COVID-19 provides an opportunity to reimagine public health systems to focus on access, writes Andrew McDowell, cultural and medical anthropologist at Tulane University. This article was originally published in Pandemic Discourses.
Not long after the Mardi Gras bacchanalia that makes New Orleans a global center of tourism, the city’s pocked streets emptied as residents braced for a what would be several weeks as the center of the United State’s COVID-19 epidemic. Though anxiety and viral clouds flourished, it was a beautiful spring and many New Orleanians tried to make the best of shuttered offices by spending time outside. Among them, I returned to running, an old stress busting habit. The reflections that daily jogs down the city’s tree-lined streetcar track stimulated for me—an anthropologist of global health and tuberculosis in India –centered first on what COVID-19 reveals about public health’s imagination of its ‘public’ and second on models for revitalized public health infrastructures. I share them here because global public health might have something to learn from this decaying city in the American South and its nexus of overtaxed infrastructure and infectious disease.
Post-diluvian New Orleans has been a 21st century American experiment in privatization similar to the 1990s structural adjustment and World Bank health economics applied to Africa, Latin America, and South Asia. During the crucial years of post-Katrina reconstruction, city and state officials privatized the entire public school system, declined to rebuild several large public hospitals, and took steps that whitened the city. The role of the pastoral and regulatory state in public life receded, and with it, so did the condition of the city’s sidewalks. Sidewalks in American cities are public thoroughfares maintained by individual property owners but regulated by city officials. In other words, sidewalks are examples of neoliberalism and responsibilization in action. They are privately provided public goods that are loosely regulated, and in New Orleans they are nearly impassable, especially in affluent neighborhoods. Indeed, the sidewalks are so treacherous that no one dares run on them for fear of broken bones or teeth.
Heeding pronouncements from the state and local governments that closed gyms, good pandemic citizens did their part to avoid burdening the crowded medical system by avoiding the sidewalks. This meant running down New Orleans’ already popular route on the streetcar tracks. Occupying the grassy median of a tree-lined avenue, the streetcar tracks are among the safest places to run in a city. Though joggers run headlong toward intermittent but oncoming trollies before dodging to the space between inbound and outbound cars, they do so because the city maintains the area around the tracks. Years of rail maintenance and runners have beaten the flat yellow earth between the two parallel iron rails to a near cement. Where runners had once confined themselves to the space between the rails, they now began leaving 10-foot berths between bodies which now extended two meters in any direction. The once straight lines between the rails now became more like waves centered on a ferrous equilibrium.
Though we may never lose these categories, public health systems must be built to address the dynamic interaction of diseases called acute and chronic. One way to do this might be to focus on how to make public infrastructures suit multiple purposes, as the streetcar line is a conduit of public transportation and a risk-reduced public exercise space.
As April 2020 wore on, it became clear that flexible infrastructures that could serve both as public transportation and as public space, as the streetcar tracks do, might inspire new ways of thinking about public health beyond disease verticals. COVID-19’s overwhelming of hospitals and public health programs around the world makes clear that our health infrastructures must attend both to acute illness and chronic conditions. Just as the streetcar line flexes to accommodate needs for exercise when the gyms close in a city without sidewalks, health systems must be able to address the intersection of two disease categories—acute and chronic—that seem to exist on different temporal scales. Building health systems that focus on protecting the public through biosecurity and the management of acute infectious disease alone, leaves them ill-equipped to manage non-communicable disease and its potential to reconfigure infectious disease risk, manifestation, and outcome. At the same time, by addressing only non-communicable illnesses, we leave microbial agency unfettered. COVID-19’s interactions with heart disease reinforce what the modulating effects of diabetes and tuberculosis or HIV and tuberculosis have long been suggesting; namely, that separating acute and chronic illnesses divides diseases and sufferers artificially. Though we may never lose these categories, public health systems must be built to address the dynamic interaction of diseases called acute and chronic. One way to do this might be to focus on how to make public infrastructures suit multiple purposes, as the streetcar line is a conduit of public transportation and a risk-reduced public exercise space.
Made famous by Tennessee William, New Orleans’ streetcars are exposed to the city’s blistering heat, are nearly entirely unscheduled, and prone to technical issues. Those with the means and urgency to drive often do. However, what the New Orleans public transportation lacks in speed and efficiency, it makes up for in accessibility. To ride New Orleans public transportation is to learn a lesson on what it means to re-orient the values of “a public” and public services. One must wait for the bus or streetcar to arrive. Once onboard, one must be prepared to stop for patrons who might not have made it to the stop in time, or to wait as the driver helps a neighbor in a wheelchair onboard, or chats with a friend who’s pulled up alongside. One must also be ready with one’s dollar and twenty-five cent user fee. Unless one doesn’t have it. Then the driver invites you to a seat anyway. One must even be prepared for a neighbor to ask to be let off at a location that is not a bus stop. One ought similarly to be prepared to slow to a crawl behind a jogger with his headphones turned up too high. These forms of flexibility do not make for an efficient public service. They do, however, make a public service accessible to a broader section of the community. True to its commitment to access, when other cities were limiting routes or trains, the New Orleans system made public transportation free through the summer of 2020 in recognition that many of those New Orleanians deemed essential workers relied heavily on this system to arrive at their low-pay, high-risk jobs in grocery stores, hospitals, and pharmacies.
A rejection of ableism’s privileging of time over access or neoliberalism’s insistence on user’s willingness to pay over ability, nearly anyone can and does ride New Orleans’ streetcars and buses. The point to make here is not that a public health system might throw efficiency out the window or that busses should run late, but that a new definition of who makes up the public emerges when access takes primacy over efficiency.
A rejection of ableism’s privileging of time over access or neoliberalism’s insistence on user’s willingness to pay over ability, nearly anyone can and does ride New Orleans’ streetcars and buses. The point to make here is not that a public health system might throw efficiency out the window or that busses should run late, but that a new definition of who makes up the public emerges when access takes primacy over efficiency. Certainly, the elderly woman who needs a hand getting on the bus would be well served if it arrived on time, but if efficiency were the only value, she would be stuck at home. Joggers like me would be fenced off or fined as well. Instead, the New Orleans streetcars suggest that a system broken from an efficiency lens, might do quite well when viewed from another, in this case accessibility. The difference is centered on the kinds of public and public needs the system addresses.
COVID-19 and the streetcar line—one of the few public services that continued unaffected in April 2020—has also taught us that a public health system based on efficiency alone leaves far too many behind. Indeed, the efficiency-driven American health system has revealed itself to have left many behind. The histories of financial and racial exclusions echo throughout the city today through the reactions to COVID-19 recommendations. Basic public health messages about masks came to be heard as techniques of control and moral posturing. Expert enthusiasm about vaccines evokes the Tuskegee atrocities, race-based disparities in accessibility to public goods, and state surveillance. Even a public reckoning of the dead seems tainted by money moves from corporate hospitals and obfuscating officials that make some deaths count more than others. Each of these rumors and reactions contest and highlight the exclusion occurring in the name of efficiency that is central to the basic public health function of a neoliberal state. So too reverberate long standing and often silenced debates about what the US public is and how subjects ought to negotiate a tense relation between ‘individual freedom’ and ‘public good.’
Similarly, as public health systems in India and China reimagine public life and their role in it during what may be the C-19 century, we must reimagine the ‘public’ in public health by expanding access, making public spaces safe, and thinking beyond single disease paradigms.
As China continues to model its public health institutions on American versions of disease control and biosecurity, and as India reckons with the decades of neglect and exclusion that spurred the growth of a massive private sector to reimagine its healthcare system in line with an American privatized insurance-based system, perhaps a view from one of America’s COVID-19 epicenters might enable ways of thinking otherwise. Running down the streetcar tracks in hopes of avoiding injury and hospitalization as the privatized health system crumbled and the public health system shuttered collective life revealed a need for infrastructures like the streetcar that are publicly financed and maintained, flexible in their use, and attend to access over efficiency. Similarly, as public health systems in India and China reimagine public life and their role in it during what may be the C-19 century, we must reimagine the ‘public’ in public health by expanding access, making public spaces safe, and thinking beyond single disease paradigms.
Andrew McDowell is an assistant professor in the Department of Anthropology at Tulane University. A cultural and medical anthropologist, he examines the intersection of infectious disease, social relations, and global health in India by focusing on tuberculosis care in rural Rajasthan and urban Mumbai.