May 13, 2021

Pandemic and Endemic COVID-19 Ethics: Lessons from the history of tuberculosis

By Susan Murphy

By: Karen M. Meagher, Ph.D.

Recent U.S. headlines are starting to reflect a dawning public awareness that health experts have long suspected: COVID-19 might be with us for a long time. As vaccine rollout continues, the crisis in India has yet again revealed the devastating consequences of pandemic mismanagement. Only two infectious diseases have been successfully eradicated globally: smallpox, and the lesser-known rinderpest. A world in which COVID-19 is endemic might be one that requires long-term public health planning, and requires bioethics to recalibrate. The scale and depth global health impact of the pandemic makes COVID-19 challenging to compare to the social and cultural aspects of other contemporary infectious diseases. However, ongoing multidisciplinary analysis of tuberculosis (TB) provides one demonstration of the possible contributions of bioethics looking forward.

A bacterial as opposed to viral infection, TB outbreaks peaked in different places across the world throughout the 18th and 19th centuries. During such time, TB affected people across social strata. The social impact of these outbreaks offers some parallels to the scope of the global COVID-19 pandemic. Affluent instances of TB contributed to the emergence of social narratives romanticizing TB as a condition striking those with a more sensitive and artistic temperament. Prior to the emergence of germ theory, TB was considered a hereditary condition, running in families with such temperamental proclivities. The notoriety of some TB patients bears resemblance to early celebrity cases of COVID-19 that circulated on social media, normalizing infection and also serving as dramatic illustrations of both recovery and vulnerability. The social and cultural variability of such notoriety is also significant, with India’s highly publicized celebrity suicides during lock-down requiring more analysis to tease apart the impact of COVID-19 on those already struggling with depression and anxiety.

In the early 1900s, incidence of TB declined as living and nutrition conditions improved, and as populations acquired natural immunity. Some of these improvements were prompted by critiques of industrialization, which contributed to crowded and inhumane living and working conditions. And yet, the same romantic narratives that normalized TB in the affluent also reflected and fostered social indifference to—and scapegoating of—the poor living with TB. The development of effective antibiotic treatment and a childhood vaccine in the 1940s and 1970s respectively accelerated population health gains, continuing the declining incidence of TB. The relative influence of economic, political, and biomedical casual factors in driving the decline of TB continues to generate debate across epidemiology and social sciences. Public health gains during this century shaped hopes for global TB eradication.

However, the 1990s marked a time of increased recognition of resurgent TB across all nations. In 1993 the World Health Organization (WHO) declared TB to be a global public health emergency. As with the recent COVID-19 surge in India, a social model of health is needed to account for resurgence of TB. 20th century rates were simultaneously influenced by public policy, global failure to address poverty, cultural and political events, and new pathogen variants. HIV and AIDS produced a distinct yet overlapping pandemic, as the immunocompromised are especially vulnerable to TB co-infection. TB also had been developing resistance to antibiotics alongside their widespread use, leading to the development of multidrug resistant strains of tuberculosis. Medical anthropologist and physician Paul Farmer has been widely critical of global economic policy which influenced to bifurcated standards of care in affluent Western nations and the global south which contributed to the rise of MDR-TB. The moral valence of populations and communities worth investing in is also intertwined with histories of colonialism and race that we have seen recapitulated during COVID-19 within the U.S., and increasingly globally.

 Antimicrobial resistance raises a distinct set of ethical issues, from obligations of antimicrobial stewardship to imperatives for drug and diagnostic tool development. The development of COVID-19 vaccine resistance is an ongoing concern. Some variants have mutations that may have arisen within immunocompromised infected hosts. While a strong antibody response will suppress viral replication, a moderate response can create natural selection pressures. The resultant viral strains are not inhibited by (are resistant to) neutralizing antibodies, thereby creating the possibility of “escaping” the immune system response. The development of immune escape is a crucial factor in determining whether COVID-19 becomes endemic. The social implications of pathogen genomics are multifaceted.

First, identification of new variants is now viewed by media organizations as newsworthy, influencing public perception of how outbreaks occur. Second, genomic surveillance illustrates one of the most promising areas of precision public health: knowing where new variants are emerging could help direct interventions at populations based on their distinct exposure risks and disease burden. However, the history of TB demonstrates the continuing global disparities in public health surveillance laboratory capacity (Third, Emily Martin’s ethnographic work on American understandings of immunity demonstrates the interplay between depictions of the body and pathogens, expert and lay experiences of disease, and normative ideals. COVID-19 has undoubtedly altered human views of their relationship to microbes, and will continue to do so.

Currently, almost one quarter of the world’s population lives infected with tuberculosis. Many have a latent TB infection, which is not contagious. However, if untreated, latent TB can develop into active TB. WHO estimates that 10 million people fell ill and 1.4 million people died from TB in 2019. (WHO, 2020) India leads the world in TB cases, an often-noted harbinger of its potential role in COVID-19 global health outcomes. Social determinants of health continue to need greater policy attention: 49% of people with TB continue to face but MDR catastrophic costs, defined as greater than 20% of annual household income. Drug resistance exacerbates these economic barriers: 80% of people with MDR-TB face catastrophic costs. The economics of COVID-19 echo these relationships. As I write, members of the World Trade Organization are meeting to consider waiving vaccine intellectual property rights – but one factor in addressing economic barriers to care.

The newly renamed MSU Center for Bioethics and Social Justice is an apt reflection of the shifting role of bioethics, including its attention to matters of health equity. Emeritus faculty member Judith Andre notably argued bioethics is best understood as a multidisciplinary practice. Bioethics practices must change in response to persistent and rising health inequities, including in infectious disease. TB outbreaks have affected community health for millennia, including residents of ancient Egypt and Greece, and the sociality of the disease has changed along with historical and cultural shifts. It is Ancient Greek, too, that provides the etymological differentiation between pandemic and endemic infections: pan, meaning “all,” en meaning “in,” and demos meaning “people.” We can sustain hope that COVID-19 will fade into the background, becoming another one of many common childhood coronavirus illnesses that does not confer serious symptoms. However, as this brief glimpse of the ethics and history of TB illustrates, COVID-19 needs distinct ethical analysis to avoid complacency.

As a practice, we must collaborate to anticipate COVID-19 becoming in the people as well as affecting all of us in this global emergency. Social science and bioethics are well-placed to further our understanding of COVID-19 as both a biological, social, and moral phenomenon. Such reflection includes evaluating the way the pandemic has shaped our understanding of collective goods like public health, and the substantive commitments to social justice we need to support more lasting realization of global health equity.

*This article originally appeared in Michigan State University’s Center for Bioethics and Social Justice as part of a "Bioethics in the News" series.)

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