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

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This post is a part of our Bioethics in the News series

By Karen M. Meagher, PhD

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. In January 2021, almost 90% of coronavirus expert respondents to a poll by Nature considered it “likely” or “very likely” that the virus will continue to circulate somewhere on the globe for years to come. 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 global health and social impact of the pandemic makes COVID-19 challenging to compare to other infectious diseases. However, ongoing multidisciplinary analysis of tuberculosis (TB) provides one demonstration of the possible contributions of bioethics looking forward.

Pandemics as social levelers

A bacterial as opposed to viral infection, TB outbreaks peaked in different places across the world throughout the 1700s and 1800s (Barnes, 2020). During such periods, TB affected people across social strata. 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 (Bynum, 2012). 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 while illustrating both recovery and vulnerability. The social and cultural variability of such notoriety is also significant, with India’s highly publicized celebrity suicides during lockdown requiring more analysis to tease apart the mental health impact of COVID-19. Meanwhile, the death of well-known human rights advocates, such as actor Vira Sathidar, from COVID-19 has prompted reflection on the pandemic’s cost to India’s creativity in addition to the devastating loss of life.

Outdoor Play and Tuberculosis print from 1922
Image description: Print from 1922 shows a girl sitting by a window watching children playing outdoors. The title reads “Outdoor Play and Tuberculosis,” with the text: “Outdoor play is as necessary to health as food or sleep. At home, let the children play in the yard or on a well-guarded roof. At school, ample open air playgrounds must be provided. The city that fails to provide public playgrounds may be forced to provide tuberculosis sanatoria.” Image source: public domain/GetArchive.

Hopes for eradication

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 (Barnes, 2020).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 (Bynum, 2012). The development of effective antibiotic treatment and a childhood vaccine accelerated population health gains in the 1940s and 1970s respectively. 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.

Rising inequality

However, the 1990s marked a time of increased recognition of resurgent TB across all nations. 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 global policy failure to address health needs of those in poverty, cultural and political events, and new pathogen variants. The rise of HIV and AIDS produced a distinct yet overlapping pandemic, as the immunocompromised are especially vulnerable to TB co-infection. Multidrug resistant tuberculosis (MDR-TB) had been developing alongside use of antibiotics. Medical anthropologist and physician Paul Farmer has been widely critical of global economic policy, which influenced bifurcated standards of care in affluent Western nations and the global south and to the rise of MDR-TB. The moral valence of communities worth investing in is also intertwined with histories of colonialism and ongoing racial and class dynamics that we have seen recapitulated during COVID-19 within the U.S. and globally.

Resistance and its social meaning

Antimicrobial resistance raises a distinct set of ethical issues, from obligations of antimicrobial stewardship to imperatives for drug and diagnostic tool development. The potential for development of COVID-19 vaccine resistance is an ongoing concern. Some fear that SARS-CoV-2 variants have mutations that render them uninhibited by (resistant to) neutralizing antibodies, thereby creating the possibility of “escaping” the immune system response seen in the already infected and/or vaccinated. The development of immune escape is a crucial factor in determining whether COVID-19 becomes endemic. The social implications of pathogen genomics are multifaceted:

  1. First, identification of new variants is now viewed by media organizations as newsworthy, influencing public perception of how outbreaks occur. The history of TB demonstrates that public interest could wane if media organizations in affluent nations lose interest in their novelty.
  2. Second, genomic surveillance illustrates one of the most promising areas of precision public health, requiring ethical guidance for establishing trust, transparency, and community welfare. However, the history of TB demonstrates the continuing global disparities in global health surveillance laboratory capacity.
  3. 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 social ideals (Martin, 1994). COVID-19 has undoubtedly altered human views of their relationship to microbes and will continue to do so in unanticipated ways.

Economics & TB

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. The World Health Organization estimates that 10 million people fell ill and 1.4 million people died from TB in 2019. India leads the world in TB cases, an often-noted harbinger of its potential role in COVID-19 global health outcomes. The social determinants of health continue to need greater policy attention: 49% of people with TB continue to face catastrophic costs, defined as greater than 20% of annual household income. Drug resistance exacerbates these economic barriers: around 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 negotiating details of waiving COVID-19 vaccine intellectual property rights.

Endemics and social justice

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 population health. Emeritus faculty member Judith Andre notably argued bioethics is best understood as a multidisciplinary practice (Andre 2002). Bioethics practices must change in response to persistent and rising health inequities, including in infectious disease. TB outbreaks have affected community health for millennia, impacting residents of ancient Egypt and Greece. 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 merits distinct ethical analysis to avoid complacency.

Join the conversation

Global eradication of COVID-19 through universal vaccination requires a collective effort on a scale rarely achieved in human history. How do you think bioethics can generate new collaborations to sustain the global response to COVID-19? What values are relevant to you if COVID-19 becomes in the people as well as affecting all of us in this global emergency?

Photo of Karen M. Meagher

Karen M. Meagher, PhD, is an Assistant Professor of Biomedical Ethics Research at Mayo Clinic. Her main research interest is in ethics and social implications of human and pathogen genomics. She also holds the position of associate director of public engagement in which she leads a community engagement network for the Mayo Clinic Biobank in the Center for Individualized Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 27, 2021. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Continue reading “Pandemic and Endemic COVID-19 Ethics: Lessons from the history of tuberculosis”

How did an OB-GYN in Puerto Rico become a key architect of the first birth control pill?

bbag-icon-decChoosing to Test: Dr. A. P. Satterthwaite and the First Birth Control Pill Clinical Trials in Humacao, Puerto Rico

Event Flyer

How did Adaline Pendleton Satterthwaite, an obstetrician-gynecologist (OB-GYN) working at a Protestant mission hospital in Puerto Rico, become one of the key architects of the first birth control pill? In 1952, Satterthwaite left the continental United States and went to Puerto Rico to work as an OB-GYN at Ryder Memorial Hospital in Humacao. She continued her work there through the early 1960s, but in 1957 she took on an additional job as Director of Family Planning Clinic and Research in Contraceptive Methods. In this capacity, Satterthwaite oversaw clinical trials of G.D. Searle & Co.’s Enovid, the first Food and Drug Administration approved oral contraceptive. This talk will examine Satterthwaite’s personal and professional reasons for bringing the trials to Humacao, Puerto Rico and demonstrate her central, if understudied, role in the development of Enovid.

oct19-bbagJoin us for Kathryn Lankford’s lecture on Wednesday, October 19, 2016 from noon till 1 pm in person or online.

Kathryn Lankford is a doctoral student in the Department of History at Michigan State University. She is broadly interested in the histories of medicine and science, gender and sexuality, and empire in the United States and Latin America. Specifically, Kathryn’s current research examines clinical trials of contraceptives in Puerto Rico during the mid-twentieth century. Before entering the PhD program in history at MSU, she received a B.S. in Biology from the University of West Georgia.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lectures. To receive reminders before each webinar, please subscribe to our mailing list.

Announcing the Fall 2016 Bioethics Brownbag & Webinar Series

bbag-iconThe Center for Ethics and Humanities in the Life Sciences at Michigan State University is proud to announce the 2016-2017 Bioethics Brownbag & Webinar Series, featuring a wide variety of topics from under the bioethics umbrella. The fall series will begin on September 28, 2016, and you can attend the lecture in person or watch live online. Information about the fall series is listed below, and you can visit our website for more details, including the full description and speaker bio for each event.

Fall 2016 Series Flyer

sept28-bbagEthics and Children with Differences in Sex Development and Gender Nonconformity
When should society constrain clinicians from intervening in these contentious arenas?
Wednesday, September 28, 2016
Joel E. Frader, MD, MA, is a Professor of Pediatrics and Professor of Bioethics and Medical Humanities at Northwestern University, and Medical Director of Bridges Pediatric Palliative Care Program at Lurie Children’s Hospital of Chicago.

oct19-bbagChoosing to Test: Dr. A. P. Satterthwaite and the First Birth Control Pill Clinical Trials in Humacao, Puerto Rico
How did Adaline Pendleton Satterthwaite, an obstetrician-gynecologist (OB-GYN) working at a Protestant mission hospital in Puerto Rico, become one of the key architects of the first birth control pill?
Wednesday, October 19, 2016
Kathryn Lankford is a Doctoral Student in the Department of History at Michigan State University.

nov9-bbagTrust and the Learning Health System
What will it take to trust the health system with all that information?
Wednesday, November 9, 2016
Jodyn Platt, MPH, PhD, is an Assistant Professor in the Division of Learning and Knowledge Systems in the Department of Learning Health Sciences at the University of Michigan Medical School.

In person: These lectures will take place in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

Dr. Mark A. Largent, Associate Dean of Lyman Briggs College, joins Brownbag Webinar Series

bbag-iconReye’s Syndrome: A Medical Mystery and a Modern Dilemma

Event flyer: Largent Flyer

Throughout the 1970s and early 1980s, parents and physicians were terrified by the emergence of an apparently new ailment that left hundreds of children dead every year and hundreds more permanently damaged. Reye’s Syndrome, first described in the early 1960s, appeared as children were recovering from influenza and sometimes chickenpox, quickly throwing them into comas and frequently death. About half of the children diagnosed with Reye’s syndrome died and about half of the survivors were left with permanent brain or liver damage. Scientists and physicians raced to find the cause and develop treatments for Reye’s syndrome, and eventually epidemiological evidence emerged that it was caused or at least made more severe by aspirin. Since the early 1980’s, parents have been warned to avoid giving their children aspirin, especially when they suffered from a viral illness. But even before the FDA began labeling aspirin bottles, the number of Reye’s syndrome cases dropped dramatically, and it nearly disappeared before the before the Public Health Service could complete its study of the hypothesis that aspirin was to blame for the ailment. This talk will examine the history of Reye’s syndrome, the hunt to uncover its cause, and the debates that have emerged over last twenty years about the role of aspirin in Reye’s syndrome.

Oct-16-for-BlogJoin us for Dr. Largent’s lecture on Wednesday, October 16, 2013 from noon till 1 pm in person or online:

In person: The lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Mark Largent is an historian of science and medicine, Associate Dean of Lyman Briggs College at MSU, and an Associate Professor in James Madison College at MSU. His research and teaching focuses on the role of scientists and physicians in American public policy debates. His first book, Breeding Contempt: The History of Coerced Sterilization in the United States (Rutgers 2008) described the rise of compulsory sterilization laws in the US. Most recently, he published Vaccine: The Debate in Modern America (Johns Hopkins, 2012), which examined current debates about compulsory vaccination laws and the autism-vaccine controversy. He is currently writing a history of Reye’s syndrome.