I often hear “public health has failed us” bandied about in the discourse these days, axiomatically, and usually in response to COVID policy. While I agree in broad strokes, I think the circulation and repetition of this phrase implies a coherence to “public health” that public health simply doesn’t have, and — as I have perhaps mentioned here before — assumes the existence of a golden era of public health at some point in the past where public health was “succeeding.” I don’t think there has ever been such a golden era, and I think it’s really, really worth thinking about what it means for public health to succeed. What does success in public health look like?
For some reason, I still get the Morbidity and Mortality Weekly Report emailed to me. My curiosity was recently piqued by a report of travelers returning to the US from Brazil and Cuba with something called “oropouche virus.” I looked it up. I suspected mosquitos and while mosquitos can transmit oropouche, its main vector is actually biting midges. I don’t know exactly what those are, but sounds bad?
The symptoms of oropouche are reportedly similar to those of mosquito-transmitted viruses like dengue (called “break-bone fever,” to give you a sense of what dengue is like), chikungunya (which was, confusingly, called dengue for a long time; after being absent from the Americas for roughly 200 years it was detected again in 2013 in St. Martin), Zika (which you may remember from the epidemic in 2015-2016), yellow fever, and malaria. These are predominantly transmitted by two Aedes mosquito species, Aedes aegypti and Aedes albopticus, which are both present in the United States and whose geographic ranges (where the conditions are favorable for them to reproduce) are expanding as climate change heats up the country.
Anthony Fauci just had West Nile, another mosquito-transmitted virus. This one is transmitted by Culex pipiens, which are all over southwestern Pennsylvania; every year since 2002, my county (Allegheny) has reported cases of West Nile in humans. Fauci was hospitalized with the virus, and described the experience as like “being hit by a truck.” The symptoms, again, are similar to other arboviruses (viruses that are spread by arthropods, a.k.a. insects, like mosquitos, ticks*, and — ugh — midges): headache, nausea, joint pain, fever, encephalitis or meningitis in severe cases, fatigue that can last for weeks or months after acute infection.
In Massachusetts, an outbreak of Eastern equine encephalitis (EEE) has prompted discussion (and implementation in one case) of some possible public health control measures, like restricting access to public fields in the evening, and a very predictable associated backlash against the measures. EEE is also transmitted by mosquito, primarily the species Culiseta melanura. The case-fatality rate is an unsettling 30%, and of those who survive acute infection, about half will go on to develop serious long-term neurological sequelae.
Climate change is making bigger and bigger regions of the continental United States hospitable for disease-transmitting mosquitos, and the number of cases of different arboviruses has been increasing at a steady but insistent drip since I started public health school in (good Lord) 2014. Local spread of dengue in the continental US has been limited (colonial holdings and territories are a different story; dengue is endemic in Puerto Rico, which experienced a huge outbreak in 2010) — most cases are still associated with travel to and from dengue-endemic regions. But who knows how long that will be the case? Autochthonous (local or home-grown) transmission has been reported in Florida, Texas, and California.
Most Americans simply do not care about any of these diseases, probably because they’ve never even heard of these diseases. (It always absolutely gags me that things like malaria, other arbovirus diseases, a huge host of parasitic infections, and more, which affect millions and millions of people worldwide, are lumped into the official subfield of public health called ‘neglected tropical diseases.’ Neglected, indeed!) This ignorance is the result of a complex success of so-called “public health.” Malaria was once endemic in the US, but was considered eradicated in 1951 following decades of intensive and environmentally deleterious malaria control efforts, beginning with “draining and ditching” and culminating with widespread, intensive application of the insecticide dichlorodiphenyltricholoroethane (DDT). It is, however, SO back. The US recorded a “home-grown” case of malaria last fall. Luckily, the mosquito (Anopheles gambiae) that mostly spreads the deadliest form of malaria (Plasmodium falciparum) is not really found in the US. Mosquitos, however can move.
The first chapter of Tim Mitchell’s book Rule of Experts, titled “Can the mosquito speak?” is about mosquitos moving, specifically moving along the Nile with hydraulic projects that dammed up the river at various points to irrigate the Nile Valley year-round, most importantly the Aswan Dam:
“The linking together of the river control projects enabled the mosquito to jump barriers from one region to the next. The accompanying cultivation based on perennial irrigation created many breeding places among a thicker population of human hosts that often lived much closer to the water now that flooding no longer occurred in many areas. The engineers who built the irrigation works had not considered the possibility that snails or mosquitoes would make use of their work to move, or that certain parasites would travel with these hosts, or that devastating consequences would ensue. In a private report in 1942, however, the British acknowledged that the surest way to restore the health of the Egyptian population would be to destroy the dams and return to basin irrigation.”
The story is this: the interaction of war, famine, and Nile engineering projects created the conditions for a devastating outbreak of malaria in 1942-1944, which was eventually stopped by a painstaking door-to-door vector eradication campaign. Mitchell notes that “In Egypt, however, DDT (and pyrethrum) also gained their effectiveness from special features of the gambiae mosquito—or rather, of the social relations between the mosquito and its human hosts.” A. gambiae is very social and prefers to feed on humans, and was thinly established as a relative newcomer to the Nile valley — which the eradication campaigners were able to take advantage of. Not so in Sardinia, where 5+ years and relentless spraying of massive quantities (and lethal concentrations) of DDT by airplane failed to eradicate the mosquito. In fact, the global malaria eradication effort that the World Health Organization announced in 1955 followed a similar pattern — eradication was successful in places where the mosquito was not as numerous or established, and failed elsewhere (Mitchell: “Although described as ‘global,’ the eradication program ignored Africa, the world’s major malarial region, aside from one or two pilot schemes”).
There are huge parallels between Mitchell’s argument and Christopher Hamlin’s book, Public Health and Social Justice in the Age of Chadwick, about the sanitarian movement of the 1840s, the passage of the British Public Health Act of 1848, and the construction of sewers — maybe more on that later. But what I really want to draw out here is Mitchell’s description of “techno-politics,” by which he is referring to public health, engineering, and various other scientific disciplines purporting to bring knowledge and expertise to bear on “nature” in a sort of dual colonialism.
“The world out of which techno-politics emerged was an unresolved and prior combination of reason, force, imagination, and resources. Ideas and technology did not precede this mixture as pure forms of thought brought to bear upon the messy world of reality. They emerged from the mixture and were manufactured in the processes themselves. Resolving these processes into reason versus force, intelligence versus nature, or the imagined versus the real misapprehends the complexity. But this misapprehension was necessary, for it was exactly how the production of techno-power proceeded. Overlooking the mixed way things happen, indeed producing the effect of neatly separate realms of reason and the real world, ideas and their objects, the human and the nonhuman, was how power was coming to work in Egypt, and in the twentieth century in general. Social science, by relating particular events to a universal reason and by treating human agency as given, mimics this form of power. The normal methods of analysis end up reproducing this kind of power, taken in by the effects it generates. In fact, social science helps to format a world resolved into this binary order, and thus to constitute and solidify the experience of agency and expertise. In much of social science this is quite deliberate. It tries to acquire the kind of intellectual mastery of social processes that dams seem to offer over rivers, artificial nitrates over sugarcane production, or DDT over arthropods.”
Public health-inclined readers will remember that there were two coronavirus pandemics before The Big One: SARS 1 in 2003, and MERS in 2012. The signs are all here that the water level is slowly rising with arboviruses too. The culprit in both instances, climate change, is ultimately the same. A lot is the same. Both diseases are zoonotic, with huge animal reservoirs. For example, C. melanura mosquitoes primarily feed on birds, and the virus that causes EEE mostly completes its life cycle among birds. The virus that causes COVID-19 has several animal reservoirs; recent research from Virginia Tech documented the extensive presence of COVID among “common backyard wildlife” and other research has documented that less biodiversity among bat species is associated with higher prevalence of SARS-CoV-2 in bats. Despite this, public health as a social science “mimics the form of power” (Mitchell’s words) that resolve the world into a neat binary of human technical ingenuity ingenuity vs. recalcitrant nature.
So what would it look like for public health to succeed? “Victory” over nature via technical expertise is a narrative, not a real possibility. It seems to me very American to believe otherwise and to lament the failure of public health to do something impossible — like eradicating COVID-19 beyond the first 6-8 weeks of the outbreak. I fear that the public in general is too turned off of public health to look back into the history of its successes and failures in order to complicate the stories of each. I have posted before about the COVID pandemic as an example and an experience of political defeat, and I also wonder about what the defeat-conditioned circumstances of possibility are for public health now facing the looming threat of vector-borne diseases on top of everything else. Is the answer to de-technicize public health? To pack it all in and focus on ecology? I don’t have a clue. But one of the ways that public health “fails” us is by propagating its own story, and making us expect more from technical and expert manipulation of complex social processes than we have any right to expect. I’ll give Tim Mitchell the last word:
“Techno-politics is always a technical body, an alloy that must emerge from a process of manufacture whose ingredients are both human and nonhuman, both intentional and not, and in which the intentional or the human is always somewhat overrun by the unintended. But it is a particular form of manufacturing, a certain way of organizing the amalgam of human and nonhuman, things and ideas, so that the human, the intellectual, the realm of intentions and ideas seems to come first and to control and organize the nonhuman.”
* Tick-borne illnesses deserve their own post and maybe, someday, they’ll get it.