Good news, FDA approval of the Pfizer vaccine is reportedly happening on Monday. This comes after intense criticism that the FDA was moving too slowly. Meanwhile, anti-vaccination folks will probably say the approval happened too quickly. There's really no way to keep everyone happy when you work at FDA. But keeping people happy isn't why you work at FDA. You work there because of ... actually I don't know. But I'm grateful.
But I'll start with global health crises, because I think there's a theme to this week's news. It informs why we're failing to beat this virus. And it may help keep concerns in perspective, locally and personally.
(And I promise it's not just you shouldn't worry so much because other people have it worse than you. Even if your arms and legs suddenly fell off, someone would still be worse off than you. That wouldn't mean your concerns are invalid, or that you shouldn't bother a surgeon about urgently reattaching your arms and legs. (This would be the use-case I see for Alexa. "Alexa, call an ambulance."))
Let's start with Haiti. Obsessively focusing on death counts always bothers me, but I think, in situations like this, it's truly misleading and bad.
Every story begins with the number of dead. Last weekend, shortly after the 7.2 magnitude earthquake rocked the island, I got a push alert from The New York Times that said 36 people had been killed. It felt like a morbid joke. Did anyone think that was anywhere near representative of the scale of this crisis? Stories always come with caveats like "so far," but why even try to quantify the damage when we're nowhere near comprehending it? It reminded me of the early days of the pandemic, when reports said things like 20 Americans have been killed by COVID-19.
Already the known death toll in Haiti is in the thousands. This isn't to mention the far more injuries, and tens of thousands of homes destroyed. With a disaster of this magnitude, the after-effects can create health issues that do incalculable damage. The 2010 earthquake led to explosive outbreaks of cholera that lasted until 2019, severely sickening or killing hundreds of thousands of Haitians over the course of the decade.
The charitable explanation for a focus on immediate death tolls is that, in acute crises like this, we need to quantify damage to create some sense of order by counting precise, finite things. This narrows the scope of the problem into something our brains can begin to process. Because suffering is incalculable. (Or, more cynically, death tolls get people to read/listen/watch?)
Whatever the reasoning, it's wrong. It leads us to the wrong solutions. And we continue to do the same, short-term, narrow-minded thing with the pandemic, to our own detriment. The death toll—which we don't even accurately know, and may be around 4 million in India alone—doesn't capture the magnitude of the problem at all. It does not capture the more common experience of nearly suffocating but surviving, maybe after spending two weeks unconscious in an ICU, and having kidney failure and a heart attack. It does not capture the fear and uncertainty of friends and family of those hospitalized, and those caring for them. More importantly, obsessing over the death toll does nothing to help capture the nature of the problems. Why is this happening, and what can be done about it?
However inevitable earthquakes are (if I were president, personally, I'd ban them), there are clear disparities in the health impacts that play out in the weeks and years that follow. Even when a massive earthquake does eventually again rock the Bay Area, mercifully setting Silicon Valley adrift into the Pacific Ocean, kids across the United States will not be dying of cholera years later.
That's what can be helped, and demands to be.
Especially because the vulnerability of Haiti's infrastructure traces directly to U.S. embargoes and invasions. As you know, the American military spent two decades occupying the country, from 1915 to 1934. Under the pretense of providing stability, we took over the Haitian National Bank, executed political dissidents, rewrote laws to allow foreign purchases of Haitian land,and invoked forced labor where it could serve American interests. As U.S. major general Smedley Butler recounted in 1933, "I helped make Haiti and Cuba a decent place for the National City Bank boys to collect revenues in. I helped in the raping of half a dozen Central American republics for the benefits of Wall Street. ... In short, I was a racketeer, a gangster for capitalism."
By successfully exploiting people and resources, we set the scene for widespread poverty and unrest in decades to follow. This, then, became not our problem. From a distance, we condemn archaic labor practices. When crises in Haiti make news, we empathetically count the deaths and send bottles of water. We may even donate to ineffective relief efforts. Five years after the Port-au-Prince disaster, NPR and ProPublica discovered that the Red Cross had mishandled millions of dollars:
Accordingly, this time, activists have implored people not to donate to the Red Cross, and to give directly to local groups whenever possible. Which is part of a quite-justified distrust of foreign intervention.
The ultimate goal is to help build systems that do not rely on other countries to swoop in for a finite period, then go back to you're-on-your-own. Because, potential misappropriation of funds aside, the swooping is the problem.
[Cue the U.S. sending one naval ship to set up some temporary field hospitals in Haiti. It will arrive on Sunday, more than a week after the earthquake.]
A more meaningful gesture might be to help with construction of an actual hospital, and help train disaster-response medical teams. Paul Farmer's group has been doing this, notably, for years. When we spoke about it in 2012, as the hospital in Mirebalais was nearing completion, he described how we tend to be "socialized for scarcity"—to think that giving means taking away. That everything is zero sum. But building an academic hospital, as one example, creates jobs and serves as a teaching facility indefinitely. It is part of an approach at helping build sustainable systems; helping to break the cycles of poverty that keep populations especially vulnerable, and turn already-bad earthquakes into decades-long battles.
The up-front cost may be greater; the long term cost is far less.
Likewise, the cholera outbreaks in Haiti weren't solved by swooping in and handing out bottled water. They were solved by a decade of work within the country to rebuild and improve access to clean water and sanitation. As Haitian-American history professor Peniel Joseph wrote this week:
Which brings us to ... okay, I should mention Afghanistan, where our military also spent 20 years. Without getting into all the issues there in this (fun, breezy!) email, suffice to say that the Biden administration's focus on getting Americans out of the country—absorbing no blame and pivoting to insist that the instant collapse was inevitable—strikes the same cord. We bounce between extreme involvement and not-our-problem, even when we've aggressively made it our problem for decades. Overnight, our posture becomes: That's super sad. What's the death toll? Maybe we can send some water? We'll send a ship with tents? And then, would it help if we ... drive your country further into poverty through sanctions and embargoes? Maybe once enough people develop severe malnutrition your leaders will have to hold elections?
Sorry, this is bleak. I've been thinking all week of that Fitzgerald quote: "They smashed up things and creatures and then retreated back into their money or their vast carelessness, or whatever it was that kept them together, and let other people clean up the mess they had made."
Which brings us to vaccines.
This week CDC said that Americans would be recommended to get a booster shot eight months after their second dose of the Pfizer or Moderna mRNA vaccines. This led to a storm of debate among doctors about whether that was necessary, medically. Many are fine with it, saying essentially, "if it will help ensure safety, sure" and others saying, accurately, that the evidence isn't there (yet) to say that this is necessary for everyone.
What we do know is that people with less robust immune systems will benefit from boosters. We do not know that younger, healthy-ish people will. It's very unlikely that they will have a negative reaction, but even a one-in-ten-million case report of a clot or some such can shake the confidence of people who are hesitant to get even their first dose.
Ideally, we'd be able to stratify high-risk groups, and recommendations would be more like: if you are over age X and have conditions A, B, or C, you need a booster after Y months. If you are over age W and have conditions H, R, Q .... you get the idea. (I think I'm developing condition Q?)
But people are already, you've surely noticed, confused about vaccines.
And so, apparently for simplicity of communication/execution, and because the virus is evolving in ominous ways, the CDC recommendation is simple and broad. But it is not meant to imply that your vaccine is going to stop working when the clock strikes midnight on month eight.
The bigger concern is that doses of these vaccines are still precious. The value of a dose to an elderly person in a country without ICUs is vastly greater than the value of that same dose going to a healthy thirty-year-old in New York. In Haiti, for example, only about 2 percent of people have been vaccinated. And with already limited resources stretched yet further now, there is some profound absurdity in the healthy American investment bankers heading in for a precautionary third shot, as to avoid any chance of a need to downsize next weekend's Martha's Vineyard soiree.
The tragic thing is that vaccine access doesn't have to be zero-sum. We could have systems of production and distribution administration that are vastly more equitable. Instead we continue to opt to artificially limit production capacity in the name of profit for a few corporations.
Our hoarding comes at a cost, medically and morally, that is not offset by some magnanimous one-time donations of a few million doses. Triply dosed Americans will watch as people in other countries die needlessly this fall and winter. We may even send a ship with tents and saline. And we'll say we're doing all we can.
Take care, have a good weekend,
P.S. Bulletin (this new platform where I self-publish this letter) just added 25 new writers who are doing local journalism. Check them out if you want to read news specific to, say, Trenton or Detroit. It's kind of a smattering of locales, but I believe there's yet more to come. Supporting local journalism was central to the appeal of this newsletter platform for me. Global commentary/analysis is comparatively simple. Local journalism is what actually keeps the world functioning.
P.P.S. Also, our new puppy Raisin arrives next week. He looks like a fuzzy brick. I'm not sure how Moses is going to deal with his arrival. There will be Instagrams, for better or worse.
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