Pandemics and Public Health History

Since the inception of the COVID-19 pandemic, historians have been frequent commentators, searching high and low through their research files, scholarly articles, and books to find the closest analogs in the history of past pandemics to the current crisis. Journalists and pundits have sought out these rarely consulted academics to offer insights for our understanding of the unfolding challenges of COVID-19 as it has circled the globe.¹

The massive influenza epidemic that torched the world following World War I has occupied the most attention in these historical sweepstakes, although other pandemics—plague, cholera, yellow fever, and HIV/AIDS, among others—have been frequently cited for their contemporary relevance. The significance of AJPH’s longstanding section “History Essays” (formerly, “Public Health, Then and Now”) has never been so clear as we face this current crisis. There is much to learn about how to think through an epidemic in the careful, analytic histories of disease so often revealed in these articles. Over recent decades, the field of public health history has been transformed as it has addressed the history of pandemics, centering attention on powerful social and structural forces that create unequal vulnerabilities to death and disease, as well as greater attention to the significant obstacles that stand in the way of effective responses.²

In the current issue, Navarro and Markel dive back into the 1918 pandemic in their article “Politics, Pushback, and Pandemics: Challenges to Public Health Orders in the 1918 Influenza Pandemic” (p. 416). They scrupulously use newspaper accounts of public opposition to public health measures, documenting a number of striking similarities to the current debates and divisions about public health strategies to reduce the transmission of COVID-19. Indeed, in reading their account, one might well conclude that we are back in 1918 fighting over the use of masks and the closing of businesses, bars and restaurants, theaters, and churches. Some 100 years later, they suggest, little has changed in the character of conflict about public health and individual liberty; inevitably, pandemics divide social interests and the economy, while often devastating both. The more things change, the more they stay the same.

But what is the conclusion we should draw from what appear to be such powerful historical parallels? And more broadly, what can history tell us about the present? No doubt there are important continuities in the opposition to public health mandates that Navarro and Markel describe so meticulously. The United States has a deep political and cultural tradition of suspicion of state authority, as well as strong cultural commitments to individualism and personal liberty. Public health efforts, which are especially centered on rules, regulations, and mandates, have, as we know, often been challenged by both protest and litigation.³

These legacies no doubt inform the trajectory and character of current debates, but it is important as we observe these similarities not to assume that they merely represent the return of well-known historical divisions.⁴ Indeed, as we recognize the continuities that Navarro and Markel point to, so too should we investigate the particular characteristics and contexts that drive these debates about US responses to the current pandemic.

Even as historians search for analogs, we must be sensitive to the powerful and fundamental discontinuities, social and political change, and seismic scientific and technological shifts that inform our understanding of the current pandemic. We cannot assume that these “symptoms” of division emanate from the same root causes. History points us to fundamental questions of context and contingency. Rather than “naturalize” mask refusal or debates about closing theaters or churches, we need to further evaluate not just similarities but also essential contextual differences.

The information ecosystem and the structure of social division today is fundamentally different than it was in 1918, when most news and knowledge was passed by word of mouth or covered in daily newspapers in expanding US cities. As we now recognize, divisions over the pandemic and sharply contentious perspectives on its risk, impact, and management are characteristic of the fractured sources of knowledge in a new media ecology, rising scientific denialism, and the intensive polarization of our polity. To track COVID-19 on CNN and Fox News is to see two wholly different phenomena, with radically distinct implications for public health and strategies for controlling the pandemic. And, of course, this is but a small element of the broader media labyrinth in which misinformation, disinformation, and conspiracy theories about the pandemic have been so widely broadcast.⁵

Given the salience of the specific contexts that have shaped responses to COVID-19, should we simply assume that every epidemic is but a reflection of its particular moment, that we must avoid all comparisons to earlier, specific pandemics? To do so, would be to misunderstand the importance and relevance of history for informing our current crisis. History offers a critical perspective on problems of disease and its amelioration. We know that disease will track social inequities and illuminate failing infrastructure. We know, from historical scholarship, that because there is a powerful functional relationship between diseases and their social determinants, in times of pandemics, these vulnerabilities will light up in sharp relief. For many historians, there have been few elements of COVID-19 that could not have been anticipated.

Nonetheless, SARS-CoV-2 is a novel virus that has traveled the world at a moment of intense division and political discord in the United States and in other nations. At a time of interdependent global trade and economy, the pandemic has sharply disrupted the national and international status quo. And at a time of attacks on democratic institutions and the fundamental values embedded in the history of public health efforts, it has been used to challenge such conventions. This perhaps explains in part the vitriol and denial that are now associated with masks and lockdowns. Even if we expect pandemics to be deeply embedded in politics, as public health has been through the centuries, the politicization of this pandemic has been the result of the specific contexts in which it has occurred and the contingent decisions and leadership that have shaped responses from nation to nation.

Is mask refusal and resistance to public health regulations the same in 1918 and 2020? We cannot assume that similar behaviors mean precisely the same thing in these distinctive, historically specific contexts. Looking at the dynamics of mask skepticism and hostility in the COVID-19 pandemic, we can see that it reflects situated forces that distinguish it from the noncompliance of 1918. This form of public health nihilism is perhaps most clearly seen in the support for pursuing herd immunity—the argument for letting the pandemic take its course, with the weak caveat of “protecting the most vulnerable.” Masks are seen as an obstacle to this strategy.

Such nihilistic views of public health are familiar to historians who are well versed in the arguments and rationalizations that disease and disparities are but an aspect of natural selection and biological determinism.⁶ The historian’s responsibility is to draw attention to these specious and historically situated arguments and to demonstrate how they reflect the particular social, cultural, and political forces of their time. Such work has the potential to inform the present and deepen our understanding of the past.