The Cure for Everything

The Cure for Everything

Chapter One

Every Life Matters

Public health was the driving force behind the formation of our clean, modern cities. But the cumulative undertow of our original sin has led to today’s inequities.

My mother didn’t know her exact birthday.

The date on her passport was even different from the one on her marriage certificate. This intimate piece of personal information was not erased out of indifference or bureaucratic oversight but because of a failure of public health.

Let me explain.

My mother was born in 1935 in a rural village in Jamaica. In those days, the custom was that the father would record the birth in the town registry. But the frequency of infant deaths was staggeringly high—more than one out of every ten babies didn’t live long enough to celebrate their first birthday. With such prohibitive mortality rates, it became a grim routine practice to delay the registrar visit for the first month or so after a child was born. The eventual registration date became the birth date, sometimes even if it was six or seven months later—a constant reminder of that undercurrent of painful uncertainty.

Jamaica was a crown colony then, part of Great Britain’s globe-girdling empire, and wouldn’t achieve independence until 1962, the year I was born. Still in the grip of its imperious colonial rulers, the island nation was plagued by severe economic hardship and civil unrest that frequently boiled over into violence at the height of the Great Depression. People were literally starving to death in the streets, and nursing mothers’ breast milk was often so deficient in calories and vital nutrients that infants suffered gravely from malnutrition. Babies died from a wide range of ills, from starvation to simply being born prematurely because of a lack of prenatal care. But what killed them most often were infectious pathogens like pneumonia and diarrheal diseases that were transmitted in dirty water.

Children born the United States that same year didn’t face such daunting odds. Even at the height of the Great Depression in 1934, infant mortality rates in the U.S. stood at six deaths per hundred live births (6 percent). The difference was clean water. The introduction of two relatively inexpensive and easy fixes—chlorination and water filtration systems—in major American cities killed the microbes responsible for high rates of death from typhus, pneumonia, tuberculosis, and other infectious diseases throughout the latter half of the 1800s. Clean-water initiatives across the United States in the first forty years of the twentieth century slashed three-quarters of infant mortality and nearly two-thirds of child mortality, an astonishing achievement that is considered the most rapid health improvement in our nation’s history.

Every life matters.

That’s the first rule of public health, and it is the moral imperative of a humane, nurturing, and thriving society. Infant mortality rates are a prime indicator of how well a society is following that rule. Babies are the most vulnerable members of any society, totally dependent on others for their health and well-being. If these fragile new lives are nurtured and cared for in a supportive environment, the chances are that society is protecting all of its citizens.

In the 1930s, Jamaica was a place where life was cheap and not valued. The white British grandees who held power did little to alleviate that nation’s grievous suffering, resulting in a terrible and largely preventable loss of life, and in wasted talent and potential. It should not have taken another seven decades to reduce infant mortality rates to the level already achieved in the United States under progressive reformers like President Franklin Roosevelt. But it did.

The creation of a society that values every life doesn’t happen magically. It’s a collective choice. At a critical juncture in U.S. history, nearly a hundred years before my mother’s birth, we collectively chose to make an enormous investment in our future. In the first half of the nineteenth century, a coalition of politicians, progressive physicians, and social reformers, backed by the strong support of average citizens, embarked on a series of massive public health interventions that completely altered this country’s trajectory. In the century following the Civil War, we saw a near-miraculous doubling of life expectancy, unlocking an entirely new set of tantalizing possibilities for the country. The civic measures that followed to improve public health, both large and small, are the very foundation upon which we’ve built our modern society.

The first fight of this opening era for public health was the battle to conquer deadly pathogens. Lethal contagions have plagued humanity since the dawn of civilization, but in the early 1800s, the rise of densely populated cities triggered an explosion of infectious diseases. The standard tools for stopping the spread of disease—isolation of the sick and quarantining the exposed—worked in sparsely populated rural areas but were woefully inadequate in cities. There, illnesses traveled with lightning speed along the fissures created by poverty. The haphazard, reactive approach to disease control had to change. We needed to get ourselves organized around prevention.

New York City was the epicenter of this seismic shift in the United States. A dense urban metropolis, nineteenth-century New York was already an engine for economic growth and prosperity and a hothouse for the fledging nation’s science, art, and cultural pursuits. But deadly diseases engulfed New York with alarming frequency, from yellow fever, measles, and malaria, to cholera, typhus, and smallpox. These pathogens festered in filthy streets littered with garbage and human feces, and in the marshy swamplands on the southern tip of Manhattan. Newly arrived immigrants to New York in the early nineteenth century would encounter a fetid city core with garbage piled several feet high on the dusty streets.

New York’s 1832 cholera outbreak would ultimately become a catalyst for transforming the city and laying the groundwork for eliminating infectious diseases that killed millions. Protecting public health became a public activity, a societal goal, and a critical cog in New York City’s—as well as the nation’s—meteoric rise.

Looking at the arc of how all of this evolved, and the forces that drove public health from its nascent stages in the early 1800s to where we are today, can show us what we need to do in the twenty-first century. Our lesson from this history is a mixed one: It is a story of death and malaise being met with collective determination and ambitious vision—but it is also a story of failure, a cautionary tale about what happens when anyone is excluded from that web of mutuality that protects us all.

Because the first and foremost lesson of public health is: Every life matters.

Cholera changed everything. The disease invaded almost every part of the United States in the nineteenth century, afflicting great cities like New York, Cincinnati, and Chicago, and claiming the lives of Iowa dirt farmers, New York longshoremen, Wisconsin miners, and Black field hands in the American South, as Charles Rosenberg noted in his book The Cholera Years. But there was a silver lining: Cholera forced civic leaders to overcome centuries of complacency and indifference, midwifing the birth of our modern public health system and forging what would become an enduring social commitment to collective health.

Plagues are nothing new. They’ve ravaged humanity throughout history, causing seismic shifts in society and toppling empires. Roman soldiers brought back what is believed to have been smallpox after the war against Parthia, in what is now northern Iran, triggering a lethal pandemic that killed an estimated five million people and contributed to the collapse of the Roman Empire. Five hundred years after the birth of Christ, the Plague of Justinian, an early incarnation of the bubonic plague, claimed the lives of nearly 10 percent of the world’s population. In the mid-fourteenth century, the Black Death, another variant of the bubonic plague, was the initial wave of what turned into a nearly five-hundred-year death march. In a scant eight years, from 1346 to 1353, it killed between 75 million and 200 million people, which comprised up to 60 percent of the populations of Europe, the Middle East, and Africa, according to some estimates, and led to the end of feudalism because of the scarcity of able-bodied laborers.

Diseases brought to the Western Hemisphere by explorers in the sixteenth century, including smallpox, led to the demise of the Inca and Aztec civilizations and claimed the lives of about 90 percent of the indigenous population. Native people on Caribbean islands like Jamaica were also hard-hit, and in 1518, the first smallpox outbreak in the so-called New World occurred in Hispaniola, which is now Haiti and the Dominican Republic.

In colonial America, there had been a patchwork of efforts to protect people from epidemics like the plague and smallpox. By the eighteenth century, isolation of the sick and quarantining the exposed were the standard tools for controlling diseases, a tactic designed for agrarian communities, but also used in the port cities that were most vulnerable to contagious maladies, like Boston, New York, Philadelphia, and Baltimore. It didn’t work. In 1793 in Philadelphia, then the nation’s capital, a yellow fever epidemic swept through the city, killing some five thousand residents, about 10 percent of the city’s population.