21st-Century Miasmas

Much of what we used to do without a second thought—pressing an elevator button, reaching for a doorknob—now feels stressful and potentially dangerous. There are so many unknowns about this virus. We lack crucial information about how it can be transmitted, how long it lingers in the air, when we are most contagious to others. We don’t know if those who have recovered from COVID-19 are immune to the disease, and for how long. The most direct mode of transmission is to breathe in droplets or exhalations from someone who is infected, or to touch something that the person has sneezed or coughed on and then to touch one’s eyes, nose or mouth. The likelihood of transmission through handling unwashed produce or a mail delivery is low, we’re told, but scientists, with their scrupulous adherence to methodology, cannot rule it out completely.

In New York City, where the virus surrounds us and has likely been circulating for several months, even going outside feels fraught. The sidewalks are never completely unoccupied. When I walk around my neighborhood, I scan the area in front of me to see who’s unmasked, who might be coughing, who is violating social distancing rules. I hold my breath when people pass by too closely.

As the weather improves, the parks have become increasingly thronged with people seeking relief from cramped apartments. Running outdoors is one of the few forms of recreation that’s still permitted, but some experts recommend keeping a berth of 10 or even 20 feet from others. That amount of distancing is nearly impossible here. Are we at risk if someone in front of us sneezes or coughs and we then run through a cloud of their exhalations? How do we factor in wind speed and direction, sunshine, levels of humidity?

Thus the air itself has become potentially hazardous, a reservoir of omnipresent, undetectable contagion. I’m reminded of miasmas, the foul-smelling clouds emanating from livestock and decaying filth that were once thought to be sources of disease. Before the widespread acceptance of germ theory in the late nineteenth century, physicians and laypeople alike believed that illnesses such as cholera, typhoid, yellow fever, and bubonic plague had atmospheric origins. The miasma theory of disease explained why poor urban areas so often experienced outbreaks and epidemics, where deficient sanitation, dilapidated housing, and streets filled with rotting organic matter created disease-causing vapors that hung over such neighborhoods in a haze.

For all the advancements we’ve made over the past decades in understanding infectious disease, the coronavirus, in its newness, is upending our one-way narrative of progress. We may no longer give scientific weight to miasmas, but at times I feel as though I’m living in nineteenth-century New York, wary of the contamination that might be hidden in the air around me. A vaccine against the virus could be 12-18 months away or more, so in the absence of any effective remedy we have been reduced to the most basic method of control: avoidance.

Confinement, Day 18

A few days ago I was awakened by the sound of an airplane overhead, something I haven’t heard in weeks. My apartment lies on a direct flight path to JFK and the roar of jet engines is usually constant, especially during the warmer months when I sleep with my windows open. Apparently there are still some commercial flights operating, and airlines need to fly their aircraft to reposition them, as well. But recently I’ve heard only sirens from the ambulances outside my building, as well as the incessant calls of birds that have grown more emboldened in their chirping now that the urban racket around them has diminished. The noise from the plane reminded me of one of the many aspects of our former lives that have been altered in our bizarre new reality.

New York State now has more confirmed cases of coronavirus than any other country in the world, including Italy and Spain. The center of the outbreak is a collection of immigrant neighborhoods in Queens­—Corona, Jackson Heights, Elmhurst—where many residents work as taxi drivers, restaurant workers, or day laborers. Across the country, African Americans are more likely to die from COVID-19, and rates of infection are disproportionately high in Black and Latino communities. While tragic, it’s hardly a surprise. Our public health infrastructure has been decimated for decades by budget cuts and neglect, and our system of medical care doesn’t address structural inequalities; it amplifies them. Race and poverty track in unison, and poor people are more likely to have underlying medical conditions that can lead to complications from coronavirus: asthma, cardiovascular disease, high blood pressure, obesity, diabetes. What’s more, people of color are filling the “essential” jobs that make them more likely to become infected, working as delivery drivers, grocery store clerks, and warehouse employees. Those who are more able to stay at home are white and wealthy. Some have simply fled the city for their second, or third, homes.

Last night I dreamt I went to the grocery store where I normally shop. The store itself had expanded, adding a seafood counter and a home décor section that sold fossilized Knightia fish. Inside, no one was wearing a mask and I realized I hadn’t had to wait in line to enter. The store was crowded and I took my time, selecting ice cream and fresh vegetables. It seemed the pandemic was over, but when I woke up, I didn’t know whether I had been dreaming of an earlier era or projecting ahead to a point when we will have moved through this. That time will come, but when it will be and what it will look like none of us can know.

Visualizing Transmission

The noise from the sirens is nearly constant now. The losses continue to mount—human, economic—and the stories of those who have died fill our media streams. I find more soothing the days when skies are overcast and gray, when the weather more closely aligns with the mood here. Sunlight feels like an affront, a callous lack of acknowledgement of what’s happening and of all that has changed.

Outdoors, more and more people are wearing masks and facial coverings, despite confusing advice from public health officials and the Centers for Disease Control. The adoption of masks, surely overdue in NYC, has required a shift in thinking about risk. We wear them not only to protect ourselves from others, but also, and more significantly, to protect others from ourselves. Researchers are reporting that up to 25% of those infected may be asymptomatic, and even those who eventually develop symptoms are probably contagious for several days beforehand. The idea of an asymptomatic carrier marks everyone as potentially dangerous. We can be a threat without even knowing it.

The coronavirus itself is invisible without an electron microscope, but its effects are evident in the destruction it wreaks. Mapping COVID-19 infections is one way to make the virus’s networks detectable. On the website of the New York Times, one can find maps showing worldwide infections, infections in the US, and infections by NYC neighborhood. This can be reassuring to those in areas with fewer infections, or alarming if one lives in an area that’s been hard-hit. A geographical visualization of this kind shows our interconnectedness, but it also highlights hubs of global travel, of high population density, and of areas where poverty and a lack of public health infrastructure put people at greater risk.

At this point, many of us who haven’t already had and recovered from COVID-19 may be asymptomatic carriers of a microbe undetectable by the naked eye. As such, we must visualize the virus’s pathways of transmission and then act to deprive it of them, by decreasing human contact as much as possible.

Responsibility and Blame

What we notice now are the sirens, punctuating the stillness with their grim wails, dozens each hour, hundreds each day. NYC’s 911 system is overwhelmed, and paramedics are making life-or-death decisions about who should be transported to the hospital, who is stable enough to remain at home, and whose condition is too critical to survive the trip. Each evening at 7 p.m., we open our windows and clap for two minutes to show our appreciation for those on myriad battlefronts, united as we are in solidarity and gratitude and fear.

Until as recently as a few weeks ago, Donald Trump and some members of his administration continually referred to SARS-CoV-2 as the “Chinese virus” or the “Wuhan virus,” emphasizing its origins elsewhere. Yesterday he floated the notion of imposing a federal quarantine on the New York City metropolitan area, and the governor of Rhode Island announced a plan to stop cars with New York license plates as they drove through the state. Both have since backed off on their proposals, which were of dubious legality. But the impulse behind each one highlights a common response when we are faced with an outbreak: the desire to blame others. We attempt to inoculate ourselves by foregrounding our distinctions from the carriers of disease. They are immoral, dirty, foreign. They behave in suspect ways, make questionable lifestyle choices, and eat unfamiliar foods. Above all, they are different.

I’ve written elsewhere about how the outbreak narrative taps into our desire to assign responsibility and blame, how we slot new information into old frameworks as a way to bring order to disorder, and how an effective program to minimize future outbreaks must tackle global inequalities in public health. New York City is, obviously, part of the United States. But to many Americans living in other parts of the country, we are a place of excess, of too many people from too many places living pressed up against one another in tiny apartments. A virus cannot be easily contained, especially one like this that is more contagious than the seasonal flu and has been circulating throughout the globe since at least December.

By locating the coronavirus elsewhere, its pathways of transmission become a way to separate and divide, rather than a means to reinforce the lesson that becomes more evident each day of this pandemic: as a global population we are linked now more than ever, by capital, by transport, and now, by disease.

Surveillance

Yesterday the US surpassed China as the country with the most diagnosed cases of coronavirus. It’s a macabre accomplishment and not at all surprising, given our government’s early missteps and the incompetence with which it has handled the crisis over the past few months. In India, 1.3 billion citizens are on lockdown, ordered not to leave their homes for the next 21 days. In prisons, refugee camps, and detention centers, people are starting to test positive, raising the specter of outbreaks among vulnerable populations that lack consistent access to running water and basic hygienic supplies. Health care workers are dying, their colleagues battling fear and fatigue as they continue to care for the sick. Here in New York State, nearly 45,000 people have tested positive, a number that will almost certainly reach 50,000 by the end of today.

Amidst our confinement at home, I struggle against uncertainty. We’re hearing that the lockdown in New York could last another month or more. That’s 4-6 more weeks in which everything we knew is upended and what was once comforting—a touch, a conversation with a stranger—has become fraught with danger. The gloominess of the prognosis contrasts jarringly with the weather outside, which feels bright and hopeful. What will become of our families and communities? Will we recover and rebuild in ways that emphasize compassion and justice, or will the inequalities and chasms that this pandemic has exposed become further entrenched in our societies?

The countries that have been most successful at containing the coronavirus—Singapore, South Korea, Hong Kong, Taiwan—share a number of approaches, gleaned from hard-won experience battling SARS in 2003. In each case, the government acted quickly to shut down travel from China and to identify and isolate the sick. Each country has a system of universal health care, the importance of which cannot be overstated; it allowed residents to seek care without worrying about the cost, and it centralized the medical response among providers. What’s more, each country has a robust public health apparatus in place. In Singapore and South Korea, in particular, trained workers focused on extensive tracing of those with whom infected patients had been in close contact, using CCTV footage and GPS data from cellphones. This level of surveillance might be unpalatable to those in Western countries who fear, with good reason, the repercussions of giving the government more access to personal data. But the tradeoff other countries made between increased surveillance and decreased privacy enabled them to weather the pandemic without widespread closings of schools and workplaces.

Public health always involves a tension between civil liberties on the one hand and the public good on the other. The starkest example is a government-ordered quarantine of someone who is ill and forbidden from leaving a containment area. It’s way too late in the US to adopt the approach of Singapore or South Korea, as it’s clear that community transmission has been occurring across the country for some time. But in our current moment, in which entire cities and states have essentially been shuttered, it’s worth grappling with uncomfortable questions about how much of our privacy we’d be willing to give up in a public health emergency, and what safeguards we’d want to see in place first.

Decoding Risk

In the time warp caused by our current crisis, I realize with a jolt that a mere two weeks have passed since I sat in a pizza restaurant with N., sharing slices and drinking soda, back when we could still go places and do things. These days I spend a large portion of my time looking out the window, surveying the streetscape, watching the comings and goings of delivery workers whose labors allow many of us the luxury of minimizing the disruptions to our lives right now. I watch a couple that lives across the street as they toilet-train their new puppy. When it’s raining, the dog tries to run back into the building; when it’s nice out, he (she?) struggles against the leash, hoping to stay out a little longer. Even for dogs, it seems, confinement can take its toll.

The coronavirus has produced new rituals, new protocols. When packages arrive, I quarantine them in a corner of my apartment for twenty-four hours. When I get home from the grocery store, I shower immediately and then wash my clothes. Is this unreasonable, an overreaction? Perhaps. But perhaps not. In the face of uncertainty, we adapt our behavior as a salve against the unknown, to give us a sense of control over the uncontrollable. Studies show this coronavirus is most often transmitted through the air, or by touching something that an infected person has sneezed or coughed on and then touching one’s eyes, nose or mouth. There are no recorded instances of the virus being transferred through food packaging or through the mail; it can live on surfaces for several days, but it appears to degrade steadily over that time.

Still, we adopt measures to reduce our risk. In industrialized countries, our biggest disease threats are chronic illnesses: heart disease, cancer, obesity-related ailments. Each has a behavioral element to its etiology. Our wellness industry prescribes “healthy” habits to reduce our risk of sickness: at their most basic, exercise, eat well, and don’t smoke. But the coronavirus has upended the normal calculus of risk and disease. Our responsibility cannot simply be to ourselves; it must encompass others, as well. Staying at home and washing my hands can protect me, but it also protects you from me. My health status, and perhaps my life, depend on your adherence to these same public health recommendations. In our highly individualized society, we are being forced to rethink the responsibility each of us has to our neighbors and fellow citizens. Risk is no longer personal; it has become communal.

In Sickness

I went to the supermarket today and bought two bags of potato chips and an extra large bar of chocolate. My neighborhood feels the way it did around Hurricane Sandy and the blackout in 2003—we’re in disaster mode, hunkered down and emerging only when necessary. It’s sunny out, the daffodils and hyacinths in full bloom, which somehow makes everything even more bizarre.

I’m at the tail end of a cold I’ve had for nearly three weeks. It started with a sore throat, then progressed to a runny nose and a cough I still haven’t been able to shake. Through extensive Googling, I know that my symptoms don’t align with those of COVID-19, but these are strange times to be sick, and a few weeks ago my anxiety propelled me to call the New York State coronavirus hotline. The woman I spoke with was kind and reassuring, but she had no more information than what I’d been able to find online. She told me to monitor my symptoms and if I got worse, to call the NYC Department of Health and find out where I could get a coronavirus test. I know now that I probably wouldn’t have been able to get one, even if I’d had textbook symptoms, since I hadn’t returned from a Level 3 country or been in contact with someone who had tested positive. Perhaps it’ll turn out that I’ve had a mild case of COVID-19 this whole time, but in the absence of a test for antibodies to the virus, it’s likely I’ll never know.

In the evenings, we watch the news from France. The country has been in lockdown for over a week, with strict rules on when and for how long people may leave their homes. Photos of empty vistas across Paris reinforce the ways in which this pandemic has altered our sense of the ordinary. The Trocadéro, the Place du Louvre, Sacré-Cœur, normally teeming with tourists, are now deserted save for police officers on patrol.

In English, we say that someone has tested positive for the coronavirus. In French, the word is more direct, more alarming: infecté. It connotes an invasion by a foreign substance. It is an act of violence, yet described in terms that are curiously passive: one is infected, one becomes infected. As a species, we have now been polluted by this virus, and before we eradicate it, it will have taken over not only our physical bodies, but our social ones, as well. Nous sommes infectés.

Confinement, Day 1

It’s the beginning of an extended, indefinite period of confinement here in New York City. Last night at 8 p.m., all “non-essential” businesses were shuttered on orders from Governor Andrew Cuomo. New York State has become the epicenter of the coronavirus epidemic in the US, accounting for 6% of cases globally. Brooklyn, where I live, has been particularly hard-hit, although all of the city and surrounding suburbs have been affected.

The scene is surreal and apocalyptic, the streets quiet and empty. The odd pedestrian or two ventures out for groceries, masked and solitary. Mandated to maintain social distance, we avoid proximity, lest our bodies contaminate or be contaminated. We change our habits to avoid crowds, our friends, and the small interactions with neighbors that characterize our daily lives. We have become a danger to one another, and protecting our community now requires that we retreat into our homes, into ourselves. We must stay inside.

It’s a strange feeling to be living through a global pandemic right now, to be watching unfold in real time what I, as a historian of medicine, have spent years studying: the conflict between civil liberties and the common good. The notion of voluntarily suppressing aspects of one’s lifestyle in order to help others. The idea of submitting to a larger concept of society. The efforts of government and public health officials to deliver effective edicts in the midst of a constantly changing situation.

Even in more normal times, I follow the public health news closely, both in the US and around the world. But now, the sheer amount of information is overwhelming, the numbers staggering. In Italy, people are dying faster than they can be buried. Doctors worldwide, and especially in New York, warn of critical shortages of ventilators and protective equipment. Delivery workers, grocery clerks, and others whose jobs bring a lot of human contact are terrified of becoming infected. But we are also hearing stories of courage among our health care professionals and other workers on the front lines, of mutual aid societies being set up to help our most vulnerable, of best practices from other countries, and of promising treatments on the horizon. Remember, as well, that while each death represents someone’s mother or brother or partner, many more have recovered from COVID-19 than have succumbed to it. The suffering—psychic, emotional, economic—is real, and it will get worse. And then at some point, the pandemic will be over.