Francesca Tomasi received her B.A. from the University of Chicago in Biological Sciences and currently studies tuberculosis metabolism and drug targets.
I read an article yesterday by Arthur Caplan, head of medical ethics at the New York University Langone Medical Center. His piece is called “How the Zika Virus Outbreak Foretold Donald Trump’s Win.” I have to admit I was skeptical when I first read the title, and I braced myself for a depiction of some far-fetched relationship between Republicans and mosquitoes. I thought I was about to read another straw-grasping piece aimed at justifying this year’s failure for most major election forecasters. I was wrong about the far-fetched correlations and grasping at straws, but I was correct about the latter point. Dr. Caplan does try to explain why the media – and society as a whole – failed both to forecast Donald Trump’s victory and understand the Zika virus. He does so in a thought-provoking and, in my opinion, unnervingly accurate way.
Two weeks ago, the World Health Organization declared that Zika virus is no longer a public health emergency of international concern. Dr. Caplan repeats this announcement, and goes on to say that most people simply read the headline and proceeded to breathe a sigh of relief with the end of a Zika-filled year, a lot like with Ebola in 2014. Re-tweet the headline, re-post the link, the end. “Well, that wasn’t as bad as I thought it was going to be, was it?”
Global health, a discipline as scientific as it is social, as basic as it is intricate, cannot even begin to be fully discussed with a 140-character limit (Twitter), a 10-second time limit (Snapchat), or even the approximate 20-minute attention span of the average adult (which is rapidly shrinking).
The significance of the WHO’s change in designation for the virus is not that Zika is over, or that we have it fully under control, or that all the travel advisories are going to go away just in time for the holidays. Zika no longer being a public health emergency signifies that it has become more than that: it is now endemic in multiple regions, and these areas need to direct their efforts against long-term effects of the virus. Preparation means money; and since, as Dr. Caplan explains, emergency money is about to run out, the WHO needs “to pivot to allocate funds from other sources.” Hence the status change.
Multiple news sites, including this Washington Post article, got it right. The media outlets that did not have to constrain their stories into ten-second bits supplemented their headlines with cautionary words like these: “But the change in designation does not represent a downgrading of Zika’s importance, officials said.” David Heymann, the head of the WHO emergency committee on Zika, said the change “represents an escalation into a major activity within WHO. If anything, it’s escalated in importance.” Just because the Washington Post or CNN had the space to explain this and the quotes to support it, however, does not mean everyone listened.
Dr. Caplan goes onto say that, of course, underreporting or under-reading are not the only reasons for lapses in understanding. They are, however, extremely important ones, especially when the right information is out there. “All in all,” he writes, both with Zika and the elections, people “didn’t get the whole story” because they only read tweets, or heard about them from other people. Messages were superficial and stories were incomplete. “Because human beings are prone to such selective attention, especially in today’s world of information overload…we see punchy, easy-to-understand language dominating thoughtful analysis of issues.” For this reason, Dr. Caplan argues for increased attention from readers, and increased commitment from news outlets.
This trend – of lagging attention and snaps of fragmented information – might be more pronounced now because of the rapid pace of today’s world, but it certainly is not unique to this decade. Paul Farmer made the same general argument nearly 18 years ago.
Infections and Inequalities is a book published in 1999 by the anthropologist-physician Paul Farmer. Dr. Farmer is a co-founder of Partners in Health, an organization whose mission is “to provide a preferential option for the poor in health care…[b]y establishing long-term relationships with sister organizations based in settings of poverty….to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.”
Simply put, Dr. Farmer’s overall thesis is that chronic infectious diseases – such as tuberculosis and HIV, which he discusses in-depth – are just as microbiologically-driven as they are propagated by social inequality. “Inequality itself constitutes our modern plague,” Dr. Farmer writes, and he has anecdotes and data to prove it.
Infectious and Inequalities asks and answers many questions, engaging readers in thought experiments that link local contexts and socioeconomic conditions with national crises. The content of his book is enough for many future articles, but one point he makes resonates with Dr. Caplan’s depiction of today’s headline skimmers. It comes with his revisit of the true meaning of “re-emerging” infectious diseases.
I have written about tuberculosis before. As a microbiologist, I study TB every day in my lab. In my own work, I have called it a re-emerging infectious disease because, once thought to be conquered with the discovery of antibiotics like rifampicin in the mid-twentieth century, Mycobacterium tuberculosis prevalence is increasing once more today, and so is its resistance to common first- and second-line drugs. The social stigma clouding tuberculosis across the world also has a clear effect on disease dynamics. I should have ended my pieces with “...in America.”
In his book, Dr. Farmer says that tuberculosis is not re-emerging at all. Instead, he argues that the notion of “re-emerging” is more often about perspective – or more specifically, a lack thereof. He writes, “From our clinic in central Haiti, it is impossible not to regard the notion of ‘tuberculosis resurgence’ as something out of a cruel joke – or yet another reminder of the invisibility of the poor.” While TB may have lurked in the shadows through the turn of the century in America and other developed parts of the world, TB persisted in impoverished countries like Haiti. There was no “re-emergence” of TB in Haiti when we saw a rise in cases in the US last year; there was just the same endemic TB that had gone unnoticed for decades.
Dr. Farmer explains that tuberculosis’s invisibility the last several decades requires an examination of “disease awareness – that is, of consciousness and publicity.” Tuberculosis was not in the headlines for the latter half of the twentieth century because the places writing headlines were unaffected. Complacency with TB therefore washed over the majority of the developed world, since it was never in the news. It was assumed conquered. “In short the ‘forgotten plague’ was forgotten in large part because it ceased to bother the wealthy.”
Now, awareness of tuberculosis is on the rise thanks to public service announcements, an increase in international coverage and public health outlets, and of course the fact that drug-resistant TB is starting to affect some developed countries again. “The story,” Dr. Farmer continues, “ends up as ‘Tuberculosis is Back’ rather than, more appropriately, Tuberculosis is Back in the News.’” While Dr. Caplan faults readers in his article for their cursory skim over titles to form inaccurate conclusions, Dr. Farmer instead puts responsibility on the sources themselves. “We live in the world where infections pass easily across borders – social and geographic – while resources, including cumulative scientific knowledge, are blocked at customs.”
Put together, today’s headline readers and yesterday’s headline ignorers are responsible for the same thing: stagnant situations. In the case of tuberculosis, what do we get when we only have semi-permeable borders of information instead of fully permeable ones? “Two things at once,” Dr. Farmer writes. “A completely curable disease and the leading cause of young adult deaths in much of the world.” In the case of Zika, we get the misconception that it is no longer a big deal.
Reading the headline “Zika is No Longer a Public Health Emergency” without understanding that it’s because Zika is now here to stay as a long-term issue, is instilling complacency in skimmers about the actual state of the virus. Likewise, not producing headlines like “Tuberculosis is Still Disproportionately Killing Haitians” instills complacency in the actual state of this pathogen and, more broadly, of marginalized populations. This lack of communication is unfair and, as Dr. Farmer says, unethical, because we are “leaving a vast ‘control group’ of unfortunates to exhibit the natural history of untreated disease.”
We need to resume making time to read full stories instead of just fitting headlines between sips of coffee. We also need to start finding headlines where nobody else is looking. We then need to write these stories, and read them, and discuss them, and engage in ways to fix them. And that is my goal moving forward with Infective Perspective: to tell the stories no one else will, and to encourage readers to contribute and do the same.
I’m going to end with one of my favorite quotes from Infections and Inequalities, and one that I have communicated many times – though perhaps less eloquently – on Infective Perspective. “Microbes, and their vectors, recognize none of the artificial boundaries erected by human beings. Theirs is the world of natural limitations: temperature, pH, ultraviolet light, the presence of vulnerable hosts, and mobile vectors.” A pathogen in one pocket of the globe can make its way to any other in a matter of hours or days, and this is a natural result of today’s massively inter-connected world. While people argue this is a problem for public health, such as with the spread of SARS in 2002, our interconnected world really just makes it no longer excusable to block the flow of medical and public health information. Thus, if a germ does cross national borders, whatever country it ends up in ought to have access to the proper tools and knowledge to curb a real problem, and without sparking an emotional roller coaster in the media.