An official in Cairo, Illinois dispatched a message to his counterparts in Washington, DC. He warned, the “country below is in the hands of a howling mob.” Locals not yet touched by the disease went into lockdown. In the absence of permanent public health officials or institutions, coalitions of citizens and elected officials living in uninfected areas took up arms to impose “shotgun” quarantines to fend off outsiders. According to the Chicago Tribune, “the people say that if necessary, to compel observation of their reasonable quarantine regulations they will burn every bridge between here and Vicksburg.”The targets of such reactionary “shotgun” quarantines were typically middle- and upper-class citizens with the resources to attempt to flee.
These familiar sounding alarms come not from yesterday’s New York Times but from 19th century obsevers, before the germ theory of disease, before antibiotics, and before the emergence of organized public health institutions. Indeed, elite fear (and occasionally exploitation) of disorganized (i.e., “panicked”) collective responses to epidemic infectious disease and, later, nuclear and bio-warfare, played a key role in the creation of these institutions. Local health departments and their federal partners (e.g., the Centers for Disease Control) were expected to calm popular fears, manage epidemics, and provide “leadership” in times of health crisis. As elaborated by Richard LaPiere in the 1930s, leadership was the essential antidote to panic: panic was not a result of rationality being hijacked by hysteria, but of the state’s failure to maintain the confidence of populations in its authority and ability to act.
As Michael Burawoy observed, “Institutions reveal much about themselves when under stress or in crisis, when they face the unexpected as well as the routine.” During the current COVID-19 crisis, President Donald Trump has sent inconsistent messages about the magnitude of the threat and of the requisite response. Leading health officials have consistently corrected him and justified strict containment measures grounded in evolving evidence. There has been extensive boundary construction, official and unofficial, geographic (external and internal), social, and personal; and boundary policing of all sorts, literal (police at state borders and on street corners in Manhattan), and figurative (ethnic slurs, shaming of perceived quarantine violators [doubtless preferable to bridge burning]).
Evidence for the intersection of resources created by wealth and caste (those “middle- and upper-class citizens”) with boundary-making are all around us: not only who can “flee” and who cannot, but also who can “shelter-in-place” and who cannot, who can work and study remotely and who cannot, even for whom the ambulance comes and for whom it does not. The “howling mobs” of today are responding to a tweet from President Trump to “LIBERATE” their citizens from lockdown orders. In Michigan, Ohio, Washington, and Colorado, protestors are shouting, honking, and hurling insults. At the Colorado state capital, demonstrators proclaimed, “Fear is the real virus.”
There is a direct connection between these echoes of the 19th century and the current fragility of the public health institutions that were created over the last century and a half to manage significant threats to the public’s health. Remarkably, the response to the 1918 influenza pandemic—the last time this country saw comparable containment measures—could not have been more different. There was widespread support for sweeping public health measures, increased funding that allowed state and local institutions to expand their capacities, and no examples of the kinds of panics that characterized the 19th century or of the orchestrated protests we see today.
What the COVID-19 crisis has so far revealed (to paraphrase Burawoy) are profound institutional fragmentation, the absence of organized capacity at the federal level for coordination of competing state and federal public health and political institutions, and an institutional vulnerability to politicization of the most trivial to the most consequential dimensions of public health policy decisions.
These are not novel observations. They have been frequently noted but never perhaps so starkly and never with the potential consequences for social chaos and economic devastation that they carry in the time of COVID-19. Although the true story behind the coronavirus testing fiasco is unlikely to be revealed before the “fog of war” has lifted, it is already clear that testing has, from the outset, been a victim of competing national (and nationalist) priorities and of longstanding competition for recognition and funding among the nation’s big three public health agencies—the CDC, the FDA, and the NIH.
The way out of our current dilemma is serious, coordinated, and fully funded public health crisis planning and execution across local, state, and federal public health agencies, in particular among the big three; and building on American public health history, not merely trusted leadership but close collaboration between political leadership and the leadership of public health.