On Pandemic Fatigue

On Pandemic Fatigue

If there is a common thread to this pandemic, it is loss. Many have lost jobs, businesses, or homes. Others have lost members of their family, and still others have lost their lives. Even the luckiest among us have lost something, if only time. But this essay seeks to focus on another kind of loss: the loss of patience. Specifically, I want to put into words for myself this strange and unsettling feeling that, of late, comes over me at least once a day, the feeling we call pandemic fatigue. 


The first time the coronavirus entered my consciousness as anything more than a blip was around Chinese New Year, in late January. I was going to see the celebratory parade in Usera, Madrid’s Chinese barrio, and I asked a friend of mine if he wanted to come. “Doesn’t seem like a good idea,” he said. “Lots of people coming from Wuhan.” Wuhan? I did not understand. “You know, that new coronavirus.”

I was stunned that someone in my life—and someone I considered sensible—was willing to change their behavior because of this virus on the news. Long before that, I had written off the periodic media frenzies about foreign diseases. Every other year there seemed to be some new virus ready to destroy the world—avian flu, swine flu, zika, SARS, Ebola—and every year it amounted to very little, at least in my life. Besides, I figured the media had such a strong financial incentive to frighten people that they would play up any potential danger, however remote.

So I went to the Chinese New Year Parade, and I didn’t get sick (though my camera was stolen), and I pushed coronavirus back to the peripheries of my awareness. It did not stay there for long. The news coming out of China seemed increasingly dire. The city of Wuhan was shut down completely. A whistleblower doctor died. Travel from China was banned. And still, stories of coronavirus infections started popping up all over the place.

I went on vacation in late February with my brother—to Poland—and, for the most part, life was still completely normal. But our flight back to Madrid took us through Milan, just for a short layover. By that time Italy was in bad shape, and parts of the country were already on lockdown. Milan was one of the worst hit areas. Even so, we did not even consider changing our flight. I was still quite sure that this virus business would blow over. All this was just our instinctual fear of the unknown. 

By the first of March, most people were still in denial. By that I mean that we were thinking of this virus like some other kind of natural disaster, a flood or a fire—one that is localized in space and time. Maybe Italy was bad, and maybe China was bad, but we didn’t live in Italy or China. The virus would go away and we would move on. Yet two weeks after I got back to Madrid, the schools were closed. Two days later, restaurants had to shut down; and the next day we were shut up in our houses. It was the lockdown.

I really believed that it would just be for two weeks. A month, tops. I encouraged my mom to buy tickets for a trip to Ireland in June. No way this would still be going on in June, I thought. No chance. But now that I had so much extra time, I decided to read a little about pandemics. I read books by experts in public health and infectious disease, by historians and novelists, and by investigative journalists. And slowly, the truth dawned on me—the hard truth that this emergency was going to last a long time.


This was the first time that I was living through a world-historical crisis as an adult. The closest thing I could remember were the attacks of September the 11th, but I was just a kid then, and I did not really understand what was going on. This time, I was painfully aware, and yet equally powerless to do anything about it.

I had heard stories of the solidarity that arises during times of crisis, but this was the first time I experienced it. Admittedly, it was difficult to show solidarity in any normal way, since we could not be physically close to one another. This was one of the most depressing aspects of the situation. But people figured out ways to lift each other’s spirits. There were the balcony concerts, the children’s drawings taped to windows, and the nightly rounds of applause for the healthcare workers.

The other aspect that helped us to get through this lockdown was fear. During these months we were still coming to grips with this new infection. How deadly was it, exactly? How did it spread? Could it stay in the air? Who was more vulnerable? What were all the symptoms? The uncertainty made the virus all the more frightening. Even so, it was clear that the virus was dangerous: overwhelmed emergency rooms, bodies stored in hockey rinks, and improvised field hospitals. With such a predator lurking the streets, it was less tempting to go outside.

The twin supports of fear and solidarity made the lockdown bearable. That, and a certain amount of creativity.


In Spain we were only allowed out to go shopping for food. We could not take walks or exercise outside. This really limited the options when it came to maintaining mental health—especially in my case, since I love a long walk or a good run.

But I adapted. I created a workout routine I could do in my tiny room, and made sure to do it every day. To get some sun, I snuck out onto my roommate’s balcony. Missing the local parks, I bought a bunch of plants. I made YouTube videos for my students learning English at home. Since we could not go to restaurants, my brother and I started cooking ever-more elaborate dishes—braised oxtail stew, Brazilian feijoada, French cassoulet, and even homemade kebab.

Still, the monotony could be numbing, the social isolation irritating. I can hardly imagine what it would have been like for someone living alone.

Eventually, after what seemed to be half an eternity, we were let out to exercise. In mid-May, I took my first run in over two months. I emerged onto the street almost shivering with excitement.

And yet the run was somehow less enjoyable than I thought it would be. Partly this was due to circumstances. For whatever reason, the Spanish government decided to let us out only at certain prescribed times; so when I set out the streets were absolutely packed. But I was more disappointed at my own physical shape. Though I had been regularly exercising in my little room, running even a fairly short distance felt difficult, heavy, painful. Breathing was so uncomfortable that I even wondered if I had gotten the virus. And, of course, I was much slower than before.


By the beginning of summer, some flicker of light began to appear at the end of the tunnel. We were coming down from the virus’s curve, and hopefully hitting a flat bottom. The state of alarm lifted on June 21 and we were free to do whatever we wanted. Except for the masks, life began to look pretty normal again.

But even at this relatively calm time, the virus could not be forgotten. This was brought home to me when I tried to get my papers in order to visit New York for the summer. I do this every year, and I was even more eager than usual to go home, since it is always nice to take refuge in times of trouble. Even after getting the requisite documents together, however, I was faced with uncertainty.

Here was my predicament: though I could legally travel there and back with my documents, there was no guarantee that the airlines would know that. Visa regulations are enforced very imperfectly by airlines, who tend to err on the side of caution since they face penalties if they transport someone who cannot legally enter a country. Aside from that, flights could simply get cancelled from lack of demand, or the rules could change while I was in the United States, leaving me unable to return to my job in Spain. I hoped that someone in authority could give me some clarity. But the Spanish consulate could only tell me that the situation was evolving, and advised me not to risk it. So, in the end, I had to forego a visit to my homeland.

I focus on this situation because it captures an essential part of pandemic fatigue: the sense of total uncertainty about the future. It is the feeling of being in limbo, of your life being totally up in the air, of being unable to plan even in the short-term. The most one could do was to wait, while the normal pleasures of life passed silently by.


During the summer, I slowly tried to regain the running facility I had lost. It was far more difficult than I anticipated. My body was slow and sluggish, and even rather delicate. On one run I pulled a muscle in my core and had to spend several days recuperating. Nearly every run was in some way a disappointment. But I did discover a new place to run: a park near my apartment, affectionately called siete tetas (seven boobs), a name the park owes to its seven prominent hills that stand above the surrounding city. Running there obviously meant a lot of running uphill, and I figured that this challenge might be enough to get me back into shape.

Practicing this way, I quickly discovered the key to uphill running: look down. It is simply too painful to focus on how much of the hill remains. When you look forward, you become hyper-aware of your labored breathing, and the urge to give up becomes irresistible. But if you look down, focus on your feet, you notice that each individual step is not that much harder than running on level ground, and so you can continue. And it quickly struck me that the pandemic requires just this same mentality: look down, focus on each step, and forget about how much of the hill is left to climb.

Perhaps a Buddhist would describe this state of mind as enlightened, since it is just this absorption in the present moment that meditation tries to cultivate. And, indeed, it is a powerful strategy when times are tough. But few runners, I suspect, would enjoy running the whole time with their head down. Part of the pleasure of a good run is the scenery—at least for me. Likewise, a big part of the motivation of running comes from setting goals and trying to accomplish them: an attitude inherently oriented towards the future. The pandemic, just like this hill, made all this impossible, and it was all we could do to just keep our heads down and keep pushing forward.


Time became a problem during the pandemic—empty time.

At first, I admit, it was exciting to have so much time to fill. Indeed, mixed in with all the alarm and frustration of the early days of the lockdown, there was a distinct note of relief—the opportunity to slow down, to maybe work on some hobbies, or simply to relax and introspect.

But very soon people began to hit a wall, or at least I did. Humans are simply not meant to spend so much time inactive, cut off, and without a fixed schedule. We need a bit of structure and variety, or else time turns into an mushy purée, thin and bland. With no reason to get up early or late, to do something in the morning or the evening, today or tomorrow, this week or next, it somehow became all the more difficult to focus on anything productive. Focus, after all, is as much an act of exclusion—expelling extraneous distractions—as it is of inclusion; and there was nothing to exclude (or, perhaps, there was everything at once?).

One consequence of this lack of any fixed temporal landmarks was an increase in my consumption of alcohol. Simply put, there was not much else to do, and none of the usual reasons not to drink. Not that I was deliberately drowning my sorrows, you see (at least not most of the time); rather, my background consumption of alcohol grew steadily, until I was drinking almost every day. This only exacerbated the physical toll of prolonged inactivity, contributing to the general sense of malaise and torpor that became my natural element. I would wake up groggy and late, and hang around the house most of the day, even when we were finally allowed outside.

The cumulative effect of all this has been pandemic fatigue: a listlessness mixed with an undercurrent of anxiety. Without a routine, unable to see my family, I passed the time the best I could—taking a few trips, teaching a few online classes, and trying to carry on with my usual hobbies. It was not an altogether unpleasant way to live, I suppose.

Yet the feeling was rather like sunbathing on an active volcano. The whole world had a delicate, fragile quality, as if the situation might suddenly and drastically change once again. This made it difficult to fully relax or to fully commit to future plans. Even the approach of the new school year seemed distant and unreal. Would the schools really re-open? And if so, how long would they remain so?


The reason I have become so aware of pandemic fatigue is that, for the moment, it is partially lifting. School has started for in-person classes, and I am once again in front of a classroom, writing on a white board, trying to memorize students’ names (much more difficult with the masks!). In short, I not only have a routine once more, but also a social purpose. It feels surprisingly good. Aristotle was correct when he noted that we are social animals. 

Now, after all this time, I have to be presentable in front of other people. This means no more gym shorts and sweatpants. The pandemic beard—quite impressively long, if I may say so—was shaven off, and my long hair trimmed. I even decided to do a dry month, Sober October, in order to reduce my drinking to pre-pandemic levels. 

Best of all, my running ability has started to reach pre-lockdown levels once again. All that running uphill paid off, and I can finally run without my body dragging behind my intentions. Better still, I can run while looking forward instead of with my head down, staring at my feet.

But this pandemic is not over yet, and neither is the fatigue. We are in the midst of the long-predicted second wave of infections. The Spanish government is scrambling, amid bitter partisan bickering, to put together a coherent response for this new challenge, and without much success. The main consequence has been a slew of new rules, changing unpredictably from week to week, the majority more annoying than effective. Even as I write this, I am not sure what I will be allowed to do by next week.

The worst part of the current situation is that we will have to endure the next round of restrictions and rules without the psychological supports from the early days. The buoyant solidarity has vanished into the usual humdrum concerns and routine bickerings of life. Lately, most of us (especially the politicians) are more concerned with finger-pointing than with lending a helping hand.

Also, the fear of the virus has lessened considerably. While this is, perhaps, partly justified, since we are more familiar with its symptoms and have better treatments, this is mostly a result of familiarity. Coronavirus is beginning to shift into the background threats in our environments, like car crashes or lung cancer—one of many dangers that we mostly ignore.

After the solidarity and the fear have mostly gone, the only thing left is the feeling of fatigue. In the end, this fatigue is a failure to live with coronavirus, to really face up to it. Most of us badly want to forget about this emergency and move on, and yet we are constantly reminded of its nagging presence. Without the support of the community or even the fear of a new threat, the virus becomes merely a burden, an extra chore, an added whisper of anxiety. Somehow, a problem affecting nearly everyone on the globe has become a dull ache that we all must deal with privately and alone.

I am afraid that there is still a lot of uphill running in our future. The only thing to do is to put our heads down, and push on. 

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Review: Evicted

Review: Evicted

Evicted: Poverty and Profit in the American City by Matthew Desmond

My rating: 5 of 5 stars

Eviction is a cause, not just a condition, of poverty.

Yesterday, on July 24, the federal moratorium on evictions—protecting about 12 million renters—ended; and many state-level moratoriums will conclude soon as well. Enhanced unemployment benefits, which gave households an extra $600 per month, will terminate this month, too, meaning that families will lose income at just the moment they are vulnerable to eviction. Meanwhile, as the virus rages on, so does massive unemployment. It seems likely, then, that the United States is on the cusp of a huge wave of evictions. Under these circumstances, I thought it was a good time to read this book.

This is an urban ethnography written about the lives of the desperately poor as they struggle to find stable housing. Matthew Desmond lived for months in a trailer park and then in the inner city, following people around, taking notes and photographs, recording conversations, conducting interviews, and carrying out large surveys. In many ethnographies—especially since the postmodern turn—the author has striven to include herself in the narrative, emphasizing the subjectivity of the process. But Desmond has effaced himself from this book, and has instead written a kind of nonfiction novel of eight families undergoing eviction.

The first thing that strikes the reader is that Desmond is an excellent writer. The narration is gripping from the beginning—dramatic, vivid, and even occasionally poetic—meaning that my first reaction was emotional rather than intellectual. Wrenching pity for the people caught up in this cycle of poverty alternated, at times, with light disapproval at seemingly self-destructive behavior, which disappeared into outrage at the landlords profiting from this situation, and then incredulity that such things can be allowed to go on in a supposedly advanced nation. Often, I found it hard to take in, and had to put the book down to take a breath:

[Crystal] had been born prematurely on a spring day in 1990 shortly after her pregnant mother was stabbed eleven times in the back during a robbery—the attack had induced labor. Both mother and daughter survived. It was not the first time Crystal’s mother had been stabbed. For as far back as she could remember, Crystal’s father had beat her mother. He smoked crack and so did her mother and so did her mother’s mother.

But if this book were merely a collection of such stories, it would be little more than poverty voyeurism. This book has quite an important point to make, though, and that is how eviction is not only a consequence of poverty, but one of its major causes.

Any account of housing instability needs to begin with the fact that most people who qualify for housing aid to not get it—3 out of 4 receive no aide whatsoever. This leaves them at the mercy of the private housing market, which has seen steadily rising rents for years, at a time when wages are stagnant. Though it is normally recommended to pay no more than 30% of your wages in rent, the subjects of this book paid far, far more—in some cases, over 90%. This has serious consequences. Most obviously, if you are paying so much of your income in rent, it is impossible to save, and often even to pay basic expenses. What is more, this means that virtually any unforeseen expense—repairs, medical problems, or a funeral—can make a renter fall behind.

Once behind, it is extremely difficult for a renter to catch up. This effectively puts them at the mercy of the landlord. Even if the house is in disrepair and violates safety codes, missing rent means that the renter can be evicted on short notice. As Desmond describes, some landlords are willing to be lax—at least for a time—and cut deals with tenants. But for many who fall behind, the sheriff will soon be knocking on their door, along with a team of movers, giving the tenants a stark choice: to have their things left on the curb, or put into storage (where they need to pay extortionate fees in order to keep it from being trashed). Most evictees do not have housing lined up, and many end up in homeless shelters.

In a market where buyers are desperate and sellers are relatively scarce, there is little incentive for landlords to reduce prices, or even to make basic repairs of their properties. As Desmond explains, it is often more profitable for landlords to evict late-paying tenants and contract new ones than to make their properties livable. The tenants in these pages put up with rats, roaches, broken walls, smashed windows, clogged plumbing, sagging ceilings, to give just a short list. Desmond himself did not have hot water during his stay at the trailer park, despite paying rent on time, repeatedly asking the landlord, and even informing them that he was writing a book about life in a trailer park.

Eviction is not a rare occurrence—there are well over one million per year in the United States—and it is also not merely a private tragedy. Unsurprisingly, evictions concentrate in poor neighborhoods; and when residence in an area is unstable, it makes it an even less desirable place to life. As Jane Jacobs pointed out, neighborhoods are not primarily made safe by patrolling police, but by the constant presence of people on the street, people with a sense of ownership of the neighborhood. Ejecting residents obviously erodes this possibility—and not only in the area where people are evicted from, but also in the areas they unwillingly move to—which makes the city generally less safe.

Eviction is also not colorblind. Just as black men are disproportionately locked up, Desmond found that black women are disproportionately thrown out. And when you consider that having either a conviction or an eviction record can disqualify you from public housing, and can legally be used to screen potential renters by private landlords, you can see that this disadvantage is compounded. The white families in these pages certainly did not have an easy time finding and maintaining housing, but the black families were significantly worse off. Desmond followed one white couple who managed to find a place despite both of them having eviction and felony records, and one of them an outstanding warrant!

It is crucial to remember that housing instability is not merely the byproduct of individuals navigating private markets. The government is not only culpable for being a bystander to suffering citizens, but for propping up this very situation. Just as government force—in the guise of police officers and prisons—has been used to deal with the social fallout of disappearing jobs, so has government force—in the form of eviction courts, sheriffs, movers, public eviction records, and homelessness shelters—been used to deal with the disappearance of affordable housing. Without this government backing, the situation could not exist.

In many cases Desmond documented, government workers actually encouraged landlords to evict their tenants. Since many properties do not meet building codes, virtually any government attention—whether from the police, the fire department, an ambulance, or social services—can motivate a landlord to eject a tenant. What is more, if too many 911 calls come from an address, the property is labeled a ‘nuisance property,’ and landlords are forced by the police to ‘take action’—usually through an eviction. Even victims of domestic abuse are often evicted, one reason that many victims do not contact the police.

If we can agree that this situation is unconscionable, then of course we must do something to change it. But what? One solution is rent control: establish maximum prices that landlords can legally charge. This can have some quite negative unintended consequences, however. For one, if low-income housing ceases to be profitable, then there is no incentive to create more. This leads to shortage. But what about simply giving people more money, such as by raising the minimum wage or a basic income scheme? The problem with this strategy is that rising rents can easily offset income gains.

One fairly easy, short-term solution would be to provide defendants in civil courts with public defenders. Currently, in the United States, only defendants in criminal courts have such a right, though many other nations also provide legal counsel in civil cases. At the moment, most people do not even show up for their eviction hearings; the majority who show up do not have a lawyer, and most of them lose the case. Legal counsel can profoundly change the odds of evictees. And it is worth noting that, though hiring lawyers is expensive, cycling people through homelessness shelters is even more so—and this does not even take into account the other forms of economic disruption caused by eviction, such as job loss (quite common when people lose their home).

Another solution, popular in the past, has been to build public housing. This has several obvious problems, too. For one, as happened in NYC, vibrant and affordable neighborhoods were bulldozed to make way for enormous housing projects. What is more, the design of public housing projects was ill-conceived: enormous high-rises with parks in between. By isolating the poor into these buildings—with no shops or other services nearby, and few good communal spaces—the projects became dangerous and dysfunctional.

It is possible that smarter public housing could play an important role in the housing crisis. If apartments are scattered through the city, rather than concentrated, and integrated with shops, restaurants, and other businesses, then it is much less likely that they will become dangerous. An added benefit to cheap public housing is that they exert a downward pressure on the housing market, since private apartments must compete with them. However, the housing shortage is so acute that public housing alone is unlikely to be enough; it would require too much building.

This is why Matthew Desmond advocates housing vouchers. These vouchers basically pick up the tab for renters, covering anything above 30% of their income. However, there is an obvious problem with such a scheme: landlords are incentivized to overcharge for their properties, since the money is guaranteed. Indeed, according to Desmond, this often happens, which leads to a lot of wasted taxpayer money. Clearly, some mechanism is necessary to establish reasonable prices. But the voucher scheme does have the great advantage of scalability: they can be distributed quickly and widely.

Such a program would not be cheap. And in the United States, welfare programs tend to be politically divisive, since in our individualistic culture we prefer to hold the poor responsible for their own poverty. This mindset runs very deep. Desmond even records a preacher who, after giving a sermon about the importance of charity, refused to help a homeless woman so that she could learn her lesson. And certainly many of the people in this book did make bad, self-destructive choices. But as Desmond points out—and as psychological studies have shown—living in poverty actively erodes people’s ability to choose wisely and to think in the long term. Furthermore, many behaviors which seem irrational to middle-class onlookers are actually sensible adaptations to poverty.

The other important point to consider is that those of us lucky enough not to live in poverty are also benefiting from government policies. The federal government subsidizes mortgages—a policy that mainly benefits people with six-figure incomes. The capital gains exception means that homeowners who sell their house do not have to include much of that money in their income, and thus are not taxed. Indeed, the United States loses far more in tax revenue through these kinds of tax breaks than it spends in housing aid for the poor. This fits into a common pattern in American life: that those least in need of help are those most likely to receive it (and vice versa, of course).

As I hope you can see, this is a gripping and important book. The reader comes away with both an intellectual and a visceral understanding of housing insecurity. There are some things that I wish Desmond included—most notably, what economic trends drove this change—but, on balance, I do not think anyone could have written a better book on this topic. Now, as we face the prospect of mass evictions in the wake of the coronavirus pandemic, perhaps we will summon the political will to do something about the problem.

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Review: Plagues and Peoples

Review: Plagues and Peoples

Plagues and Peoples by William H. McNeill

My rating: 4 of 5 stars

Looked at from the point of view of other organisms, humankind therefore resembles an acute epidemic disease, whose occasional lapses into less virulent forms of behavior have never sufficed to permit any really stable, chronic relationship to establish itself.

It is risky to write a book like this. When William H. McNeill set out to analyze the manifold ways that infectious diseases have shaped world history, it was almost an entirely novel venture. Though people had been writing history for millennia, specialized works focusing on the ways that civilizations have been shaped by illness were few and far between. This seems rather strange when you consider that it was only in the twentieth century when disease reliably caused fewer casualties than enemy action during war.

Perhaps thinking about faceless enemies like viruses and bacteria simply does not come naturally to us. We personify the heavens readily enough, and do our best to appease it. But it is more difficult to personify a disease: it strikes too randomly, too mysteriously, and often too suddenly. It is, in other words, a completely amoral agent; and the thought that we are at the mercy of such an agent is painful to consider.

This tendency to leave diseases out of history books has come down to our own day. The 1918 flu pandemic is given a fraction of the coverage in standard textbooks as the First World War, even though the former caused more casualties. Curiously, however, that terrible disease did not even leave a lasting impression on those who survived it, judging by its absence in the works of the major writers of the day. It seems that memory of disease fades fast, at least most of the time. The 1968 Hong Kong flu killed 100,000 Americans that year (which would translate to 160,000 today), and yet neither of my parents remembers it.

This is why I think this book was a risky venture: there was not much precedent for successful books written about the history of diseases. Further, since there was not much in the way of prior research, much of this book must perforce consist of speculation using the spotty records that existed. While this does leave the historian open to the criticism of making unfounded claims, as McNeill himself says, such speculations can usefully precede a more thorough inquiry, since at least it gives researchers an orientation in the form of theories to test. Indeed, in my opinion, speculative works have just as important a role as careful research in the advancement of knowledge.

McNeill most certainly cannot be accused of a lack of ambition. He had completed an enormous amount of research to write his seminal book on world history, The Rise of the West; and this book has an equally catholic orientation. He begins with the emergence of our species and ends with the twentieth century, examining every inhabited continent (though admittedly not in equal detail). The result is a tantalizing view of how the long arc of history has been bent and broken by creatures lighter than a dust mite.

Some obvious patterns emerge. The rise of agriculture and cities created population densities capable of supporting endemic diseases, unknown to hunter-gatherers. Living near large masses of domesticated animals contributed much to our disease regimes; and the lack of such animals was decisive in the New World, leaving indigenous populations vulnerable to the invading Europeans’ microbes. Another recurring pattern is that of equilibrium and disturbance. Whenever a new disease breaks in upon a virgin population, the results are disastrous. But eventually stasis is achieved, and population begins to rebound.

One of McNeill’s most interesting claims is that the great population growth that began in the 18th century was partly a result of a new disease regime. By that time, fast overland and sea travel had exposed most major urban centers to common diseases from around the world, thus rendering them less vulnerable to new shocks. I was also surprised to learn that it was only the rise of modern sanitation and medicine—in the mid 19th century—that allowed city populations to be self-sustaining. Before this, cities were population sinks because of endemic diseases, and required constant replenishment from the countryside in order to maintain their numbers.

As I hope you can see, almost fifty years after publication, this book still puts forward a compelling view of world history. And I think it is a view that we still have trouble digesting, since it challenges our basic sense of self-determination. Perhaps one small benefit of the current crisis will be an increased general curiosity about how we still are, and have always been, mired in the invisible web of the microscopic world.



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Review: And the Band Played On

Review: And the Band Played On

And the Band Played On: Politics, People, and the AIDS Epidemic by Randy Shilts

My rating: 5 of 5 stars

The story of these first five years of AIDS in America is a drama of national failure, played out against a backdrop of needless death.

Though this book has been on my list for years, it took a pandemic to get me to finally pick it up. I am glad I did. And the Band Played On is both a close look at one medical crisis and an examination of how humans react when faced with something that does not fit into any of our mental boxes—not our ideas of civil liberty, not our categories of people, and not our notions of government responsibility. As such, this book has a lot to teach us, especially these days.

Randy Shilts was working as a reporter for the San Francisco Chronicle. This position allowed him to track the spread of this disease from nearly the very beginning. Putting this story together was a work of exemplary journalism, involving a lot of snooping and a lot more interviewing. What emerges is a blow-by-blow history of the crisis as it unfolded in its first five years, from 1980-85. And Shilts’s lens is broad: he examines the gay community, the epidemiologists, the press, the blood banks, the medical field, the research scientists, and the politicians. After all, a pandemic is not just caused by a virus; it is the sum of a virus and a society that allows it to spread.

The overarching theme of this book is individual heroism in the face of institutional failure. There are many admirable people in these pages: epidemiologists trying to raise the alert, doctors struggling to treat a mysterious ailment, gay activists trying to educate their communities, and a few politicians who take the disease seriously. But the list of failures is far longer: from the scientists squabbling over claims of priority, to the academic bureaucracies squashing funding requests, to the blood bankers refusing to test their blood, to the government—on every level—failing to take action or set aside sufficient funding.

A lot of these failures were due simply to the sorts people who normally caught AIDS: gay men and intravenous drug users. Because both of these groups were (and to some extent still are) social pariahs, major newspapers simply did not cover the epidemic. This was crucial in many respects, since it gave the impression that it simply was not worth worrying about (the news sets the worry agenda, after all), giving politicians an excuse to do nothing and giving people at risk an excuse not to take any precautions. The struggle in the gay community over how to proceed was particularly vexing, since it was their very efforts to preserve their sexual revolution which cost time and lives. As we are seeing nowadays, balancing civil liberties and disease control is not an easy thing.

But what made these failure depressing, rather than simply frustrating, was the constant drumbeat of death. So many young men lost their lives to this disease, dying slow and agonizing deaths while baffled doctors tried to treat them. When these deaths were occurring among gay men and drug users, the silence of the country was deafening. It was only when the disease showed the potential to infect heterosexuals and movie stars—people who matter—that society suddenly spurred itself into action. This seems to be a common theme to pandemics: society only responds when “normal” people are at risk.

Another common theme to pandemic is the search for a panacea. At the beginning of the AIDS crisis, there were many claims of “breakthroughs” and promises of vaccines. But we still have neither a cure nor a vaccine. Fortunately, treatment for HIV/AIDS has improved dramatically since this book was written, when a diagnosis meant death. Pills are now available (Pre-Exposure Prophylactic, or PrEP) which, if taken daily, can reduce the chance of contracting HIV through sex by almost 99% percent. And effective anti-viral therapies exist for anyone who has been infected, greatly extending lifespans.

Unfortunately, these resources are mostly available in the “developed” world. In Sub-Saharan Africa, where resources are scarce, the disease is still growing, taking many lives in the process. Once again, a disease is allowed to ravage in communities that the world can comfortably ignore.

One day, a hardworking journalist will write a similar book about the current coronavirus crisis and our institutions’ response to it. And I am sure there will be just as much failure to account for. But there will also be just as much heroism.



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Review: The Great Influenza

Review: The Great Influenza

The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry

My rating: 4 of 5 stars

People write about war. They write about the Holocaust. They write about the horrors that people inflict on people. Apparently they forget the horrors that nature inflicts on people, the horrors that make humans least significant.

Like so many people nowadays, I have been scrambling to wrap my mind around the current pandemic. This led me, naturally, to the last major worldwide outbreak: the 1918 influenza. I have a distant connection to this disease. My great-grandfather (after whom I was named) was drafted out of Cornell’s veterinary school to work as a nurse in a temporary hospital set up for flu victims. I read the letters he sent to his mother, describing the experience.

John Barry’s account of this virulent flu is sobering to say the least. In a matter of months, the flu spread across the world and caused between 50 and 100 million deaths. More American soldiers died from this flu than from the entire Vietnam War. In most places the mortality rate hovered around two percent, but it struck much more fiercely elsewhere. In the Fiji Islands, 14 percent of its population succumbed; in Western Samoa, twenty-two percent; and in Labrador, a third of the population died. And because the disease mainly struck young people—people in their twenties and thirties—thousands were left orphans.

Barry’s book is not, however, simply a record of deaths. He sets the historical scene by giving a brief overview of contemporary medicine. In the early 1900s, modern medicine was just coming into its own. After centuries in which it was thought that bad air (“miasma”) caused illness, and in which bleeding was the most popular “cure,” researchers were beginning to discover viruses and bacteria, and were beginning to understand how the immune system combats these germs. Major public health initiatives were just getting underway. The John Hopkins School of Public Health had been founded, and the Rockefeller Institute was making new types of research possible. It was not the Dark Ages.

The other major piece of historical context is, of course, the First World War. Undoubtedly this played a major role in the epidemic. Not only did troop movements help to spread the disease, but press censorship virtually guaranteed that communities were unprepared. Barry notes how newspapers all across the country consistently downplayed the danger, which ironically only further increased panic. (The pandemic is sometimes called the “Spanish flu,” because the press in neutral Spain was uncensored, and so reported freely on the disease.) The war effort overrode all of the warnings of disease experts; and by the time the disease struck many communities, most of the available doctors and nurses had been sent to the military.

Barry’s narration mainly focuses on the United States. Partly this is because this is where he believes the disease originated (there are several competing theories), partly this is because the disease’s impact in Europe was overshadowed by the war, and partly this is simply because of the amount of easily available sources. I did wish he had spent more time on other countries—especially on India, which suffered horribly. The sections on science—both on the history of science, and summarizing what we know now about flu viruses—were in general quite strong. What was lacking, for me, were sections on the cultural impact of the disease.

But perhaps there are not so many. As Barry notes, no major novelist of the time—Hemingway, Fitzgerald, Lawrence—mentioned the pandemic in their works. I have noticed the same thing myself. I cannot recall a single mention of this flue in biographies and autobiographies of people who lived through the pandemic, such as John Maynard Keynes or even John D. Rockefeller (who personally funded research on the disease). This is perhaps understandable in Europe, where the deaths from the pandemic were swallowed up in news of the war; but it seems odd elsewhere. What is more, the pandemic did not seem to exacerbate existing racial or class tensions. In many ways the virus seems to have swept through communities and then disappeared from memory.

(Barry does have one fairly controversial claim in the book: that Woodrow Wilson contracted the flu while negotiating the treaty of Versailles, and that it caused him to capitulate to Clemenceau’s demands. If this is true, it would be a major historical consequence.)

It is illuminating to compare the 1918 pandemic to the current crisis. There are many similarities. Both are caused by easily transmissible viruses, and both spread around the world. The H1N1 flu virus and the SARS-CoV-2 virus both infect the respiratory system, causing fever, coughing, and in severe cases pneumonia and ARDS (acute respiratory distress syndrome). In both cases, no vaccine is available and no known treatment is effective. As in 1918, doctors are turning desperately to other therapies and medicines—those developed for other, unrelated diseases like malaria—and as in 1918, researchers are publishing at a frantic pace, with no time for peer review. Police are again wearing masks, hospitals are again overrun, and officials are struggling to catch up with the progress of the virus.

But of course, there are many important differences, too. One is the disease itself. The 1918 flu was almost certainly worse than the novel coronavirus. It was more deadly in general, and it killed younger people in far greater numbers—which resulted in a much bigger dip in life expectancy. (Young people died because their immune systems overreacted in what is called a “cytokine storm.”) The H1N1 flu also had a far shorter incubation period. This meant that the gap between infection and the first symptoms was short—often within 24 hours—and patients deteriorated far more quickly. Barry describes people being struck down within mere hours of showing their first symptoms. The challenge of the SARS-CoV-2 virus, however, is the very long incubation period—potentially up to two weeks—in which people may be infectious and yet not show symptoms. This makes it very difficult to keep track of who has it.

The explanation for this difference lies in the nature of the virus. A virus is basically a free-floating piece of genetic code incased in a protein shell. It needs to highjack animal cells in order to reproduce; and it infiltrates cells using proteins that link up with structures on the cells’ surface. Once inside, the virus begins to replicate until the cell literally bursts, spilling virus into adjacent cells, which in turn get infected, and which in turn burst. Each burst can release thousands of copies. The rate at which the virus replicates within the cells determine the incubation period (between first infection and first symptoms), and coronaviruses replicate significantly more slowly in animal cells, thus explaining the slower onset of symptoms. Their greater speed also means that flu viruses change faster, undergoing antigenic drift and antigenic shift, meaning that new strains of the virus are inevitable. The novel coronavirus is (likely) more stable.

Another potential difference is seasonality. Flu viruses come in seasonal waves. The 1918 virus struck first in spring, receded in summer, and then returned in autumn and one last time in the winter of 1919. Every wave hit very quickly—and then left just as quickly. Most cities experienced a sharp drop-off in cases after about six weeks of the first patients. The seasonality of the 1918 flu was partly a result of the genetic drift just mentioned, as the different waves of this flu were all at least subtly different strains of the virus. Atmospheric conditions—humidity and temperature—also presumably make some difference in the flu virus’s spread. COVID-19 may exhibit a very different pattern. It may, perhaps, be less affected by atmospheric conditions; and if it mutates and reproduces more slowly, it may linger around for one long wave rather than several short ones. This is just my speculation.

Well, so much for the virus. How about us? The world has changed a lot since 1918. However, not all of those changes have made us better prepared. Fast and cheap air travel allowed the virus to spread more quickly. And economic globalization did not help, either, as both medicines and medical equipment are often produced overseas and then imported, thus rendering countries more vulnerable to supply-chain disruption than in the past. As we witness countries and states compete for supplies, this vulnerability is very apparent.

But of course we have many advantages, too. Many of the deaths caused by the flu and the coronavirus are not from the virus infection itself, but because the virus renders us vulnerable to secondary infections by bacteria, causing pneumonia. Antibiotics (which did not exist in 1918) can save many lives. Another advantage is medical care. The most severe patients of both epidemics were struck with ARDS, a condition with an almost 100% mortality rate for those who do not receive intensive medical care (using a ventilator machine). In 1918 they were able to administer oxygen, but far less effectively than we can. Even so, even with the best intensive care, the survival rate of ARDS is between 40-60%. And our ability to administer intensive care is quite limited. The ventilator shortage has become a global emergency in itself, as hospitals are overrun.

Medical science has also advanced considerably. Now we can isolate the virus (which they could not do in 1918), test individuals for it, and work on a vaccine. However, testing has so far been unable to keep up with the virus. And the most optimistic estimate of an available vaccine is in a year. Arguably a much bigger advantage is information technology. The press is not censored—so citizens have a much better idea of the risks involved—and experts can communicate with each other in real time. We can coordinate large-scale societal responses to the pandemic, and can potentially even use technology to track individual cases. As we come to better understand the virus, we will be able to use more sophisticated statistical methods to understand its progress. None of this was possible in 1918.

One thing that we will have to contend with—something that is hardly even mentioned in Barry’s book—is the economic toll that this virus will take. Even in the ugliest days of the 1918 pandemic, governments did not require businesses or restaurants to close. War preparations went on unabated. (In 1918, after years of slaughter and at the height of the war, life was simply cheaper than it is now.) Our societal response will likely mitigate the health crisis but will create a secondary economic crisis that may ultimately be more difficult to solve. The solutions to this crisis could be our most lasting legacies. Already Spain’s government is talking of adopting universal basic income. Though of course it is far too early to predict anything with confidence.

Comparisons with 1918 are partly depressing, and partly uplifting. Depressing, because we knew this was possible and did not prepare. Depressing, because so many governments have gone through the same cycle of early denial and disorganized response as they did back then. Uplifting, because we do know much more than we did. Uplifting, because—after our early fumbles—we are finally coordinating as a global community to deal with the crisis. Perhaps most uplifting of all, despite some ugly stories here and there, the crisis has revealed a basic sense of solidarity in the face of a universal threat. Hopefully, unlike 1918, we will not do our best to forget about this one.



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Review: Deadliest Enemy

Review: Deadliest Enemy

Deadliest Enemy: Our War Against Killer Germs by Michael T. Osterholm

My rating: 5 of 5 stars

This is a critical point in history. Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose. Someday, after the next pandemic has come and gone, a commission much like the 9/11 Commission will be charged with determining how well government, business, and public health leaders prepared the world for the catastrophe when they had clear warning. What will be the verdict?

If I had read this book in more normal circumstances, I do not know how I would have responded. Perhaps I would have been slightly unnerved, but I think I would have been able to sleep soundly by dismissing most of it as alarmist. In fact, I did just this a few months ago, when I read Bill Bryson’s book on the body, and scoffed at his claim that another 1918-style pandemic was easily possible. Nowadays, however, reading this book is more depressing than anything. Those in the field saw this crisis coming from miles away, but few of us listened. The epidemiological community must feel rather like Cassandras right about now: uttering prophecies that nobody pays any attention to.

(As Osterholm was responsible for most of the ideas in this book, and as it is written from his perspective, I will refer to him as the author in this review.)

This book attempted to be the Silent Spring for infectious diseases. That it did not succeed in doing so is attributable just as much to human nature as to the book itself. Limiting the use of pesticides is fairly easy and relatively painless for most of us. But mobilizing the political will necessary to prepare for health crises in the hypothetical future—preparations that would involve a great deal of money and many institutional changes—is not such an easy sell, especially since we had been lulled into a false sense of security. As is the case with climate change, the dangers seemed so remote and theoretical that for most of us it was difficult to even imagine them.

After witnessing what this new coronavirus has done to our entire way of life in a few short weeks, I was quite disposed to take Osterholm seriously. And I think the entire content of the book—not just the warnings about a potential pandemic—are valuable. Osterholm turns his attention to a wide array of threats: Zika, AIDS, Yellow Fever, Typhoid, Malaria, Ebola, MERS. We are vulnerable on many fronts, and we are generally not doing much to prepare.

One example are the many diseases that are transmitted by mosquito bites. As modern transportation has introduced disease-carrying mosquitos into ever-more parts of the world, and global warming expands the geographic range of mosquitos, this will be an increasing concern. (Silent Spring may, ironically, have contributed to this problem.) Another worry is bio-terrorism. Now that we can see how paralyzing even a moderately lethal virus can be, imagine the damage could be inflicted by a genetically-modified virus. And the technology to edit genes is becoming cheaper by the year. We have already experienced bio-terrorism in the US on a relatively small scale with the 2001 anthrax attacks. This is just a taste of what is possible. According to Osterholm, a mere kilogram of the anthrax bacteria could potentially kill more than an atomic bomb. And it would be far cheaper to acquire.

But these are not even the biggest threats. According to Osterholm, we face two virtual certainties: another flu pandemic, and the imminent ineffectiveness of antibiotics.

The latter is quite terrifying to consider. Antibiotics are not easy to discover, and our arsenal is limited. Meanwhile, bacteria constantly evolve in response to environmental pressures, including to the use of antibiotics. It is inevitable that resistance to available antibiotics will increase; and this could have a profound effect on modern medicine. Even routine operations like knee-replacements would be unsafe if we did not have effective antibiotics. Slight injures—a scratch in the garden from a rose-bush—could result in amputations or even deaths. And yet, antibiotics continue to be widely prescribed for ailments they cannot treat, and given indiscriminately to livestock, which only accelerates the impending bacterial resistance.

The other major threat (as we are learning) is a pandemic. Now, Osterholm was not precisely correct in predicting the cause of the next pandemic, since he thought it would be a flu virus (though he does have a good chapter on coronaviruses, and in any case a flu pandemic is still just as possible). But he is certainly correct in identifying our many structural weaknesses. He notes our lack of stockpiles and correctly predicts a shortage in protective gear, face masks, and ventilators in the event of a pandemic. And though medical science has advanced a lot since 1918, in many ways we are even more vulnerable than we were back then, most notably because of our supply chains. Since so many of our medicines and medical equipment—among other things—are produced overseas, shortages are inevitable if trade is disrupted.

Osterholm is quite illuminating in his discussion of pharmaceutical companies and their incentives. As private businesses, they have little to gain by investing in preventative vaccines or in new antibiotics. In the former case, this is because vaccines have to undergo thorough testing and pass FDA approval, requiring millions in investment, only to face the prospect of uncertain demand once the vaccine hits the market. The case of SARS is instructive. After the disease was identified in 2002, companies rushed to make a vaccine; but when SARS receded, interest in the vaccine disappeared and pharmaceutical companies, cutting their losses, stopped work on the vaccine. We still do not have one.

The incentive system is just as ineffective when it comes to antibiotics. Finding new antibiotics is costly; and since there are currently many cheap antibiotics on the market, a new patented antibiotic probably would not turn a large profit. Besides, effective antibiotic stewardship requires that we use them sparingly, thus further limiting profit potential. Drug companies have much more to gain by creating products that would require continuous use, such as for chronic conditions. Letting the free market decide which drugs get developed, therefore, is not the wisest decision. Osterholm advocates the same approach as taken by government in weapons contracts, wherein the government essentially guarantees payment for any product that meets specifications.

Osterholm’s most ambitious idea for government funding is for a new universal flu vaccine. The flu vaccine we are all familiar with is based on old technology, and can only provide protection from a few strains of flu. Scientists essentially must guess what sort of flu will be circulating in a year; and they must do so every year. But Osterholm thinks that there is good reason to believe that a universal flu vaccine is possible, and recommends we devote at least as much money to such a vaccine as we devote to AIDS research. This seems very sensible to me, since the next pandemic will likely enough come from a flu virus.

I am summarizing Osterholm’s book, but I do not think I am doing justice to its emotional power. Now that I am living through the events that Osterholm predicts (in surprising detail), I feel a strange mixture of outrage and fear: outrage that governments did not listen when they had time, and fear that we will repeat the same mistakes when this current crisis is over. I cannot help but be reminded of another situation in which we comfortably ignore the dire warning of scientists: climate change. My biggest hope for the current crisis, then, is that afterwards we will be more willing to heed the warnings of these nerds in lab coats.



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