Coronavirus, Epidemiology, and the Myth of the Primacy of Will over Matter
Coronavirus, Epidemiology, and the Myth of the Primacy of Will over Matter
The coronavirus outbreak is an intensification of a pre-existing state of emergency in the West. That condition has become possible through the cultural reception of social science data as evidence that the human will takes precedence over material conditions in shaping history. Epidemiology has been particularly instrumental in contributing to the sense that prudence—behavioral propriety—is the main hedge against death. The state of emergency reanimates death not as a normal part of life but as an offense; failing to follow the prescriptions said to allow death to be avoided implicates the individual in the preoccupying crisis, be it coronavirus, the earlier crises of AIDS and obesity, or the inevitable next one.
Cultural Sensibilities, Plague, and Death
EVERY epidemic is a story. Inevitably, it is suffused with the cultural sensibilities of the day. The coronavirus pandemic, with its massive suffering and heavy toll in death, isn’t just the spread of a virus; it’s the story we tell ourselves about the world we live in.
In F.W. Murnau’s 1922 expressionist masterpiece Nosferatu, the eponymous vampire isn’t the customary bloodsucker of Dracula films: he is a carrier of plague, and therefore death.1 His own body is insubstantial, almost incorporeal—at times it is almost translucent. It is a body that is utterly manipulated: diminished, distorted, the work of a demented sculptor. But this is also a body that is beyond supervision. Free, but also compelled: the vampire can’t stop himself from conveying contagion. Here, prefigured, is the crux of the dilemma posed by coronavirus: The world has been mastered by human ingenuity. Our bodies are fully shaped by nutritional advice and scientific advances. Our selfhood is fixed by medical identifications. Yet the corpses pile up, relentlessly. How can such a thing happen?
In one sense, Murnau’s film alluded to the so-called Spanish Flu pandemic of 1918-19 (Murnau had lived through it in Berlin). It is generally held to have been the worst short-term outbreak in history, with at least 50 million deaths worldwide in a period of just over a year. But the Spanish Flu arrived in a world in which, technical advances notwithstanding, death was still a regular part of life. In the US, which was already the wealthiest country in the world at the time, life expectancy was only 51 years in 1917, before the flu arrived. Death occurs more rarely now: in 2018, life expectancy in the US was 79 years and in the EU 81 years; in some regions of Europe half of the 65-year-olds can expect to live beyond age 88.2
But death is also a different entity. Although it still happens to everyone, we regard it as if it might not. Specifically, the individual today may—should—take certain actions to avoid death. To fail to do so is to violate a cultural norm. This reconfiguring of death is an essential aspect of life in the modern West. For us, Susan Sontag writes, “death is the obscene mystery, the ultimate affront, the thing that cannot be controlled. It can only be denied.”3
My subject here comes from the insight Sontag offers in her next line: “A large part of the popularity and persuasiveness of psychology comes from its being a sublimated spiritualism: a secular, ostensibly scientific way of affirming the primacy of ‘spirit’ over matter.” How has science, or what we call science, come to play a central role in this re-enchanting of death? Who benefits from portraying it as not only avoidable, but morally tainted?
Today, with coronavirus at large, how the culture construes death is a suitable subject for an epidemiologist. Because it is mortality that is easily counted, readily tracked over time and compared from place to place, and therefore the constant symbol of the severity of the outbreak. Of disaster. But of the possible consequences of viral infection, death is also the one with the potential for meaning. And therefore, mass death is the harbinger of crisis.
Numbers are supposed to be unimpeachable clues to reality now. Often, they are approached as the only valid clues. Therefore, the numerical statement serves as a shibboleth: the muddle-headed people who believe coronavirus is a hoax are out of touch with reality; we rationalists, looking at the numbers, know that coronavirus is real, is an unprecedented threat, is an emergency.
But numbers are only signs—at worst misleading, and at best clues to some deeper realities. That the contemporary sensibility is so inclined to read numbers not as signposts but as depictions of reality has perhaps never been more evident than in the confusion over how to think about and respond to coronavirus.
The sensibility of the culture is perhaps an expression of moral tastes,4 or, perhaps more to the point, of an abdication of any obligation to have a consistent moral view. The devotion to numbers as echt language, as the truest form of reality, is thus a sign: of indifference, and also of a kind of arrogance. The arrogant sense that the universe is ultimately at the mercy of human ingenuity is indispensable to the persistence of the Western setup. We allow ourselves and our policies to be in the thrall of numbers, and yet to be indifferent to what they mean in human terms. Increased life expectancy and wealth accumulation are the key measures of human thriving, justifying the assumption that power wielded so as to make some people healthier by the first standard and wealthier by the second is sufficient reason to preserve the status quo.
I mentioned life expectancy earlier because it is such a good example of the double persona of numbers: at once irresistible (How long will I live? What about my spouse?) and superficial. By definition, life expectancy is the age at which half of the population has died and half remains alive; it’s therefore an average, and one that only makes sense in reference to a defined population, e.g., citizens of a given nation. To invest this average with meaning is a betrayal of the essence of what makes any individual life worth prolonging. It serves primarily as a reminder that, in today’s sensibility, death is not simply fearful but offensive: it is evidence that human ingenuity has failed, that there are effects that have no clear cause, that the art of the possible has some limitations after all.
Thus the counting of coronavirus deaths (1.8 million worldwide as of the end of 20205) carries the tone of incantation, an appeal to that which can’t be named. With the case count (83 million), the active-case count (22 million), the percentage rise or fall in the 7-day or 14-day moving average of new diagnoses, the numbers of existing and new hospitalizations, and so on, this faux epidemiology offers a kind of Gematria, a coded guide to the malign. It signals there must be something malign in the world, not normal. Outside of nature.
The virus’s havoc is really rather limited, if the data alone reveal a truth: the number of deaths attributable to COVID-19 in 2020 amounts to something like three percent of all the deaths worldwide this year. More revealingly, the number of deaths from coronavirus roughly equals the number of deaths that occur every year from diarrhea.6 Coronavirus is a daily feature of conversation in the West; diarrheal death, which almost always occurs to poor children in poor countries, never is.
This is why I see the appeal of the data on coronavirus cases and deaths as false epidemiology. These numbers are not a clue to any deeper reality. On the contrary, what is offered is a collection of numbers, percentages, rates, and so forth that are meant to convey the impression of revealing meaning but actually hide it.
Science and “the Science”
Scientific experimentation has yielded plenty of useful information about the new coronavirus, SARS-CoV-2. For instance, the knowledge that it spreads through aerosols,7 which allows for policies banning large gatherings and requiring mask wearing. Treatment with hydroxychloroquine, although hyped early on for people sick with COVID-19, seems to confer no strong benefit,8 and the drug Remdesivir leads to improvement in patients with severe COVID-19, but its effect for people with moderate or mild illness is undetermined.9 Several vaccines against SARS-CoV-2 have been efficacious in clinical trials, to the point that one has been approved in the US, UK, and EU, yet another in the US and Canada, still another in the UK, and one in China; others will likely be approved soon. Dozens of vaccine candidates are currently being tested through various experiments on lab animals and humans.
Experimentation is the essence of science, but most of what is called science in the culture comes from a process more like stamp collecting than experiment: observations on the who, where, and when of cases and deaths. My epidemiologist friends will object that such observations are the essence of epidemiology. They are wrong: such observations are the form of epidemiology; its essence is the drawing of tentative inferences about the world from information about who gets sick, where, when, at what rate, and so forth. From the observations on coronavirus infections to conclusions drawn from those observations, the tentativeness of inference is dropped. The conclusions are received as “the science.”
When simplistic constructions are mistaken for a scientific knowledge product, the necessary epistemological process is elided. With it, the essential humility of scientific reasoning is abandoned. When any set of sufficiently quantitative observations may be connected to conclusions, pronounced as “real” by someone who calls him- or herself a scientist, and packaged in the discourse as “the science,” the purpose isn’t to extend knowledge; it is to deliver cultural norms. And if the norm is indifference—that is, the jettisoning of any obligation to make moral judgments—the scientist becomes no less significant than the social media influencer, albeit garbed in more authority.
I draw a distinction here between experimental findings and observations. Naturally, this oversimplifies. Still, the difference is worth considering in the context of coronavirus. The deliberate hand of hypothesis formation and testing has no time to steady itself when a new threat seems to create a global emergency, and that sense of emergency allows all sorts of truth claims to be asserted to an audience too fearful to evaluate them critically.
An experiment has a Popperian simplicity.10 Too simplistic, yes, but offering a clarity of interpretation that isn’t available in the social sciences. It puts one clear truth proposal under examination (this drug works better than nothing, for instance). There’s a quantitative result. The result can be subjected to the so-called significance testing demanded by frequentist probability, yielding a p value that, however much it conveys no information about the validity of the idea being tested, tends to confer an imprimatur of rectitude on a published finding. Nobody will think it isn’t science.
The experiment is vexed in the medical context, though. That’s especially apparent in the current coronavirus event. In the medical (which is to say, human) context, an experiment has a bad name now, even though experimenting on humans has been going on for centuries. In the 1790s, Edward Jenner tested out his idea for smallpox vaccine on a milkmaid. In her indispensable Medical Apartheid, Harriet Washington documents the sordid history of experimentation by white physicians on enslaved Blacks in the US in the eighteenth and nineteenth centuries.11 Sir Almroth Wright tested a typhoid-preventive immunization on British troops in 189612 and Waldemar Mordecai Haffkine tested a cholera inoculation on British and Indian troops from 1893 to 1895.13 In the 1920s, Kurt Beringer and fellow psychiatrists at Heidelberg learned about the effects of mescaline by trying it out themselves.14 And so on. Experimenting on humans has been, and remains, the scientific sine qua non for treatments or preventives intended for humans.
But after the Nazis’ infamous human experiments, the medical-research industry had to find a different name for what they do. Some ethical standards were promulgated in the Nuremberg Code of 1947, such as the necessity of consent and the absence of coercion. Eventually, experimentation on humans came to be called clinical trials, pre-clinical studies, safety studies, or just human-subjects research. In theory, especially after later ethics codes were developed in the 1980s, the subject is a partner in the research, not doing it in shackles or to avoid the gas chamber. What happens in practice is beyond the scope of this review. What’s important is that the human experiment, albeit renamed, remains sacrosanct as an attestation of truth in the medicalized emergency of coronavirus. So too in other emergency states, such as cancer and obesity, and the medicalized social disasters of depression, addiction, attention-deficit/hyperactivity disorder, poor educational attainment, and more.
Even with the more scientific framework of the human experiment, though, equating the results with truth reveals a special place in the contemporary sensibility for the numerical, the quantitative. This sort of truth—“the science”—does say something about a technical innovation (drug, vaccine), but on the condition that nothing about the actual lives of people who are infected with coronavirus, or who are protected from infection by a vaccine, be admissible as relevant. Beyond those facts pronounced by researchers as deterministically related to the occurrences of interest (“endpoints,” in the jargon), the reality of experience is irrelevant to the truth.
For instance, having an allergy to one of the inactive ingredients in a drug preparation might be grounds for exclusion from an experiment, because you might get sick for allergic reasons and therefore erroneously and confusingly appear to be showing an adverse effect of the drug being tested. But having a melancholic worldview, chronic stress at the workplace, or a marriage that is dissolving because of the difficulties of responding to the coronavirus emergency would not be an aspect of discoverable Truth, however important it is to your place in the world. That the quantified validity of a clinical trial result is received, in the larger conversation, as a sufficient statement of truth has the invidious effect of demoting those other facts of life and livelihood to a secondary status, merely ancillary—and of elevating other, quantified observations to an undeserved status as fact. “The science,” again.
“The Science” Makes Risk a Fact
Valorizing the quantifiable result as the key indicator of reality is a leaky process. It tends to spread. Those stamp-collecting observations on numbers of positive tests, required days of self-quarantine, and so forth acquire a similar validity status in the culture. For instance, when media commentators or public health officials report that there have been twenty times as many coronavirus deaths in Sweden as in Norway,15 it is construed as a meaningful truth about the differences between the two nations’ response to the coronavirus outbreak. By extension, it is understood as presenting objects for praise (physicians, nurses, Norwegians who didn’t dine in restaurants) or scorn (the Swedish health authorities, administrators of care homes for elderly Swedes). The contrast between the two countries is lent both vigor and meaningfulness by the numbers: 6,972 deaths and 351 deaths, as of the beginning of December 2020.
In the US, where I live, the widely reported data showing repeated upsurges in coronavirus case rates and corresponding increases in number of deaths have been widely viewed as an indictment of Donald Trump or, alternatively, as evidence of a media conspiracy to discredit Donald Trump with a “virus hoax.”16 Such a dichotomy of responses to published information is supposed to offer evidence of unprecedented polarization in American life—as if the manifest variety of Americans’ lives had suddenly reduced itself to just two fixed and diametrically opposed categories. Not only are the numbers understood to be revealing some underlying truth about the nature of Americans or American life, but the response to the numbers—the extent to which one believes or does not believe that the numbers represent reality—is understood to demonstrate a further, meta-truth.
The emergency of coronavirus has accentuated a growing phenomenon in the culture. For many years, the zeal for quantified measures of danger was held to be an aspect of what Ulrich Beck famously dubbed Risk Society.17 The sociologists Anthony Giddens, Deborah Lupton, and others developed the idea that the consciousness of potential harm is embedded in any appreciation of the innovations, like insecticides and rapid international travel, that have remade the world. Modernity, as Giddens calls it, thus has a “double-edged character.”18 In a sense, these risk thinkers were responding to Max Weber’s famous prediction, in The Protestant Ethic and the Spirit of Capitalism, that with the collapse of magical-mythical explanations for the world and the hegemony of means-ends thinking (Zweckrationalität), life would be experienced as if constrained by a steel structure (stahlhartes Gehäuse). Values would be fragmented, moral certainty elusive. In the view of the risk-society sociologists, the craving for quantified assessments of risk reveals a collapse of meaning. This view presupposes that authentic meaning exists, our view of it being clouded by the quantifying of danger.
And danger really has been quantified, increasingly. The heyday for epidemiologic assessments of risk began in the 1980s, with sudden demand in the West for measuring HIV/AIDS risk. Indeed, it was in this context that the concept of risk came to be definitively attached to illness (risk as a measure of possibility had been most firmly attached to financial jeopardy for several centuries before that).
Epidemiology and the Reign of Prudence
Beginning in the 1980s, risk was connected to behavior. The main impetus was a campaign in the US to define a new illness, AIDS, as a matter of lack of prudence rather than a consequence of social determinants like poverty, class, or stigma. The campaign built on the identification of elevated rates of lung cancer and cardiovascular disease among cigarette smokers and the subtle shift from naming smokers as a group at risk to naming the activity of smoking as the risk. Quickly, the same shift happened with AIDS risk: by 1984, same-sex intercourse and injection of illegal drugs (heroin or cocaine) became risky activities and, eventually, just risk.19 With risk reformulated as a measure of the success of prudentialism, the epidemiologic and economic studies that quantified so-called behavioral risk became ever more important markers of acquiescence with the new rationality. 20 21 22 23 24
In this new prudential sensibility, preventing illness becomes inseparable in the culture from avoiding risk—risk, now quantifiable, in its new guise as individual behavior. Witness, for instance, the almost immediate furor over the importance of mask wearing once coronavirus had been recognized as a global danger.25 Coronavirus prevention ceases to be a matter of public measures like contact tracing or lockdown orders (of the sort that the Chinese government had instituted in Hubei Province in response to the outbreak centered in Wuhan), but about personal behavior. Now that vaccines are becoming available, the sensibility is shifting to vaccine acceptance or “resistance,” and naturally to the so-called anti-vaxx movement.
The framing of measurable risk avoidance around personal behavior is not just a way of assuring conformity with demands of a power structure, as Foucauldian thinkers have suggested.26 More important, it offers possibilities for defining meaning in new ways. The Weberian conundrum will be escaped not by breaking out of the steel case and rediscovering universal meanings, but by making accessible the principles of propriety and consumption that can be embraced as if they were fundamental values.
The values that are now presented as fundamental by the dominant voices in the discourse will be advanced by science, in science’s contemporary role of spiritualist—that is, its role of upholding the claim that the material can always be conquered by the will. The values will be framed in numbers. They will be ratified by people who may reasonably claim they are scientists, or at least physicians (a false equivalency, but one that I will not go into here). The “science” will tell us to wear a mask, because that will prevent coronavirus transmission,27 probably by reducing the concentration of infectious virus particles.28 Just as it had previously told us not to smoke and not to have sex with strangers. (Indeed, smoking is deemed by American authorities to be so potent a threat to young people that a report by the US Surgeon General warned about the potential public health danger caused by smoking in Hollywood movies,29 and calculated that if films in which characters smoke were required to carry an “R” rating, it would save one million American lives.30 Advancing a number—a million deaths averted—is essential to the establishment of value.)
Obesity might decrease life expectancy, a pooled analysis using statistically modeled results of a number of studies found,31 so avoiding obesity is a way of showing that new values are embraced. That obesity is fairly strongly related to lower social or economic status in many countries32 is a sign of the framing of obesity as inimical to aspects of modern Western life whose social desirability has already been marketed, notably education and earnings.
Epidemiology thus abandons its original raison d’être of generating useful knowledge on aspects of the social fabric that make people more vulnerable to illness. In its place, epidemiology takes on the function of lending validity to behavioral norms that are in keeping with the sensibility of the culture—the sensibility of moral abdication. The numbers are epidemiology’s grammar. In contemporary culture, that grammar lends the behavioral findings an admonitory cast.
The New Sense of Emergency
In their role as validators of propriety, epidemiology and other quantitative social sciences become indispensable to the modern state of emergency. This state is not temporary; it is an enduring one. It was already in place before the special emergency that coronavirus has triggered.
In the US, the connection of quantification and the politics of emergency began to be evident over the past decade with the so-called opioid epidemic, involving oxycodone and other opiate pain relievers. Powerful evidence showed that these drugs can lead to overdose only very rarely. For instance, in a study of over 9,000 Americans using opiate pain relievers by physician prescription, the rate of overdose was 0.26 percent per year, and most overdoses were not fatal.33 When a furor over dangers associated with opiate pain killers (drug panic being a common enough event in America) led physicians and regulators to pull back on the availability of these medications, under-the-counter sale of the same drugs, along with aggressive illicit marketing of heroin and heroin substitutes, supplanted prescription drugs as causes of overdose—so much so that, after 2015, fatal overdoses in the US were far more commonly caused by the street drug fentanyl, a synthetic opiate, than by prescription painkillers like oxycodone or even heroin.34
These epidemiologic findings were understood not as a warning about a potentially helpful medication that carries a slight chance of adverse events, but as something much closer to an anathema cast on opiate pain killers. They led to a vilification of the Sackler family, owners of the company (Purdue Pharma) that marketed the highest-selling one, OxyContin. The attorneys general (i.e., state prosecutors) of forty-nine of the fifty US states filed lawsuits against Purdue; many suits were also against the Sacklers themselves. In 2019, Purdue Pharma filed for government protection against bankruptcy.35
The moral landscape is uneven here. The Sacklers aren’t lambs sent to slaughter; considerable evidence depicts them as conniving profiteers.36 Still, they were not particularly more venal than many other American corporate owners. They were do-gooders, endowing the Louvre’s Sackler Wing; the Serpentine Sackler Gallery in Kensington Gardens, London; the Sackler Gallery of Asian art at the Smithsonian in Washington, D.C.; and other museums and institutes; as well as chairs at academic institutions (many of these have jettisoned the Sackler name since the uproar over Purdue Pharma). And OxyContin was very effective for some people.
Americans’ traditional ambivalence about pharmaceuticals, especially opiate-related ones,37 was an indispensable background. Deep misgivings about opiates were often wrapped up in racial anathemas—powerful themes in American life. Teamed with collusion between pharmaceutical companies and the policy-making apparatus in the US, those anxieties turned into moral opprobrium directed against users of certain drugs, notably opiates—at the same time as other drugs, like cancer-treating monoclonal antibodies and HIV treatments, are celebrated for their life-preserving effects. The moral value of opiates’ capacity to ease the suffering of people with chronic pain was downplayed, but the moral offenses of Purdue, and of doctors who prescribed their products, were continually declaimed. My point here is that the susceptibility of epidemiologic findings to being both distorted and turned into moral indictments of behavior (selling, prescribing, and using painkillers) was instrumental to the drama.
The “opioid crisis” in America, the “mad cow” disease crisis in the UK, the crisis of vaccine refusers throughout the West, and most prominently the AIDS crisis—all are evidence of the emergency nature of response. Not only because risk avoidance has become so prominent, and not only because governments may now resolve legitimation crises through strident public declarations of danger—but because the modern state of emergency’s demand is for behavioral propriety. Therefore, the potential benefit accrues not only to institutions through control in the Foucauldian sense of biopower, but to the culture at large—by declaring the holding of humane moral values to be secondary to acting appropriately.
Always, there must be a crisis—because the emergency is necessary in order to valorize behavioral propriety over any humane values. The type and origin of the meat you eat must be carefully monitored to avoid all danger of transmitting bovine spongiform encephalopathy, even when that danger is known to be minuscule. Every aspect of sexual comportment should be subject to self-examination. Not only your own but your neighbors’ views on vaccination must be scrutinized by you, may be corrected by the authorities if faulty, and might even be subject to public correction in the form of social media anathemas—because your children’s health would be endangered otherwise. And that remains so, even if all of the diseases against which immunization protects them are exceedingly rare in your region. You might prefer to have resources devoted to helping migrants, slowing climate change, or alleviating poverty, but that preference comes from your moral compunction entreating you to pay attention. The emergency, by contrast, demands you pay attention.
That declaring a state of emergency was the common governmental response to coronavirus was therefore understandable—especially given the newness of the virus and the rapidity with which people sick with COVID-19 in early 2020 overwhelmed unprepared medical facilities. The specifics of the emergency state varied widely, and often controversially. The variation itself became a political issue, essentially founded on the availability of numbers to argue over and a near-total lack of inquiry about what ought to matter. For instance, an uproar ensued following the publication of the Great Barrington Declaration by health professionals who were troubled by lockdowns.38 In response, other health professionals, troubled that the Great Barrington writers failed to see a state of emergency as essential, issued the John Snow Memorandum, arguing that lockdowns were part of a robust public health response.39
None of these people who were troubled about what sorts of behavior to demand seemed alarmed by their own instinct to demand control of behavior in the first place. Again, the “science” offered a route to asserting the primacy of human will over the merely material without taking any moral position. To say that coronavirus is pandemic is to say that each nation, even each locality, must deal with its own version—obviously enough, since no epidemic can be divorced from the social forces that shape it or the cultural ones by which it is apprehended. But the scientists, in lieu of interpreting and humanizing the new force of the virus and the all-too-mortal power of the fear that ensued, became part of the cultural shaping of emergency—without becoming a useful part of the alleviation of the widespread suffering that resulted from the economic consequences of lockdown, the stresses on children unable to attend school and the parents who had to help the children at home, or the heartbreak of absence.
For Giorgio Agamben, the state of emergency is key to establishing the state of exception, the conditions in which a government may flout its state’s own laws and deprive people of rights, even endanger or kill them. Early in the current coronavirus outbreak, he wrote on his publisher Quodlibet’s website of his astonishment at the Italian people’s willingness to enter a zone of exception for the sake of prolonging life.40 For Agamben, to allow the state so much control of the biological self is to acquiesce in the limitation of human freedom. Agamben misses the fact that collectivity itself is a response to power, as I have argued elsewhere.41 But he is right that the question of the reach of state power vis-à-vis human life is vexed in today’s world of mass displacement, climate change, and other perceived reasons for emergency.
At some point, either through vaccines, treatments, evolution, or a combination thereof, COVID-19 will become a disease of the poor parts of the world. The wealthy countries will shift to other concerns. The story of coronavirus will turn into a story of hardship, persistence, “following the science,” and ultimately triumph. But there will be new “crises,” because the myth that human will and know-how conquer the merely material world is essential. The emergency must remain.
PHILIP ALCABES was trained as an infectious disease epidemiologist. He is Professor of Public Health at Hunter College of the City University of New York, and a member of the affiliated faculty in both Urban Policy and Public Policy there. His book on epidemics, Dread, was published in 2009.
dePICTions volume 1 (2021): Pandemic Times
1. F. W. Murnau, Nosferatu, Prana Film, 1922, film.↑
2. European Commission, “Life Expectancy Across EU Regions,” 30 September 2020 [25 December 2020}.↑
3. Susan Sontag, “Illness as Metaphor,” in Illness as Metaphor and AIDS and Its Metaphors, Palatine: Anchor Books, 1993, 55-56.↑
4. Susan Sontag, “Notes on ‘Camp,’” Partisan Review, 31.4 (1964), 515.↑
5. Worldometer Coronavirus Cases, 30 December 2020 [31 December 2020].↑
6. Global Burden of Disease 2016 Diarrhoeal Disease Collaborators, “Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016,” 19 September 2018, The Lancet Infectious Diseases 18.11 [16 February 2021].↑
7. Kimberly A. Prather, Chia C. Wang, and Robert T. Schooley, “Reducing transmission of SARS-CoV-2,” Science 10.1126/science.abc6197 (2020) [31 December 2020].↑
8. Wesley H. Self, Matthew W. Semler, Lindsay M. Leither, et al., “Effect of Hydroxychloroquine on Clinical Status at 14 Days in Hospitalized Patients With COVID-19: A Randomized Clinical Trial,” JAMA 324.21 (2020), 2165–2176 [16 February 2021].↑
9. Christoph D. Spinner, Robert L. Gottlieb, Gerard J. Criner, et al., “Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients with Moderate COVID-19: A Randomized Clinical Trial,” JAMA 324.11 (2020), 1048–1057 [16 February 2021].↑
10. Karl Popper, The Logic of Scientific Discovery, London: Abingdon, 1959.↑
11. Harriet Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, New York: Doubleday, 2006.↑
12. Frederick F. Russell, “Anti-typhoid Vaccination in the American Army,” American Journal of Public Health, 1.7 (1911), 473-479.↑
13. Waldemar Mordechai Haffkine, “A Lecture on Vaccination Against Cholera: Delivered in the Examination Hall of the Conjoint Board of the Royal Colleges of Physicians of London and Surgeons of England, December 18th, 1895,” British Medical Journal, 2.1825 (1895), 1541–1544 [26 February 2021].↑
14. Kurt Beringer, Der Meskalinrausch: Seine Geschichte und Erscheinungsweise, Berlin: Springer-Verlag, 1923.↑
15. Cumulative number of coronavirus (COVID-19) deaths in the Nordic countries as of 1 December 2020 [5 December 2020].↑
16. For instance, Jakie Salo, “Florida man who thought COVID-19 was a hoax loses wife to virus,” New York Post, 25 August 2020 [5 December 2020]; Sarah Krouse, “Covid-19 Disbelief Saddles Health-Care Workers With Another Challenge,” Wall Street Journal, 3 December 2020 [5 December 2020].↑
17. Ulrich Beck, Risk Society: Towards a New Modernity? (1986), translated by Mark Ritter, London: Sage, 1992.↑
18. Anthony Giddens, The Consequences of Modernity, Palo Alto: Stanford University Press, 1990, 10.↑
19. Detail on this evolution appears in chapter 6 of Philip Alcabes, Dread: How Fear and Fantasy Have Fueled Epidemics from the Black Death to Avian Flu, New York: PublicAffairs, 2009, 143-180.↑
20. Shin-Yi Chou, Michael Grossman, and Henry Saffer, “An economic analysis of adult obesity: results from the Behavioral Risk Factor Surveillance System,” Journal of Health Economics, 23.3 (2004), 565-587.↑
21. David E. Nelson, Eve Powell-Griner, Machell Town, and Mary Grace Kovar, “A comparison of national estimates from the national health interview survey and the behavioral risk factor surveillance system,” American Journal of Public Health, 93.8 (2003), 1335-1341.↑
22. Maria Vassilaki, Manolis Linardakis, Donna M. Polk, and Anastas Philalithis, “The burden of behavioral risk factors for cardiovascular disease in Europe. A significant prevention deficit,” Preventive Medicine, 81 (2015), 326-332 [26 February 2021].↑
23. Seth C. Kalichman, Chauncey Cherry, Denise White, Miche’L Jones, Tamar Grebler, Moira O. Kalichman, Mervi Detorio, Angela M. Caliendo, and Raymond F. Schinazi, “Sexual HIV transmission and antiretroviral therapy: a prospective cohort study of behavioral risk factors among men and women living with HIV/AIDS,” Annals of Behavioral Medicine, 42.1 (2011), 111-119.↑
24. Pablo Mallaina, Christos Lionis, Hugo Rol, Renzo Imperiali, Andrew Burgess, Mark Nixon, and Franco Mondello Malvestiti, “Smoking cessation and the risk of cardiovascular disease outcomes predicted from established risk scores: results of the Cardiovascular Risk Assessment among Smokers in Primary Care in Europe (CV-ASPIRE) study,” BMC Public Health, 13.1 (2013), 362.↑
25. Ed Yong, “Everyone Thinks They’re Right About Masks,” The Atlantic, 1 April 2020 [6 December 2020].↑
26. Deborah Lupton, Risk, New York: Routledge, 1999, 97-98.↑
27. Mingming Liang, Liang Gao, Ce Cheng, Quin Zhou, John Patrick Uy, Kurt Heiner, and Chenyu Sun, “Efficacy of face mask in preventing respiratory virus transmission: a systematic review and meta-analysis,” Travel Medicine and Infectious Disease, 36 (2020), 101751 [26 February 2021].↑
28. Monica Gandhi, Chris Beyrer, and Eric Goosby, “Masks do more than protect others during COVID-19: reducing the inoculum of SARS-CoV-2 to protect the wearer,” Journal of General Internal Medicine, 35.10 (2020), 3063-3066 [26 February 2021].↑
29. U.S. Department of Health and Human Services, Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General, Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and Health Promotion, Office on Smoking and Health, 2012.↑
30. U.S. Department of Health and Human Services, The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General, Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.↑
31. Cari M. Kitahara, Alan J. Flint, Amy Berrington de Gonzalez, Leslie Bernstein, Michelle Brotzman, Robert J. MacInnis, Steven C. Moore, et al., “Association between class III obesity (BMI of 40–59 kg/m 2) and mortality: a pooled analysis of 20 prospective studies,” PLoS Med, 11.7 (2014), e1001673.↑
32. Paola Zaninotto, Jenny Head, Emmanuel Stamatakis, Heather Wardle, and Jenny Mindell, “Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 2012,” Journal of Epidemiology & Community Health, 63.2 (2009), 140-146.↑
33. Kate M. Dunn, Kathleen W. Saunders, Carolyn M. Rutter, Caleb J. Banta-Green, Joseph O. Merrill, Mark D. Sullivan, Constance M. Weisner, et al., “Opioid prescriptions for chronic pain and overdose: a cohort study,” Annals of Internal Medicine, 152.2 (2010), 85-92.↑
34. Daniel Ciccarone, “Fentanyl in the US heroin supply: A rapidly changing risk environment,” International Journal of Drug Policy, 46 (2017), 107–111 [26 February 2021].↑
35. Jan Hoffman and Mary Williams Walsh, “Purdue Pharma, Maker of OxyContin, Files for Bankruptcy,” The New York Times, 15 September 2019 (updated 17 September 2019) [4 October 2019].↑
36. Patrick Radden Keefe, “The family That Built an Empire of Pain,” The New Yorker, 30 October 2017. See also Jan Hoffman, “Sacklers Face Furious Questions in Rare Testimony on Opioid Epidemic,” The New York Times, 17 December 2020 [28 December 2020].↑
37. Philip Alcabes, “Medication Nation,” The American Scholar, 7 December 2015 [16 February 2021].↑
38. Martin Kulldorf et al., “The Great Barrington Declaration,” 4 October 2020 [15 December 2020].↑
39. Nisreen Alwan et al., “Scientific consensus on the COVID-19 pandemic: We need to act now,” Lancet, 396.10260 (2020), e71-e72, 31 October 2020 [15 December 2020].↑
40. Giorgio Agamben, “L’invenzione di un’epidemia,” Quodlibet, 26 February 2020 [14 December 2020]. Clarification by Agamben published in the European Journal of Psychoanalysis, 17 March 2020 [14 December 2020].↑
41. Philip Alcabes, “Coronavirus and the Withering of the Public Sphere,” The American Scholar, 9 September 2020 [29 December 2020].↑