Trump passes Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, after a briefing of the coronavirus task force at the White House, March 2020
Jonathan Ernst / Reuters

To borrow and paraphrase Fyodor Dostoevsky’s famous quote about prisons, you can tell a lot about a society by its response to epidemics of infectious disease. 

Plagues put a mirror to the societies they afflict.

A pandemic will expose the failures of a government that does not invest in the health of its constituents or address the collective risks that arise when vulnerable groups lack health protections. For such a society, taking those lessons and applying them to reduce the risks of future contagion is surely the better of two possible outcomes.

The Plague Makes the State

The historian Mark Harrison has argued that starting with the first major Black Death epidemic in the fourteenth century, the need to control plagues helped create the modern state. Otherwise, predatory elites were compelled to assume greater responsibility for their constituents’ lives and well-being in order to protect themselves and their workforces.

The quarantine and isolation measures that helped arrest the bubonic plague proved ineffective against the six pandemics of cholera that swept the United States, the Middle East, Russia, and Europe in the nineteenth century. Societies had to adapt again as a terrifying disease struck seemingly healthy people, killing tens of thousands in the cities of Europe and the United States—and, very likely, many more in India, where the pandemics originated. Quarantine could not contain the microbes that arrived at ports and rail stations. It devolved instead into a tool that nations used to advantage their own merchants and punish other nations.

The United States had little or no sustained public health administration at the time of the first cholera outbreaks. New York City had established a Board of Health in 1805, but the body was staffed by aldermen without relevant expertise or real authority. Most American cities had similarly deficient public health administration. Thousands of pigs, goats, and dogs still roamed city streets in the first half of that century, feeding on refuse and decomposing filth; stories of pigs knocking over city residents and invading their homes regularly appeared in U.S. newspapers at the time. In New York, piles of trash clogged gutters, uncollected for days or weeks.

The United States had little or no sustained public health administration at the time of the first cholera outbreaks.

Taxpayers initially opposed the expense of providing piped clean water and sanitation in New York and many other American cities, but public terror of cholera, typhoid, and other water-borne infections soon overcame their objections. After the cholera outbreak in 1866, New York City established the Metropolitan Board of Health, staffed by medical personnel. Chicago, Milwaukee, Boston, and other large U.S. cities followed. These new public health boards banned roaming pigs and goats, forced property owners to connect to the new waterworks, and built sewers at a breathtaking pace.

In 1857, no U.S. city had a sanitary sewer system; by 1900, four out of five urban residents were served by one. The number of municipal waterworks in the United States increased from 244 in 1870 to 9,850 in 1924. The percentage of urban American households supplied with filtered water grew from 0.3 percent in 1880 to 93 percent just six decades later. The improved access to filtered and chlorinated water alone accounted for nearly half of the decline in mortality in U.S. cities between 1900 and 1936.

The reforms that cholera spurred extended beyond the domestic level. Infectious diseases were the first global problem that nation-states realized they could not solve without international cooperation. In 1851, European states gathered for the first International Sanitary Conference to discuss cooperation to reduce the ruinous health and economic costs of responding alone to cholera, plague, and yellow fever. That convention later led to the first treaties on international infectious disease control and—in 1902—the International Sanitary Bureau, which later became the Pan American Health Organization. These international initiatives were the early models for later international treaties and agencies on other transnational concerns, such as pollution, the opium trade, and unsafe labor practices.

Bellwethers

Epidemics demonstrate the collective risk that arises from failing to provide health and welfare measures to the most vulnerable. When HIV/AIDS became a pandemic, people in the world’s most impoverished nations died without access to the lifesaving treatments that were in widespread use in wealthy nations for HIV/AIDS and many other infectious conditions. The controversy over this inequity transformed global health, elevating the issue as a foreign policy priority and helping to raise billions of dollars for researching, developing, and distributing new medicines. 

Tuberculosis thrives in persistently impoverished communities, especially among those with prolonged exposure to crowded conditions. While the disease is still a leading killer globally, U.S. death rates from tuberculosis fell as authorities enacted public health and welfare reforms, such as adopting child labor laws and extending greater oversight to overcrowded tenements and factories. But the disease still has occasional resurgences. In 1992, rates of drug-resistant tuberculosis soared in New York City among marginalized homeless men, and outbreaks occur all too frequently in the prisons that Dostoevsky saw as bellwethers of civilization. 

The historian Christopher Hamlin cautions against the “myth of the good epidemic”: the notion that new outbreaks of cholera, tuberculosis, and other infectious scourges might have a salutary effect by motivating needed investment in sanitation and other government reforms. I likewise do not subscribe to that myth. The novel coronavirus, which causes the disease now known as COVID-19, might infect 40 to 70 percent of the world’s population, causing thousands or even millions of deaths. Humankind will not be better off for having had the experience.

But since societies, including that of the United States, must now bear the cost of this terrible pandemic, we might as well learn and profit from the experience. Only greater investment in public health and prevention-based health care, affordable access to medical services for the most vulnerable, and the federal and international architecture needed to prevent, detect, and respond to future outbreaks can prepare the world for future threats like COVID-19.

The most important lessons to be learned concern the coronavirus itself less than what this microscopic organism reveals about the political systems that respond to it. History suggests that those are the lessons to heed.

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  • THOMAS J. BOLLYKY is Director of the Global Health Program at the Council on Foreign Relations and the author of Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways. Follow him on Twitter @TomBollyky.
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