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Global to Local: Cholera Riots and Public Health Opposition in the U.S.

Vaccine scarcity and deadly COVID spikes are dominating the global public health terrain. Here in the U.S., we’re on the verge of entering an era of vaccine surplus, driven by increasing supply and decreasing demand. The question of what to do with our excess, and how the U.S. can operate with intelligent self-interest to mitigate the risk of new vaccine-resistant variants, has been written about beautifully. What we’re exploring today is dampened vaccine enthusiasm in a significant portion of the U.S. population, and how this connects with broader opposition to COVID control measures.


Cholera riots may seem like an unlikely place to start, but it seems like we can usually find precedent for what has been happening throughout this “unprecedented” global pandemic. Around the world and across centuries, cholera outbreaks have triggered conspiracy theories targeting medical and public health professionals, attacks on health workers, and riots. Similarities have also been noted in context of ebola outbreaks, and the idea is well established that from cholera to corona, disease outbreaks expose underlying societal problems. There have been COVID protests outside the U.S. as well, but the U.S. is distinguished by some of the highest rates of COVID infection and death around the world:

https://ourworldindata.org/covid-cases



In the U.S., some examples of revolt:

-Armed agitators stormed the Michigan Capitol in April 2020, and capitol protests have occurred in multiple other states as well.

-Public health workers have been threatened and attacked in multiple states, including here in Colorado.

-A mob forced the temporary shutdown of a vaccination site at Dodgers Stadium in Feb. 2021.


Resistance to the vaccines that are our most promising pathway out of this pandemic, most significantly among Republicans (see excerpt below; green shows hesitancy), is threatening our return towards normality. Like cholera riots, and anti-mask demonstrations in the 1918 flu pandemic, we believe that history will look back upon the COVID riots and opposition to public health measures as misinformed and self-destructive. We also hope that we can increase COVID vaccine enthusiasm and that history will show an inflection point, where the moment of the COVID public health crisis was met. There are at least two channels through which we can move forward.

https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard



First, public health leaders can do more to make their work visible and relevant to the communities they serve, with a new focus on understanding the public’s values as one of the key approaches to safe and effective engagement in the face of threats and attacks. This is another angle of global-to-local learning: community engagement is emphasized by USAID, is a key theme in PEPFAR, and you would be hard-pressed to find a Peace Corps project or any worthy non-governmental organization work that does not aim to meet people where they are and serve according to the local perspective on community needs. This may involve negotiation; a donor project may be based on epidemiological data that shows what a community needs for public health, while the community itself may have more pressing issues to address from their perspective. The community engagement approach often used in international development can play a greater role in our domestic COVID response.


Second, a lasting lesson of the cholera riots can be applied today: while riots occurred for different reasons, and community demands varied, a common denominator was class-based impositions for public health control. Historically, those class lines were drawn along lines of poverty and marginalization. In our current COVID response, public health impositions have disproportionately impacted lower income individuals and communities of color; but where we have seen COVID riots and public health resistance, it is not driven by these groups. The picture gets murkier when considering basic measures, like median household income: while Republicans represented higher income voters prior to 2008, in the past decade Democrats have made much more significant gains. At the same time, Black and Hispanic/Latino income remains lower overall. Pandemic response, and really global health security overall, means acknowledging and addressing underlying economic and social factors as some of the most powerful drivers for public health impact. We hope that this approach can allow intelligent self-interest to prevail.


These channels do not require magical changes to take place in our country. While it would be very helpful for Republican leaders to stop downplaying the pandemic, or misleading on the safety of vaccines, this is not necessarily a realistic option in the near term. And we don’t need to depend on this change immediately. We do need public health interventions that recognize society and culture as the drivers of success, or failure, of disease control measures. The techniques we use for work around the world have a place right here, right now.

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