I might have mistaken my intensified attention to the wind for intensifying wind.
Ben Lerner, 10:04
In late August 2011, on the eve of the tenth anniversary of 9/11, Hurricane Irene tore northwards up the Atlantic, its projected path fixed over the U.S. East Coast. So great was the force of the tropical storm’s anticipation that flood-prone and low-lying metropolitan areas from Virginia Beach to Providence were preemptively evacuated. New York City mayor Michael Bloomberg, in what would later be dismissed by some as an overblown display of preparedness, closed the New York City transit system, shut off water and electricity in lower Manhattan, and preemptively deployed the National Guard.
It is under Irene’s kinetic spell that we find the protagonist of Ben Lerner’s novel, 10:04, stocking up on provisions alongside other New Yorkers enrapt by the imagination of her landfall. Crowds effervescing sociality, groceries radiating an aura of scarcity—the city seems to rearrange itself around the storm’s approach: “what normally felt like the only possible world became one among many, its meaning everywhere up for grabs” (19).
It is the strange serendipity of maternity leave that finds me reading 10:04 and The Pandemic Perhaps at odd hours and in tandem; two books for which hurricanes—or, more specifically, the preparations they precipitate—relay the condensed temporality of the coming catastrophe, a dovetailing of past perils and precarious futures for which a New York City ‘on the brink’ provides a hyperactive backdrop. Through often-exquisite prose (Lerner is a poet; Caduff’s formulations can approximate verse) these authors explore the worlds that surface and dissolve under the shadow of prediction and the modes of attention that give them their shape. This late-night imagined conversation turned on the performative power of engrossment—a topic that spoke to my state of attenuated awareness, and offered an unexpected entry point to the nexus of issues elaborated by The Pandemic Perhaps.
Global Health Attention
Global Health attention is intense, but fickle. An awkward compromise of economic interests and geopolitics, moral and epidemiological logics, global health ‘emergencies’, as Caduff shows, crystalize around distinct and often countervailing values. There are emerging threats and persistent plagues; examples of gross negligence and near-triumph; devastating illness that demand large-scale investment and mundane suffering that could be redressed with the application of minimal resources. But whether it is HIV, Guinea Worm or obesity, the ways in which a public health issue becomes a global concern depends on how its present danger is drawn to our collective future. Following Caduff’s deft descriptions of influenza’s configuration as an object of research and policy—its multi-faceted political-materiality—I will offer some brief reflections on how that connection is drawn in other corners of the ever-shifting global health landscape.
Attention to what?
Given the precarious constitution of the category and the difficulty of defining pandemic influenza, what are the prophets of pandemic influenza actually predicting? (Caduff, 98)
Influenza, The Pandemic Perhaps teaches us, is a quintessential moving target. Constantly mutating and recombining, the flu’s identity is a statistical compromise of emerging strains and classic pathologies, a rapprochement of laboratory practice and clinical experience. The very concept of pandemic flu revolves around degrees of genetic difference, and the ensuing transmissibility across populations with no acquired immunity. This future orientation of pandemic flu, its potential to spread and spread widely, provides the ground for large-scale global health intervention—an epidemiological perhaps that governments cannot afford to ignore.
Malaria shares influenza’s ontological slipperiness: whether the disease is understood as primarily a problem of the parasite or the vector, of the clinic, the home or the field, has a considerable impact on how it comes to matter for global health. The Global Malaria Eradication Program (GMEP), launched in the mid-1950s, was built upon a mathematical model of transmission that foregrounded the interaction between vector and human population—a precarious stabilization that, with the advent of DDT, nevertheless promised massive and rapid global health dividends. Linked to the abundance and longevity of mosquitoes and to the chemical agency of residual insecticides, malaria became an object of technocratic intervention: with sheer manpower and manufacturing efficiency transmission could be irreversibly interrupted within a matter of years. In this way malaria-control became a global event, a contest between an emerging public health internationalism and the mosquito’s adaptive resistance.
The collapse of the GMEP has been etched in the annals of environmentalism and global health policy as a parable of American hubris and of the limitations of vertical interventions. In the last decade, however, those failures have been recast (Kelly and Beisel 2011). Malaria’s persistence, we are told, was the product of the program’s lack of follow-through rather than its overreaching ambition—a tragedy of untimely abandonment that has served as the rallying cry for the Bill and Melinda Gates Foundation.
A new eradication campaign, a new malaria: this time defined by the parasite. Doubling-down on the “high risk-high reward” strategy espoused by GMEP, the effort to remove the parasites from the human population has precipitated a new arsenal of experimental vaccines and novel drug regimens. Launched in 2013, the Foundation’s “Accelerate to zero” strategy reprises the race against resistance, but this time its end game is not the interruption of transmission but it’s preemption, assured through an ever-intensifying hail of magic chemical bullets (McGoey 2015).
Once the instrument for the West ‘to win hearts and minds’ in the war against Communism, malaria has returned to the limelight as an engine for biomedical innovation. Its eradication is no longer driven by ideological commitment—the disease owes its salience to the R&D opportunities it presents.
Once the virus was detected in the bodies of soldiers at Fort Dix, the outbreak was considered a significant sign, announcing the event, and the fulfillment of a prophecy. (Caduff, 71)
The swine-flu strain isolated from recruits at Fort Dix in 1976 triggered memories of overwhelmed army infirmaries, a materialization of the past that had haunted global health since the First World War. But this time the public health community had the tools to head off the pandemic before it started; the outbreak therefore presented a “splendid opportunity to prove the power of preventative medicine” (Caduff: 63). With ambition characteristic of the nation that spear-headed GMEP, the 1976 National Influenza Immunization Program (NIIP) sought to vaccinate the entire U.S. population by the end of the year, reaching over 40 million Americans in 10 weeks. That the outbreak originated in an army base Caduff finds apposite—the program was, in the rhetoric of the time, “a declaration of War”.
The rally, however, quickly became a rout—the campaign was, ultimately, sabotaged by its own weapons. The strain’s similarity to the one that swept the globe in 1918 had been overdrawn. Eventually only one death would be attributed to it. The vaccine became a greater source of suffering: by the time NIIP was shutdown, 500 recipients had suffered serious side effects and twenty-five died.
1976 was an eventful year for Global Health, albeit only in retrospect. A few months after the virus was identified at Fort Dix, a storekeeper fell ill in Sudan, suffering from a disease that after a second outbreak in DR Congo (then Zaire) would come to be known as Ebola. A disease of terrifying but ultimately self-limiting virulence, for decades it was solely the province of remote sub-Saharan villages and apocalyptic fantasy (Lynteris 2016). Classified as a potential bioterrorist agent, Ebola took center stage in a new regime of scenario-based exercises and emergency simulations, surveillance systems and intensive R&D investment intensified in the aftermath of 9/11 (Lakoff and Collier 2008; Keck 2014).
That the 2014 Ebola outbreak was partly the product of an emphasis on preparedness at the expense of investments in basic clinical infrastructure is an irony that does not escape Caduff (see also Lachenal 2014; Nugyen 2014). More telling is that Ebola became a global health problem—or formally, a ‘public health emergency of international concern’ (PHEIC)—neither at the point of its detection nor even when it had devastated communities across the Mano River Region. Rather, it crystalized into a global health emergency after an infected Liberian collapsed upon arrival at an airport in Lagos, threatening the apocalyptic scenario of a gigantic, ungovernable metropolis in the grip of a lethal virus. At this moment, the outbreak shifted from a humanitarian crisis to international security threat, best contained by checkpoints and border controls and, critically, by accumulating vaccine stockpiles.
This is where Caduff’s reading of the response to flu at Fort Dix is most instructive. The NIIP, he argues, was propelled by two opposing figures: the virus, a “living fossil” of a past catastrophe, and the novel vaccine, a harbinger of hope. For previous outbreaks there had not been enough time from initial detection to manufacture a viable vaccine on a large scale. The early isolation of the strain in Fort Dix made population-wide immunization a possibility, but only with considerable political and financial capital. In hindsight, nation-wide immunization was perhaps a reckless gamble—the WHO, for instance, shifted to a ‘wait and see’ policy, monitoring emerging infections—but in the U.S., where the battle between virus and was closer to home, the moral imperative to vaccinate “every man woman and child” quickly became a feature of its own momentum.
The recent Ebola outbreak has also been configured as a scientific opportunity, though the moral logics of experimental exigency have been decidedly more complex. Unlike the 1976 strain of swine flu, the transmissibility of this pathogen was, if anything, underestimated. By the time the pharmaceutical companies entered the scene, policy discussions were not characterized by bold decisions but by desperate measures. “We wasted time before speaking about a vaccine and treatments” lamented Jean-Hervé Bradol, the director of Médecins Sans Frontières’ (MSF; Doctors Without Borders) internal review body, back when the outbreak was at its peak: “it’s very hard to imagine controlling this epidemic now without a vaccine” (Flynn and Bartunek 2014).
Urgency, again, provided the syntax for policy decisions: within a matter of months, consortiums of international experts, government and industry representatives were assembled, charitable funding was released, clinical trials designed, regulatory requirements streamlined and indemnity funds set aside by the World Bank. But a large-scale immunization program resonates rather differently in contemporary sub-Saharan Africa than it had in Gerald Ford’s America, buoyed by the resounding success of the campaign against polio. A long and sinister history of unethical experimentation and medical iatrogenesis, from forced sterilizations to pharmaceutical negligence, has generated popular suspicions of vaccine as vehicles for western imperialism (e.g. Giles-Vernick & Webb 2013; Fairhead and Leach 2012).
That legacy cast its shadow over high-level meetings at the World Health Organization regarding design of vaccine trials, where West Africans were, at once, cast as needy patients denied compassionate access and as guinea pigs exposed to unnecessary risks. Either way, the belatedness of the global health response meant that the experimental delivery of the vaccine could only be justified by the protection it would bring to future populations. As the WHO summarized in its report of the meeting that “all efforts to develop, test, and approve vaccines must be followed through to completion at the current accelerated pace even if transmission dynamics meant that a vaccine was no longer needed…as a contribution to global health security, fully licensed and approved vaccines should be stockpiled in readiness for the next Ebola outbreak” (WHO 2014).
Caduff reads the NIIP as the moment when the future took precedence over the present: “American experts,” he writes, “took rapid action, leaped over the present, and rushed forward to the conclusion” (65). The haste triggered by the Ebola outbreak carries an even heavier moral freight: the experimental deployment of untested vaccines was compelled by the scale and severity of the outbreak; a present that, owing to the belatedness of the response, was of global health’s own making. While efforts to enhance country capacity—setting up community care centres, distributing home biosafety kits and training health workers—might help slow transmission only the vaccine trials offered a way to make up for lost time, to halt the current outbreak while, at the same time, refashioning response time oriented towards the inevitability of future outbreaks (Kelly 2015).
As the epidemic now submerges into endemicity, the apocalyptic outbreak is again deferred, while for those populations in its immediate reach Ebola becomes an everyday reality. Transformed from extreme event to, as Caduff puts it, “an ordinary harm”, it is unclear what kind of sustained global health attention the virus will receive, other than as an object of research and continued experimentation.
Time to Take Note
To what extent is the notion of a ‘new regime’ of ‘public health vigilance’ itself a force in the making of structure and order?…t o what extent such a form of analysis is making it easier for projects of “public health vigilance” to impose themselves on populations in the global South. (Caduff, 195)
In an extended footnote to the introduction, Caduff suggests how The Pandemic Perhaps departs from dominant critiques of biosecurity. To describe the “prophetic scene of influenza” demands an ethnographic attention that goes beyond the geopolitical consequences of a thoroughgoing securitization of health. The dialectics of faith and reason that Caduff locates at the heart of global health expertise turn upon the failures of pandemic prediction and the structures of expectation, interest and investment the non-catastrophe precipitates. Thus rather than marveling at the extension of preparedness policies, our analyses would be better served plotting the points at which the problems that do the most damage and those these initiatives anticipate diverge.
Zika is now in the global health spotlight, and there is much here to catch our anthropological attention: the tragic spectacle of microcephaly, the uncertainty of state-collected health statistics, the rapid dissemination of conspiracy theories. Could there be a more invasive biopolitics than a policy dissuading pregnancy? If even Pope Francis comes close to condoning the use of contraception, has global health reason overtaken the sovereign doctrines of faith?
As the shadow of Zika moves across the Americas, the responses it will elicit will inevitably vary according to the ways in which global health problems have been historically brought to light, particularly when it comes to vector borne diseases (e.g. Lees-Stephan 1997; Nading 2014). To indicate their readiness for the coming outbreak in the US, decision-makers there have returned to a familiar figure: “The way I think about it, it’s just like a hurricane,” said Florida Governor Rick Scott, “get prepared, hope for the best. So what we’re doing is we are preparing and we’re doing everything we can to make sure this does not get worse.” Whether the winds will intensify or dissipate remain to be seen, but in either case, it will not be the last time our attention is directed towards the coming viral storm.
Giles-Vernick, T., and J. LA Webb Jr, eds. 2013. Global health in Africa: historical perspectives on disease control. Ohio University Press.
Fairhead, J., and M. Leach. 2012 Vaccine Anxieties:” Global Science, Child Health and Society”. Taylor & Francis.
Flynn, D., and R.-J. Bartunek. 2014. “Exclusive: MSF Should Have Called for Ebola Vaccine Earlier, Says Aid Group Veteran.” Reuters, Nov. 14.
Keck, F. 2014. Birds as sentinels for pandemic influenza. BioSocieties 9 (2): 223-225.
Kelly, A.H. 2015. Ebola, Running ahead, LIMN. http://limn.it/ebola-running-ahead/
Kelly, A.H., & U. Beisel. 2012. Neglected malarias: The frontlines and back alleys of global health. BioSocieties, 4:71-87.
Lakoff, A., and S. J. Collier. 2008. Biosecurity interventions: global health & security in question. Columbia University Press.
Lynteris, C. 2016. “The Epidemiologist as Culture Hero: Visualizing Humanity in the Age of ‘the Next Pandemic’”. Visual Anthropology, 29(1), pp.36-53.
McGoey, L. 2015. No Such Thing as a Free Gift: The Gates Foundation and the Price of Philanthropy. Verso Books.
Nading, A. M. 2014. Mosquito trails: ecology, health, and the politics of entanglement. University of California Press..
Packard, R. M. 2007. The making of a tropical disease: a short history of malaria. Johns Hopkins University Press.
Stepan, N. L. 2001. Picturing tropical nature. Cornell University Press.
World Health Organization (WHO). 2014. “WHO High-level Meeting on Ebola Vaccines Access and Financing.” Summary Report, October 23.
Ann H. Kelly is Senior Lecturer of Global Health in the Dept. of Social Science, Health and Medicine, at King’s College, London. Her work focuses on the practices of global health research and experimentation, with special attention to the built environment, material artifacts, and practical labors of tropical disease control in sub-Saharan Africa.