Public Health
In 1923, barely five years after the end of the World War I and the great influenza pandemic that killed at least 50 million people worldwide, the British author H. G. Wells published a science fiction novel titled Men Like Gods. It opens with the protagonist, a journalist named Barnstaple, near mental collapse after many sleepless nights, brought on by the news that “seven eighths of the world seemed to be sinking down towards chronic disorder and social dissolution.” Ordered by his doctor to take a therapeutic holiday, Barnstaple suffers a mysterious accident that transports him, along with a mismatched group of fellow Britons, to a “sister universe” similar to Earth 3,000 years in the future. There, people—Utopians, as Wells calls them—live in an idyllic existence. After a prolonged period of war, famine, and disease known as the “Last Age of Confusion,” they embraced a scientifically informed way of life that enabled them to eliminate deadly diseases. “By isolation, by the control of carriers, and so forth, the fatal germs had been cornered and obliged to die out,” they explain to their new visitors. When the germy earthlings bring about a miniepidemic, the Utopians quickly bring it under control, and send Barnstaple back to Earth to share their wisdom.
Reading Wells’s tale a century and one pandemic later prompts the question, are we in a Last Age of Confusion? We are certainly experiencing a scale of disruption productive of the sleepless nights and “nervous exhaustion” that Wells described. COVID-19 has exposed problems that twenty-first century earthlings have tried to ignore: climate change, economic and ecological transformations that have escalated both famine and novel emergent diseases, and deepening inequalities that ensure that those changes fall hardest on the most vulnerable. Worst of all, many people have lost faith that scientific discovery and technological innovation can easily redress those problems.
In our present moment, Wells’s optimism seems farfetched. Even he admitted the folly of imagining “men like gods,” confessing later that he “tired of talking in playful parables to a world engaged in destroying itself.” Although Wells’s vision of Utopia was science fiction, his premise of a period of great disruption followed by productive change was not completely farfetched. Born in 1866, Wells lived through a period of rapid urbanization and industrialization that produced great societal disruptions, including rising rates of communicable diseases; Wells himself suffered from tuberculosis, the leading cause of death in the late 1800s. But over the course of his lifetime, a public health revolution dramatically reduced overall rates of illness and death from infectious diseases—with nary an antimicrobial drug and only a handful of vaccines.
The public health achievements of Wells’s era reflected the power of prevention. New “germ theories” of disease, combined with expanding governmental and engineering capacities, inspired massive investments in physical infrastructure (water and sewer systems), state sponsored public health interventions (registration of disease, mass vaccination), and popular health education (including campaigns against spitting on sidewalks). Entrepreneurs and educators used the fear of the disease germ to promote a vast remodeling of domestic spaces—out with the dusty, germy plush of Victoriana, in with the clean look of modernism, which had the addition benefit of being easy to keep clean. And along with this came a new focus on personal hygiene—the antiseptic cleansing of the body and careful disposal of its germy secretions. This massive reengineering of everyday life started in the big cities of the West and spread outward, via the networks of global trade and colonialism, to the rest of the world.
These developments inspired Wells over his long career as a science educator and novel writer. Among his many scientific interests, the “man versus microbe” story line clearly intrigued him. In an 1895 short story, “The Stolen Bacillus,” he imagined an anarchist stealing a vial of cholera to try to start an epidemic (fortunately without success). Soon after, he wrote his famous novel War of the Worlds, in which a terrifying lot of Martian invaders are finally defeated by their lack of immunity to Earth’s microbes. Two decades later, in Men Like Gods, he flipped that scenario, contrasting germy earthlings with their superior future selves, the Utopians, who have banished infectious diseases by eliminating their vectors (insects, rats), improving their diet, and embracing cleanliness.
What of Wells’s fantasizing and the historical experience it reflected might be useful in our own time of “Great Confusion”? We need to start by appreciating the many flaws in Wells’s thinking: his flirtation with eugenics, his disdain for “the dusky skinned,” his faith in technocratic elites. The turn-of-the-century public health movement embodied the same weaknesses. Change was uneven and often unjust; global citizens who were poor, not white, and lived in the wrong neighborhood remained (and remain) at much higher risk of dying from infectious diseases. This is not a “golden age of the past” to be held up for uncritical emulation.
That said, there are still aspects of the public health dynamics of Wells’s day that are worth emulating. In the mid-1800s, the sciences had not yet specialized and professionalized, and their new understanding of infectious diseases reflected the intersection of three different trends: clinical and pathological investigations into the signs and symptoms of specific infectious diseases, experimental methods that linked specific ailments to specific microbial pathogens, and “shoe leather” epidemiology that tracked infectious agents’ distribution in time and space. This knowledge came together in a public health science that promoted disease prevention first, through attention to broad environmental factors, such as water supply and sewage disposal, and then by reform of household and individual practices of hygiene. Building on older commonsense beliefs that dirt was bad and that sick people carried substances that could make other people ill, they made an argument for collective action against an all-pervasive “germ menace.”
That argument addressed a pressing problem that a broad swath of politicians, businesspeople, and citizens wanted to solve, namely the epidemic dangers associated with rapidly growing cities and the global trade routes that linked them. Because communicable diseases were the leading causes of death, people had an intense interest in avoiding them. By promising protection from diseases that easily spread across class and color lines, public health leaders were able to promote massive infrastructure investments and sweeping behavioral changes as measures for the general good. They convincingly equated controlling disease with strengthening both the economy and national security.
Those lines of argument grew more difficult to make after World War I. Ironically, the public health movement’s success in bringing down rates of infectious disease helped justify narrowing its scope. As infectious diseases became more associated with the poor, public health departments turned to targeted strategies such as contact tracing and surveillance in place of structural reforms. And as more vaccines and antibacterial drugs became available, medicine replaced public health as the response to infectious diseases. With the 1970s turn toward market-driven, privatized models of health care, the “public” in public health became a “population-based” perspective with little direct connection to communities or individuals.
These long-term trends have contributed to our current state of biological vulnerability. The public health infrastructure built a century ago desperately needs rebuilding, but no one wants to assume the cost of its repair. With health care dollars invested primarily in treating rather than preventing diseases, decades of overuse and misuse of antibiotics have produced resistant strains of dangerous bacteria while we have become overly dependent on vaccines to save us from the threat of emergent viral diseases. Meanwhile, climate change, ecological disruption, and global inequality increase the risk from reemerging and emergent infectious diseases such as COVID-19.
If we continue down our current path of market-based, individualized solutions to these risks, the pandemic will likely yield a flurry of uncoordinated responses to the Great Confusion that privilege greater reliance on electronic media, artificial intelligence, and gated communities. In this scenario, employers fire workers and retool for greater use of robots and low-paid workers working from their homes. Architects and engineers rethink the built environment to make it more pandemic resistant—but only a privileged few can afford to use their innovations. Those few escape into their COVID-free bubbles while everyone else is subject to disruptions that they must struggle to evade. The fact that some people fare well and others do not is attributed either to their genomes or their individual choices about education, career, and neighborhood in an updated form of Gilded Age Social Darwinism.
How do we find a better path forward? Wells’s science fiction is not much help; in Men Like Gods, he simply had the Utopians realize the error of their ways and work miracles in their society. In real life, he championed a more workable option, which he dubbed the Open Conspiracy: an alliance of experts and reformers committed to using scientific knowledge to foment “a world revolution aiming at universal peace, welfare and happy activity.” Perhaps 20 years from now, we will look back on this pandemic moment to see it as the starting point for a grand revisioning of global public health that takes seriously the threat of climate change, ecological disruption, and resource inequality. Shorn of its limiting prejudices, the late-nineteenth-century public health movement provides a model for that integration. In their insistence on investing in the common good as essential both to sustainable growth and national security, H.G. Wells and his generation had a vision that we would do well to emulate.