Recalling public health efforts in Pennsylvania

This week in North Philly Notes, Jim Higgins, author of The Health of the Commonwealth, looks back on past epidemics.

By the last half of the nineteenth century, science began to unlock the secrets of infectious disease, most importantly that bacteria and viruses were the cause. No cures for human infectious disease emerged until the 1890s, when antitoxins for diphtheria and tetanus debuted. Even without cures for most infectious disease, public health efforts made remarkable inroads at the turn of the twentieth century in Pennsylvania and across the nation. 

As The Health of the Commonwealth neared its final edits, the new coronavirus responsible for the COVID-19 pandemic was on the move. Even the barriers posed by the Atlantic and Pacific Oceans, which I suspect millions of Americans depend upon, if unconsciously, to keep a dangerous world at bay, delayed the virus by only a matter of hours once it got aboard a transoceanic passenger jet.

 

The responses of the citizenry in the midst of an epidemic varies. Many quiet people in quiet corners cooked food for neighbors, checked on friends, took care of family, and generally soothed unsteady nerves. Most of those stories went unrecorded in our history. Most go unrecorded today, too. At the same time, there has always been resistance to modern public health measures in Pennsylvania. During a smallpox vaccination effort in 1906, parents allowed their elementary school aged children to parade the streets of Waynesboro, Franklin County with an effigy of the commissioner of health, which they kicked, spat upon, and ultimately burned.  The city council of Allentown declared in late-1918 that the flu, which was just beginning to infect people in the city, was actually nothing more than a “regular” cold. Homes, they suggested, should be kept warm to avoid catching these widespread, severe colds, even as the same councilmen were preparing that day to deal with a severe coal shortage throughout the region. Many people just tried to go about life as if nothing were amiss. Just push through it, they seemed to think, through the years and through the typhoid, smallpox, polio, and HIV tragedies. If one continues to go through the motions of life, eventually the threat will pass and (provided one survives) the stout-hearted (or delusional) person who ignores the presence of an epidemic will…what?  I’ve never been able to figure that part out. I guess the best I’ve come up with is that people who ignore epidemics satisfy a psychological need for control. Or because they are terrified. Sometimes, like now, politicians can harness an epidemic as a vehicle for meeting political ends. It happened in 1918 when Pennsylvania’s response to the flu became a major political issue in the 1918 senatorial race.    

But I’ve got news for you. The way people react to widespread disease outbreaks is nothing compared to the changes that have sometimes followed in the wake of epidemics. A single typhoid outbreak in the obscure town of Plymouth, Pennsylvania in 1885 led to the creation of the state board of health. Twenty years later, another typhoid epidemic in Butler, Pennsylvania led to the creation of the state department of health. Five years after that, Pennsylvania possessed the most aggressive and powerful state health department in the nation. 

On a broader note, the standard narrative for both prohibition and women’s suffrage is that after years of agitation, both efforts finally bore fruit nationally in the period 1919-1920. The war helped accelerate both social efforts. During the First World War, many voices demonized alcohol production because it directed labor, grain, and coal away from the war effort—and because the beer industry was dominated by people with German names. We have forgotten that in late-1918, in Pennsylvania and beyond, the alcohol industry was hit with hammer blows by public health officials who closed saloons and banned alcohol sales as an anticrowd measure in the face of the epidemic of flu. In Pittsburgh, the fight over alcohol sales involved military officials and threats of a near-martial law. The alcohol industry lost a great deal of sympathy during the epidemic. In the case of women’s suffrage, a long, bitter fight for the right to vote was pushed to a quicker successful conclusion by the war. Perhaps the flu epidemic offered national sentiment a final shove. Hundreds of thousands of women volunteered in emergency hospitals during the epidemic. Many were middle class and unacquainted with blood and pus and the sounds and sights of dying. Across Pennsylvania, newspapers, politicians, and civic leaders lauded the work of the state’s women and memorialized those who died with a prominence never before seen in American history.   

I really don’t know—nobody knows—whether the video of George Floyd would have sparked the response it did in the absence of COVID-19. But if the response to systemic racism continues, we might look back on a moment, in the midst of pestilence, when certain things changed in our society. I can’t predict exactly how America will change after COVID-19 fades, but if the history of epidemics teaches us anything, then changes are afoot.    

Jair Bolsonaro, Brazil, and COVID-19

This week in North Philly Notes, Philip Evanson, coauthor of Living in the Crossfire, provides an interim report about Brazil during the pandemic.

Mexican President Andres Manuel López Obrador (AMLO) met with U.S. President Donald Trump at the White House on July 8. It marked López Obrador’s long overdue debut as a statesman in need of establishing international credentials. During nearly two years as president, his whereabouts did not include any trips, official or otherwise, outside of Mexico. He had consistently soft-pedaled Trump’s anti-immigrant insults and truculence, but there was an official agenda celebrating the United States-Mexico-Canada (USMCA) trade agreement that went into effect July 1. The meeting became an exchange of compliments, and a state dinner followed. There was no reference to common views held by the two chiefs of state on the COVID-19 pandemic. Had COVID-19 been on the agenda, Brazil’s Jair Bolsonaro might well have been invited. The three presidents stand out as world leaders opting for “life must go on as usual” (López Obrador’s quietly expressed view) in spite of COVID-19.

JAIR BOLSONARO AND COVID-19

Jair Bolsonaro’s efforts to lead Brazil in the COVID-19 pandemic have shown mixed results. Numbers of deaths were high, but not everywhere in Brazil, and well below the U.S. as numbers per 100,000 (ca. 29 per 100,000 in Brazil [comparable to Brazil’s homicide rate] compared to ca. 39 per 100,000 in US). Then a new surge in numbers of deaths largely closed the gap with 44.7 deaths per 100,000 for Brazil, and 46.8 deaths per 100,000 for the US. These figures placed Brazil 5th and the United States 4th in COVID-19 mortality rates as calculated around the world with only Sweden (57.4), Italy (67.5), and the United Kingdom (69) showing higher rates. Eight state governors in Brazil have been or are ill with coronavirus. Governor Carlos Moises of Santa Catarina announced July 1 that he was ill. Santa Catarina had 26,341 cases but only 341 deaths. Official Brazilian statistics unlike in the U.S. give equal emphasis to number of cases, number of deaths, and number of people who become ill and recover. A Johns Hopkins study had Brazil with the largest number of people who recovered from COVID-19. In the U.S., preference is for a dichotomy: the number of new cases and number of deaths, and very little about the large number of people who recover.

Brazilians are very open about expressing fears of dying. The feeling seems shared equally by men and women. Summoning courage to face threats or problems, Brazilians will identify the enemy as in the expression: “Ou ele ou eu,” “It’s either him or me.” (Portuguese nouns are either masculine or feminine. Ending in a consonant, the Portuguese word virus is masculine.) Bolsonaro has made himself the face in identifying COVID-19 as a threat to Brazil, its people and economy. It has been an uncovered face when he appeared in large public gatherings without a mask. But the message was clear: “It’s the virus or us.” Bolsonaro brought an unusual personal history having been nearly fatally knifed at a presidential election campaign rally in 2018. Subsequently, he underwent three serious operations to resize his slashed intestines. The experience seems to have spiked an “I’m not afraid of anything” attitude with displays of over the top virility. Also reignited has been his presumed homophobia. He joked with a group of visitors that wearing a mask was “a thing for queers.”*

Bolsonaro’s aim is to move Brazil out of its erratically applied COVID-19 lockdown which he thinks further shrinks a national economy mired in recession since 2014. Even as recently as July 6th, he continued down this path and vetoed parts of a new law sent to him by Congress. Struck out were provisions that masks must be worn in prison, and that instructions for social distancing must be posted on churches or certain other places where people gather. In the vetoes, he remembered federalism: laws already exist that assign responsibility to the municipal and state in these matters, not the national government.

Layout 1Bolsonaro’s bravura public appearances in mixing with his followers have not won universal approval. Critical and outspoken Brazilians may be found among groups with high and low incomes. The upper middle class and upper class elites voted for him for president in large numbers, but many have lost their enthusiasm, and some now despise him. Low income Brazilians living packed together in dense communities in large urban agglomerations such as Rio de Janeiro and São Paulo have been unable to practice social distancing, and have little good to say about the government, authorities in general, or presidential antics. The coronavirus is with them, and infection and illness are widespread. Reports in the large circulation daily A Folha de São Paulo (which low income Brazilian cannot afford to buy) record widespread, growing levels of infection in low income neighborhoods, but tend to provide little information about numbers of deaths.

PRESIDENT JAIR BOLSONARO HAS CORONAVIRUS

On July 7, a test confirmed that Brazilian President Bolsonaro had coronavirus. He took the test with symptoms of low fever and cough. Though insisting he felt “perfectly well,” people were instructed to keep a suitable distance from the president. A prominent Brazilian journalist welcomed the news in his column: “I’m cheering for his condition to worsen and that he may die.” His editors wrote to the contrary that they were cheering for recovery, and that the experience would change the president’s attitude about the “greatest public health crisis that Brazil has faced in many generations.” Eighteen days later on July 25, Bolsonaro announced that he had tested negative and was free of the virus. The president celebrated driving a motorbike to a store where he spoke with various people. He wore a mask and only removed it briefly to put on a biking helmet.

Despite being ill, Bolsonaro has not abandoned the positions he took at the beginning on the COVID-19 pandemic: that coronavirus is flu, that many people will be infected, some will become ill and recover, but very few will die. An exception are the elderly, the age group with a far higher incidence of mortality than any other who must do social distancing, wear masks, etc. A vaccine is not available, but several available drugs are that speed recovery. Bolsonaro himself announced he was taking repeated doses of the anti-malarial drug hydroxychloroquine as recommended by his doctor. While science had not verified that hydroxychloroquine works as a cure, “it’s a matter of observation” he declared, “that many people seem cured, and it works for me.”

Lockdowns are wrong because they stop or slow economic activity and can lead to more business failures, and to more unemployment in Brazil whose economy has been long stagnant and is still contracting. These have been Bolsonaro’s positions during the coronavirus pandemic—he hasn’t wavered, and it seems certain he will stand by them. As for masking, while Bolsonaro had appeared prominently in public without a mask as at mass rallies of his supporters, at other times was seen wearing a mask. Since the diagnosis of coronavirus, he has been using a mask.

Bolsonaro’s hard core supporters elevated him to mythic status, and like to chant “mito” (myth) at rallies. Their reasons include that he survived near death following knifing by a would be assassin, that he easily won the presidential election after having been completely discounted at the outset, and that he served 28 years as a federal deputy without enriching himself. Elected politicians in Brazil are widely seen as corrupt, but Bolsonaro apparently isn’t, an important fact for his supporters. That he is now apparently recovering from coronavirus can only strengthen the mythic status conferred by chanting followers. Masked and recovering, he is in a position to provide constructive leadership and policy making. Of course, he has never been able to act or speak in a manner that suggests attributes of a statesman.

Surgeons at a public hospital successfully sutured his slashed intestines and saved his life in a delicate emergency procedure following the knife attack. This might have prompted a statement strongly in support of Brazil’s often maligned SUS (United Health System) public health system, but did not. Articles 196-200 of the 1988 Constitution require the state to make health care available to all Brazilians, though a private system is allowed to complement SUS, and excellent private hospitals are available to serve the elite, usually paid for by high cost private health insurance. SUS meanwhile has been chronically underfunded and suffers from various shortages. A minister of health in the Michel Temer government (2016-2018) which immediately preceded Bolsonaro’s recognized the limitations with the dismal declaration that it might be necessary to forget about certain social rights guaranteed by the Constitution. Nevertheless, SUS has carried the burden assigned it, and treated 75% of Brazil’s COVID-19 patients. Bolsonaro himself only expressed gratitude to the members of the staff who saved his life, and later offered the hospital some left over campaign funds which it turned out was illegal. His entrenched positions on coronavirus, like other positions Bolsonaro has taken though often supported by his followers also allow numerous critics to continue to believe and assert that the president is something akin to a moronic know nothing, or a clown which leads them into name calling such as Bozo or Bozonaro.

*In November, 2019 before the arrival of COVID-19, Bolsonaro declared he was no longer homophobic. He met with Diego Hypolito, Brazil’s multi-medal winning gymnast shortly after Hypolito came out as gay. The meeting included a photo op with Bolsonaro’s arm around the athlete’s shoulder. According to São Paulo state deputy and Bolsonaro defender Douglas Garcia who is a gay, black, and hails from a favela, Bolsonaro’s homophobia is the result of spending half his life as a soldier—he retired with the rank of captain—in an environment of virility. Garcia added this didn’t mean Bolsonaro would go into the streets ready to shoot at all that’s gay. 

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