by experts that regional manufacturing is critical to worldwide vaccination in a crisis. This problem will not be solved by pledges by rich countries, well-intentioned and generous as they may be. Global vaccine distribution (fraught not only with inequities but also gross inefficiencies) has reflected the functioning of a social system in which vaccines are a commodity that is produced for profit. In an ironic twist, significant public investments over decades supported the research that allowed us to develop novel vaccines so effectively. The system we rely on to produce vaccines has indeed produced large quantities of vaccine very quickly, but its distributional and equity consequences are clear for all of us to see. Remarkably, even the fact that only global vaccination can protect the rich in rich countries from the deadlier and more contagious strains that can emerge if transmission continues unabated globally is not enough to overcome the dynamics of the system we have in place.

Because of its contagious nature, SARS-CoV-2 has made very clear how protecting oneself from a deadly disease depends in large part on what we do collectively as a society. Vaccines are the paradigm of protecting the individual in the interest of the collective, but other examples abound: reducing air pollution emissions down the street from my home reduces my risks of respiratory diseases; speed limits reduce the risk that I will die in a car crash, even if I myself never speed; food inspections protect me from food-borne pathogens. In the case of a contagious disease, reducing transmission by vaccinating people in other countries or by halting evictions and providing sick leave to residents of neighborhoods in my city protects me as well. The perception of threat created by the pandemic, a contagious threat that no one (even the powerful) can escape, is perhaps why we have seen such unprecedented social action, despite the opposition from libertarians for whom even protection from a deadly infectious disease does not justify curtailing any individual liberties. Not unexpectedly, we have also seen growing and organized opposition to any government action, including vaccine mandates and even indoor masking, to the point where several states have actually passed legislation banning evidence-based public health actions.¹⁶ The broader lesson of the pandemic, beyond the well-established need for the collective to intervene in the case of contagious diseases, is that the collective needs to intervene to protect health in general, and not just under pandemic circumstances. Fundamentally, health and disease emerge from the social and economic systems that we have constructed, systems that include racism and an economy whose dynamics lead to environmental extraction, sustained inequalities, and consumption patterns with reinforcing adverse consequences for health and the future of our planet.

There is little doubt that the pandemic will end, perhaps as soon as early next year thanks to a combination of vaccination, immunity resulting from infection, and preventive measures such as masking, although SAR-CoV-2 will likely continue to circulate and become endemic as are many respiratory viruses. Treatments that will prevent severe cases and deaths are rapidly emerging as well. Hopefully, we will be better prepared when the next respiratory virus pandemic emerges. For example, efforts are underway to facilitate even faster vaccine development and develop early warning systems, ¹⁷ although, sadly, there is already evidence that the pandemic has done little to solidify basic public healthinfrastructure or strengthen public health authority—in fact, it has done just the opposite.¹⁶ More broadly, the extent to which the pandemic experience will result in sustained change to the systemic drivers of health that the virus has so starkly made visible is much less certain. I, for one, am much less optimistic on that than I was 18 months ago, but if this pandemic has taught us anything, it has taught us that the unexpected can happen and that predicting the future is fraught.

1. Urban Institute. [October 15, 2021]; Available from: https://www.urban.org/research/publication/2021-poverty-projections-assessing-impact-benefits-and-stimulus-measures.
   
2. Supreme Court Ends Biden’s Eviction Moratorium [October 15 2021]; Available from: https://www.nytimes.com/2021/08/26/us/eviction-moratorium-ends.html.
   
3. What is Title 42? Amid backlash, Biden administration defends use of Trump-era order to expel migrants. ABC News. [October 15 2021]; Available from: https://abcnews.go.com/US/title-42-amid-backlash-biden-administration-defends-trump/story?id=80149086.
   
4. Evans ML, Lindauer M, Farrell ME. A Pandemic within a Pandemic - Intimate Partner Violence during Covid-19. N Engl J Med. 2020; 383:2302-4.
   
5. An Arms Race in America: Gun Buying Spiked During the Pandemic. It’s Still Up. [October 15 2021]; Available from: https://www.nytimes.com/2021/05/29/us/gun-purchases-ownership-pandemic.html.
   
6. A Year After George Floyd: Pressure to Add Police Amid Rising Crime. [October 15 2021]; Available from: https://www.nytimes.com/2021/05/23/us/george-floyd-police.html.
   
7. Inequalities At Work And The Toll Of COVID-19, Health Affairs Health Policy Brief, June 4, 2021. DOI: 10.1377/hpb20210428.863621.
   
8. Strikes are sweeping the labor market as workers wield new leverage. Available from: https://www.washingtonpost.com/business/2021/10/17/strikes-great-resignation/.
   
9. Avoiding a Plastic Pandemic: The Future of Sustainability in a Post COVID-19 World. Available from: https://www.belfercenter.org/publication/avoiding-plastic-pandemic-future-sustainability-post-covid-19-world.
   
10. Global Dashboard for Vaccine Equity UNDP.
    
11. Where a Vast Global Vaccination Program Went Wrong NYT.
    
12. WHO chief urges halt to booster shots for rest of the year.
    
13. Pfizer Reaps Hundreds of Millions in Profits From Covid Vaccine NYT.
    
14. COVID-19 vaccine boosters could mean billions for drugmakers. Available from: https://apnews.com/article/coronavirus-pandemic-business-science-health-coronavirus-vaccine-5305defac283ac5f352bc47fcb74c82b.
    
15. Maxmen A. The fight to manufacture COVID vaccines in lower-income countries. Nature.
    
16. Why Public Health Faces a Crisis Across the U.S.; Available from: https://www.nytimes.com/2021/10/18/us/coronavirus-public-health.html.
    
17. American Pandemic Preparedness. [October 15, 2021]; Available from: https://www.whitehouse.gov/wp-content/uploads/2021/09/American-Pandemic-Preparedness-Transforming-Our-Capabilities-Final-For-Web.pdf?page=29.