In 1992, there was a silent epidemic running through New York City jails. A drug resistant strain of tuberculosis proliferated throughout the damp cells, leading Morris E. Lasker, federal judge for the Southern District of New York, to decree a state of emergency on January 24. In his order, he demanded that the New York City Department of Corrections create forty-two isolation beds for the highly contagious inmates with tuberculosis. He was prompted by the death of thirteen New York City inmates from TB over the course of the previous year, all of whom were HIV positive. Investigators and medical practitioners found that immunosuppressed prisoners who were HIV positive were especially vulnerable to tuberculosis, pneumonia, and other communicable diseases.
The outbreak was happening at the height of the HIV epidemic, years before the first antiretroviral drug for HIV became widely available to people with the virus. As is the case today, the prisoners at Rikers Island were disproportionately black and brown, and they were made to be susceptible to tuberculosis in part by poor ventilation in the prisons, which allowed bacteria to spread easily through the air. For many people awaiting the end of their sentence, isolation and proper ventilation could have prevented them from being infected.
The late intellectual Susan Sontag wrote in Illness as Metaphor that “all evidence indicates that the cult of TB was not simply an invention of romantic poets and opera librettists but a widespread attitude, and that the person dying (young) of TB really was perceived as a romantic personality.” In the current phase of our new global pandemic, where Covid-19 has led people and governments to adopt strict social distancing measures to prevent spread, illness is much more than a metaphor. While Sontag deftly delineated the social and psychological contours of disease in her 1978 work, her gloss on the “romantic” nature of tuberculosis was myopic. In particular, it obscured the uneven reality of people of color and those living the global south who might find themselves dying unnoticed from an epidemic long after tuberculosis’s romantic sheen had worn off.
For many people awaiting the end of their sentence, isolation and proper ventilation could have prevented them from being infected.
For the mostly black and brown prisoners in the New York City jails in the early 1990s, the tuberculosis epidemic was so pernicious because there was, at first, little will to do anything about it. This was long before the publication of Michelle Alexander’s The New Jim Crow; most Americans did not yet see a relationship between slavery and the criminal injustice system, and the incidents of drug-resistant tuberculosis in New York State jails in the early 1990s did not warrant a call to action from most of society. As a result of this lack of action, during the eighteen months of this tuberculosis outbreak in New York state, at least twenty-seven prisoners and one prison guard died.
The symptoms for respiratory illnesses can be mild, or they can trigger a range of inhalation ailments—shortness of breath, wheezing, a sense that your lungs will collapse. Like coronavirus, one way to stop the spread of tuberculosis is to isolate the ill. But in 1992, the United States had one of the highest known incarceration rate in the world. If tuberculosis had still been a disease that impacted the upper class and non-incarcerated, politicians might have found the will to speedily subside this epidemic. Instead, New York was willing to jeopardize the health of incarcerated people. The same is true today as Covid-19 ravages inmates at Rikers Island. While prison abolitionists called for the release of vulnerable incarcerated people, rightly fearing that Rikers and other jails would be swept by a wildfire of coronavirus infections, the number of those freed lags far behind official promises.
The tuberculosis epidemic of 1992 is one of many episodes in which a disease became more virulent and deadly over time. What made drug-resistant tuberculosis so dangerous was in part its combination with other diseases like HIV/AIDS and Hepatitis C. But during this period, tuberculosis also spread to other parts of the world, finding a home in impoverished spaces that struggled to tame the outbreaks. Tuberculosis today remains a top ten global leading cause of death and, according to the World Health Organization, over 25 percent of tuberculosis deaths now occur on the African continent. Respiratory diseases like tuberculosis are exacerbated by existing global inequalities—prisons cells and shantytowns incubate them.
Even when the world is aware of these inequalities, how we react is a product of the empathy we extend to the sick and dying: those who look like us, and those who do not. For the poor and disenfranchised, the experience of living through epidemics shows how microbial contagions mutate with a society’s pre-existing prejudices.
How do we make sense of the ways that the fear of epidemics spread? History might summon an answer. As Walter Benjamin remarked in The Arcades Project, “At any given time, the living see themselves in the midday of history. They are obliged to prepare a banquet for the past. The historian is the herald who invites the dead to the table.” As we venture into the not so recent past to excavate how the different shades of contagion reproduce the conditions that make viral and bacterial transmission possible, it is important to reckon frankly with mass death and learn to exercise compassion and forestall racism when fighting a disease.
Often, fear starts with a name. During the nineteenth century, various cholera epidemics broke out in metropolitan areas including New York City, London, Alexandria, and Shanghai. The outbreaks were partly spread through contaminated water, and they proliferated through interregional trade. European imperialism and global capitalism were on the rise, and cholera traveled on the merchant ships from the Atlantic Ocean, Mediterranean Sea, and Indian Ocean. Despite the epidemic ravaging Europe and North America, the first pandemic of 1817–21 was referred to “Asiatic” cholera, as Mark Harrison notes in his article “A Dreadful Scourge.” The ebbs and flow of the disease had more to do with the spread of the bacteria Vibrio cholerae in water sources than the continent of Asia. Yet the name entered into polite European circles.
Later, between 1918 and 1919, fifty to one hundred million people died of a new type of influenza—some reportedly within hours of contracting the illness, others within days. The pandemic had drastic commercial and political consequences: it forced many businesses to shut down, garbage collection to be postponed, and farm workers to postpone harvesting their crops. Some of the sick were bedridden, and their loved ones took care of them rather than working; the economy experienced a temporary shock. Even though the disease was brought to Spain, it eventually became known as the “Spanish” flu because the Iberian country, as Laura Spinney reported for the Guardian, was not censoring its health reports, making the death tolls seem disproportionately high.
While the history of scientific racism is mired in pseudoscience, anthropologists of the era such as William Z. Ripley constructed hierarchies of “whiteness,” arguing in the 1899 work The Races of Europe that northern European features such as blond hair represented the upper echelon of humanity, while southern Europeans with darker features such as the Spanish were on the lower rung of whiteness. Linking the flu to the Spanish in the early twentieth century, within a context where notions of race within Europe could be used to demonize a southern European country, was no coincidence. Both the 1918 flu outbreak and the cholera epidemics of the nineteenth century demonstrate that people who were not explicitly responsible for the emergence or spread of a new disease can be linked permanently to the ailment in ways that can ultimately affect the public health response.
The racialization of epidemics continues to result in very disparate outcomes. The 1990s tuberculosis outbreak in New York City jails is just one example of how racism can obstruct speedy response to an epidemic. In that case, reticence led to something bigger: drug-resistant tuberculosis mutated into a more virulent disease that was later articulated in the Global South, expressing itself in post-independent countries that had been impoverished by former European colonial powers. A striking example of how former colonial powers continue to infect their one-time colonies can be found on the African continent today: the first confirmed case of Covid-19 in the Democratic Republic of Congo was from a Belgian citizen. The imprint of Belgian’s colonialism in the Congo continues to cripple the country’s health care system, which will now have to handle the pandemic in the shadow of an Ebola outbreak and a current measles eruption. Rather than receive international aid without strings, the World Bank is offering a $47 million loan to the DRC to combat Covid-19.
The tuberculosis, cholera, the 1918 flu, and now Covid-19 all teach us that the people whose health is deemed less important are often the same people who will be most devastated by the economic effects of a pandemic. The response to Covid-19 has changed significantly from January, when the outbreak was largely confined to East Asia, to the more immediate context, when the virus has devastated communities in Italy, Spain, the United Kingdom, and the United States. The global response has also come with anxiety about the global economy: the sense that labor, trade, and travel will never look the same.
As epidemiological research continues to try to better understand Covid-19, scientists have reported that the disease is asymptomatic for many and harrowing for others. The symptoms can be more horrific for the elderly, men, and smokers; in other cases, people with obesity and autoimmune conditions have also been found to be more vulnerable. The vast difference in health outcomes across global populations reflects this slippery nature of the disease but also the uneven quality of care. Altogether, it is what’s likely to make this crisis so prolonged, doing disproportionate harm to communities of color.
The people whose health is deemed less important are often the same people who will be most devastated by the economic effects of a pandemic.
For many black people in the United States, the fear of being infected by Covid-19 coincides with the grim reality of being more likely to die from it. From midwestern cities like Detroit and Milwaukee to semi-rural communities in Alabama and Louisiana, black Americans are dying at a disproportionate rate from the novel coronavirus. One recent study found that in Chicago, where 30 percent of the population is African American, black people accounted for 70 percent of all coronavirus deaths. These chilling statistics are a product of an unequal society in which black Americans are less likely to have health insurance, more likely to live in health care deserts, and more likely to work outside the home as essential staff in health care, grocery stores, and transportation. All in all, black Americans are living in a social and medical apartheid.
The same is true for people living in the global south more broadly, where acting late might cost millions of lives. One place where the coronavirus could have a drastic outcome is on the African continent, where a surge in cases in South Africa has led to a twenty-one-day countrywide lockdown. But the social distancing encouraged by most countries around the world is not possible for everyone. As Karsten Noko reported in Al Jazeera, social distancing is a privilege in many African countries.
If public health measures are to be an effective weapon against the current pandemic, it will mean upending the system that has caused these drastic inequalities. We should exercise insightful research that considers how all populations are impacted by epidemics by not only exercising empathy for those who are disenfranchised. Public health measures applied universally to a non-universal, unequal world, these measures will not work unless that world is radically rearranged.