For most of human history, the majority of people died of infectious disease. Scourges like tuberculosis, typhoid, plague, smallpox, and (in some places) malaria carried most people to their graves, many as infants or children. As public health and biomedicine advanced, cancers and organ diseases replaced microbes as the main causes of mortality. The control of infectious disease, and consequent doubling of average life expectancy, helped to bring the modern world as we know it into being. But paradoxically, the control of infectious disease also helped to widen health inequities, both within and between societies.
COVID-19 now appears to be falling along these familiar lines. The effort to bring the coronavirus pandemic under control has really become two distinct battles. Within America’s borders, where vaccine doses are abundant, it’s a fight against misinformation and hesitancy. Globally, it is a race between vaccine delivery and virus transmission.
These two sides of the effort are dangerously interconnected. The untrammeled spread of COVID-19 through large, vulnerable populations worldwide increases the risk that new variants will emerge and then roar through pockets of undervaccinated groups in the U.S. The harm done by a now-preventable disease throughout the world is a humanitarian crisis in its own right. But we are also creating an enormous risk. Every new variant carries with it the possibility of a devastating turn in the pandemic‚ a mutation that further weakens the efficacy of the vaccines, or that causes the disease to be more severe in children and young adults.
It is tempting to push such fears aside and to insist that we “learn to live with” the virus. But adapting to a world where COVID-19 is endemic should not mean complacency about the global inequities that are already stark and only getting starker. In the words of the International Monetary Fund, “The world is facing a worsening two-track recovery, driven by dramatic differences in vaccine availability, infection rates, and the ability to provide policy support.” As these gaps widen, success in managing the pandemic is starting to correlate more clearly (if still imperfectly) with national income. In the United States, more than 60 percent of the adult population is fully vaccinated. In Indonesia, that number is only 11 percent. In India, it’s 9 percent. In countries such as Vietnam, Tanzania, and Nigeria (as well as many others), it is still below 2 percent. This two-track recovery, where protection against the disease mirrors wealth and power, unfortunately reflects a historical pattern that is several centuries old. The world’s only hope lies in breaking it.
The pattern began in earnest with the start of the Industrial Revolution. Social elites were able to take advantage of new ideas and new technologies, while the working classes were crowded into factories and tenements. This widening of health disparities within societies is familiar enough. Inequities between societies are less appreciated, even though plagues and pandemics played a decisive role in the massive and enduring global gaps that formed in the century before World War I.
The emergence of new infectious diseases is an externality of modernization. Explosive population growth, rapid urbanization, mechanized transportation, the exploitation of natural ecosystems, industrial agriculture, and ever-more-global networks of trade and migration all intensified the threat of infectious diseases. Outbreaks of cholera, influenza, polio, and AIDS are only the most notable precursors of the current crisis.
The human and economic costs of new diseases are borne by all, but unequally. The societies that industrialized first were also the best-equipped to mitigate and contain the challenges of new infectious diseases. To make matters worse, European imperialism deprived many less industrialized societies of control over their own citizens at a crucial juncture. The result was a two-track world. Societies unprepared for the biological shocks of modernization disproportionately bore the costs of modern pandemics, further impeding economic development and miring them in cycles of poverty and disease that have been hard to break.
The cholera pandemics of the 19th century made these patterns vividly evident. Cholera is a severe diarrheal disease. Without treatment, a cholera infection causes a dramatic course of sickness marked by copious evacuations of bodily fluid. The lurid symptoms made it terrifying. Cholera was the quintessential new disease of the 1800s, a highly contagious fecal-oral disease adapted to spread in environments without sanitation infrastructure or clean drinking water. Much as COVID-19 seems diabolically adapted to take advantage of our highly connected, jet-setting world, so cholera was the ultimate pathogen in an age of squalid industrial urbanization and steam-powered travel. Cholera erupted in 1817 in British-controlled Bengal. Then outbreaks expanded and contracted in rapidly moving waves for the rest of the century.
In the West, cholera was terrifying precisely because it threatened to disrupt the fragile control over epidemic disease that had been so recently achieved. Faced with cholera, Americans picked up the crusade for sanitary reform, while European states mobilized the first recognizably modern efforts at global health cooperation in the form of the International Sanitary Conferences. Although cholera was the most feared disease everywhere, its global impact was wildly uneven. In Western Europe and the United States, it killed by the thousands. But elsewhere, it was catastrophic. Mortality figures can be taken with a grain of salt, but in India, for instance, cholera killed an estimated 15 million people from 1817 to 1865. By 1947, it had taken the lives of another 23 million people. Cholera was born as a disease of globalization, and it quickly became—and remains—a disease of poverty and underdevelopment.
We cannot afford to let the same happen with COVID-19. It is unprincipled to enjoy the fruits of modernization while letting others disproportionately bear the costs. Wealthy countries, which are even now backsliding on their already-too-meager commitments, must redouble their efforts to ensure that vaccines are available to all, and quickly. The humanitarian reasons for action are strong enough, to say nothing of the selfish motivations. High case numbers anywhere are a threat to all, wherever we are privileged to live. We have heard public-health experts remind us over and over throughout the pandemic that we are in this together, that my choices affect your health and vice versa. We cannot forget that this truth applies globally.