Pathogenesis: A History of the World in Eight Plagues

by Jonathan Kennedy

Health is so closely linked to wealth and social status that Michael Marmot, the influential British epidemiologist, has likened contemporary Britain to Aldous Huxley’s Brave New World, in which the lower castes were given chemicals—with the most lowly group receiving the highest dosage—to inhibit their intellectual and physical development.

In order to emphasize the way in which poor people are disproportionately affected by non-communicable diseases, some epidemiologists argue that these afflictions are “socially transmitted”: people who live in poverty are subjected to similar pressures and tend to respond to them in similar ways, as if a certain behavior were contagious.

A recent study found that the poorest 10 percent of households in the UK would have to spend over 70 percent of their income in order to follow healthy eating guidelines.

The local doctors have coined the phrase “Shit Life Syndrome” to refer to the common denominator for most of the maladies they see: destitution and hopelessness.

The suffering we see in Blackpool is a consequence of deindustrialization—or what some economists have called the “deindustrial revolution.”

Health inequalities in the UK stem from policy choices made by the government. When Margaret Thatcher became prime minister in 1979 she reintroduced many ideas that had been popular in the mid-nineteenth century: not just the emphasis on free-market economics and an aversion to state intervention, but also the belief that people who are left behind by these brutal macroeconomic transformations are underserving scroungers who must be shamed into working harder. This was self-imposed, structural adjustment.

A recent study estimates that since 2010, cuts in UK government spending have been responsible for more than 10,000 extra deaths a year.

The British experience demonstrates that, even when a country has passed through the epidemiological transition, disruption and deprivation can still create new, non-communicable plagues that have a similar impact as infectious diseases.

The United States spends more on health care than any other country—almost $11,000 per person every year, compared to $4,300 in the UK, for example.

The system is so inefficient that if the U.S. had a national health service like the UK’s, its health outcomes would improve and it would save almost 2.5 trillion dollars every year. Deaton and Case point out that the dysfunction in the U.S. health care system is, in monetary terms, more of a handicap than the reparations that Germany had to pay following the First World War.

There were enough vaccines to go round, but the self-interested actions of high-income countries created artificial scarcity in low-income countries. Rich nations bought far more vaccines than they actually needed; one study estimates that by the end of 2021 they had stockpiled 1.2 billion doses, despite having vaccinated their populations already.[69] That is more than enough to vaccinate all adults in sub-Saharan Africa twice.

The stark disparity in supplies of vaccine between rich and poor nations has been condemned as “vaccine apartheid” and “vaccine colonialism.”

Richard Horton, editor of The Lancet, argues that the devastation wrought by coronavirus in the UK and the U.S. should be understood as a “syndemic” or “synergistic epidemic.” In other words, the impact of the coronavirus pandemic can only be understood if we take into account the pre-existing pandemics of poverty and obesity that were already ravaging wealthy societies. In rich nations, poor people tend to have jobs which they cannot do from home; they travel by public transport and live in crowded housing, often with multiple generations. As a result, they are more likely to be exposed to the pathogens than wealthier people. To make matters worse, poor people are also more likely to have risk factors that could make them very ill if they contract Covid-19. These include obesity and non-communicable diseases such as diabetes, asthma or chronic lung disease. In the UK, adults in the poorest parts of the country were almost four times more likely to die from coronavirus than those in the wealthiest areas.[71] In the U.S., death rates were four and a half times higher among the poorest people than those with the highest incomes at the height of the pandemic.

Governments’ policy responses haven’t tried to tackle the twin pandemics of poverty and obesity that make the impact of Covid so much worse.

Although China was the original source of Covid-19, the pandemic has killed fewer than 15,000 people there, according to official statistics: 0.001 percent of the population.[*3] This achievement has come at an enormous cost, however, as it involved a massive curtailment of individual freedom and brought economic activity to a standstill—an approach that is unthinkable in most other parts of the world, where states have neither the will nor the capacity to enforce such stringent restrictions.

A century after Klimt’s Medicine shocked the faculty at the University of Vienna, medical knowledge remains just a small part of dealing with infectious diseases. Pathogens thrive on inequality and injustice.

This whole thing is not about heroism. It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency. —Albert Camus

But these “heroes” didn’t bend the arc of history with their genius and force of personality; rather, these qualities allowed them to take advantage of the opportunities that had been created by devastating epidemics.

China—one of the poorest societies on the planet fifty years ago—airlifted medical equipment to North America to help ease the crisis.

But North America and Europe can no longer delude themselves that their political and economic system is an enticing model for the rest of the world.

“Covid-19 may mark a transition from western democratic leadership of the global system.”[6] The crucial question is: what follows?

“Covid’s a lobster dropped into boiling water, making a lot of noise as it expires, whereas AMR is a lobster put into cold water, heating up slowly, not making any noise.”[9] The water already seems to be uncomfortably hot.

As a species, our best chance of surviving the threat posed by pathogens will come from working collaboratively. The great improvement in health that high-income countries experienced in the nineteenth and twentieth centuries was not a result of better medicine—as William McNeill claimed—or even economic growth per se. It was, rather, the consequence of political decisions to make massive investments in drinking water, sanitation, housing and poverty reduction. Just as cholera and other waterborne diseases forced cities to undertake vast infrastructure projects, Covid-19 should encourage us to tackle the causes of ill health.

Although such profound changes might seem unachievable in the current political climate, we should take inspiration from the fact that, throughout history, pandemics have driven momentous political and economic transformations. They shine a light on corrupt and incompetent leaders, reveal and exacerbate pre-existing social divisions, and encourage people to question the status quo. The Covid-19 pandemic has highlighted many of the problems that blight modern society. It is now up to us to seize the opportunity to address these iniquities and to build a happier and healthier world.