Two pandemics bookend the last forty years—HIV and Covid-19. The first changed our view of health care and its delivery in dramatic ways. Perhaps the second will change our view of health and who has access to it.
Three years past the initial 1981 report of persons with a new infectious syndrome was published, the activist Larry Kramer wrote an article “1112 and Counting” in which he berated every government official connected with health care—from CDC and NIH administrators to local politicians—for refusing to acknowledge the widening AIDS epidemic. (President Reagan had not yet said the word HIV publicly and wouldn’t for four more years). The burden of HIV fell on certain marginalized groups. As the HIV epidemic surged, gay men demanded vigorous federal intervention on their behalf. They wanted the benefits, protections, and resources that only Washington could provide. Cohesive activism slowly developed, taking years to organize, but what the reshaping of public opinion around HIV and biomedical activities produced was dramatic. The average FDA approval time of new drugs went from a decade to a year. Patient groups had to be consulted when new drugs were being reviewed by federal agencies. The purity of the placebo-controlled trial was re-imagined. Consumers started to demand to know treatment options and success rates and to be able to shop for the best care. It was a new era in biomedicine and in being a patient in the health care system.
We jump ahead 40 years. The political response to Covid-19’s arrival was actually worse than Reagan’s choice to ignore AIDS. On January 2, 2020, the director of the CDC contacted the National Security Council to warn about early cases of the coronavirus in China and the potential that it could spread to the United States. Yet when President Trump’s first televised remarks came 3 weeks later, he said, “We have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” Warnings by scientists were soon termed a “hoax.” The disinformation campaign that followed mattered gravely because Covid-19, a respiratory illness, was a broader threat to the general public than HIV ever was.
Unlike with HIV, we watched our health care infrastructure become overloaded by persons with Covid-19, and thousands of health care workers die. Yet our experience of this pandemic will not be shaped by any activist group attacking the health care system or its governing institutions. After all, the NIH and its pharmaceutical company collaborators developed miraculous vaccines with astounding speed and hospital workers did the best they could.
Vaccines, however, require vaccination; biomedicine becomes prevention via distribution through public health channels. We have now witnessed the problems of delivery of this form of preventive care with thousands of Americans dying each day while vaccines sat in warehouses or were inequitably delivered. As production of vaccine ramped up, we were delivering on an old-fashioned medical schedule; few vaccination centers ran around the clock, seven days a week.
Will more fundamental changes follow the Covid-19 moment as they did in the decades after HIV? How will the experience of Covid-19 then reshape the working of public health? What are the benefits and protections that government can provide in 2021 and into the future? Will we widen insurance coverage to all Americans? Will we address the structural inequalities that produced high Covid-19 vulnerability among Black Americans, essential workers, the poor, and those living in rural communities?
Covid-19 has not evidenced the need for a change in health care delivery, but rather in how we think of health more generally. This means a new conceptualization of public health and what we are owed as citizens.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.