Via The Lancet, a review by Mary T. Bassett: Cracks in the foundation: how COVID-19 showed our failures.
In 1963, James Baldwin, one of the USA's greatest essayists, published The Fire Next Time. The book's title comes from a slave song—”God gave Noah the rainbow sign/No more water but the fire next time”. Baldwin's words sounded a warning that the USA needed to confront its racial hierarchy by embracing racial equality or doom its future.
Sandro Galea's book, The Contagion Next Time, is titled in a homage to Baldwin and it also sounds a warning. Galea's central argument is that vulnerability to COVID-19 lies with a societal failure to recognise that the foundation of health rests on a healthy everyday life and not simply in the provision of health care. He ponders why this key lesson is not at the centre of pandemic discourse, which instead focuses on vaccination and treatment. In often lyrical prose, Galea roams across history, culture, literature, moral values, economics, politics, and personal pandemic experience. Although situated in a global context, the book's focus is the USA. Galea considers especially the enduring impacts of racism on health and the centrality of structural racism to understanding the USA.
Globally, there were more than 6 million COVID-19 deaths by early April, 2022. Amid this carnage, few have asked why, if this novel virus was the spark, there was so much dry grass. The Contagion Next Time is suffused with Galea's anguish that failure to grapple with this question will cost more lives. Worse, the world may fare even more poorly when the next contagion arrives.
After the omicron (B.1.1.529) surge, which occurred after this book was written, the USA is now approaching a staggering 1 million COVID-19 deaths. An analysis in 2021 by the Lancet Commission on public policy and health in the Trump era, to which both Galea and I contributed, found that about 40% of US COVID-19 deaths “could have been averted had the US death rate mirrored the weighted average of the other G7 nations”. In February, 2022, the per capita cumulative COVID-19 death rate in the USA exceeded that of other wealthy nations and during omicron placed the USA in a league all its own. Just what is going on?
Galea, who is Dean of the Boston University School of Public Health, USA, seeks the answers with erudition and passion. He begins with reflections of an array of relevant data. But most of the book reads as a journey towards understanding why the USA has fared so poorly. The answers have little to do with the scientific breakthroughs that brought us COVID-19 vaccines in such record time.
Galea points to the US obsession with individualism, making achievement of health a personal project, rather than a collective one, and an attachment to technology that has given priority to medical care over public health. He also posits widespread lack of compassion, which erodes solidarity. Galea does not shrink from naming an aversion to complexity in some quarters that made policy making difficult in the pandemic. COVID-19 demanded high-impact decisions that rested on imperfect, incomplete information. A lack of humility may also have contributed to at times contradictory public pronouncements. And there is a failure to confront racism (embedded in the founding of the USA), marginalisation, and socioeconomic inequality. Galea ends by observing that choosing health will mean “reorienting our social, economic and political priorities” to support our collective wellbeing.
But there are questions that go unasked and unanswered. Just why would a belief that medical care creates health persist, faced with decades of public health thinking that has shown the minor share of population health attributable to clinical care? The WHO Commission on Social Determinants of Health began its 2008 final report, “Social justice is a matter of life and death.” It would seem time to ask, who benefits from these unhealthy arrangements?
And there are answers. At their root lies an unfettered pursuit of profit that is not good for health. The US departure from the health performance of its peer nations began in around 1980 as market-oriented policies triumphed. Nicholas Freudenberg in his book At What Cost: Modern Capitalism and the Future of Health confronts directly how with present predatory capitalism in the USA there is widespread damage to the public's health. Haven’t we seen this also with COVID-19? Millions lost their jobs while the stock market flourished. Income inequality increased as life expectancy plunged precipitously among racially marginalised groups in the USA. Meanwhile, equitable access to COVID-19 treatments and vaccines is not a reality for many people in low-income and middle-income countries. Debates continue over patent protections.
The impact of anti-communism in the USA has limited interrogation of capitalism. But the USA is a capitalist country. Nearly 60 years ago, Baldwin sounded the alarm for the enduring harm of racism to the future of the USA, a lesson which Galea has amplified. Perhaps a more courageous book that contemplates the next contagion would go a step further in sounding the alarm for the health effects of modern capitalism.
