By Tim Stephens

War and disease (guns, germs and steel in Jared Diamond’s terminology) are irrevocably linked in American history. The early English colonies thrived largely because measles, smallpox and other novel viruses introduced by Europeans had reduced the native population by more than 80% by the early 17th century. George Washington’s insistence on inoculation of his troops against smallpox is considered one of his greatest strategic decisions. In all wars, before the introduction of penicillin in the Second World War, more soldiers died from disease than the violence of war.

The Great War coincided with the Great Influenza, and in many ways they are the same event. The German army was unable to sustain its spring offensive. The Liberty Loan Parade of September 28, 1918, in Philadelphia is an over-cited public health error. The infection of the Assistant Secretary of the Navy, Franklin Delano Roosevelt, was heavily covered in the newspapers. Ironically, his polio would incite the March of Dimes to crowd-source the funding of the vaccine that would eradicate the disease from this continent.

The war analogies are flying thick and fast as the Pandemic Pause consumes the globe and its resources. The coronavirus appears as a character in the manifold stories, taking on adjectival characteristics of an enemy – “deadly,” “pernicious,” “destructive” – pick your synonym. If this is a war, there are many questions, including: who is fighting; who is doing the recruitment; who will win the war; and, what can we learn from the past?

Wars expose inequities and focuses the mind on the combatants. The poor are enlisted by the rich. In the Civil War, rich slave owners were accused of shirking their duty as they sent their poor neighbors to defend their way of life. The draft was termed a “life lottery.” In New York City, the biggest civil insurrection in American history (other than the confederate rebellion) broke out just 10 days after the Union victories at Gettysburg and Vicksburg in July 1863.

The cry of “rich man’s war, poor man’s fight” went up again as the European monarchs blundered into war in 1914. The opposition to a standing army was strong before the declaration of the Great War. The United States had the 14th largest army in the world (smaller than Serbo-Croatia) and needed officers from the Allied armies to train the recruits raised in early 1917. Those recruits were famously sent to the proving grounds for the Great Pandemic – huge camps (Devens, Funston, Cody, Dodge and others) built in weeks at the edge of towns, absent municipal water and sewage, to accommodate 50,000 troops transported from all parts of the country. These were true petri dishes that successfully concentrated the influenza virus as effectively at the trenches at the front.

Predictably, the “poor man” is fighting this new coronavirus “war.” But this man was sick before the battle began. The public health system has issued libraries of reports demonstrating that the American “sick care” system was and is ill-equipped to treat the diseases exacerbated by poverty.

More than 40,000 Americans have died from drug overdoses each year for the last 10 years; in 2018, the number was more than 67,000. Suicide rates among 10-14 year olds more than tripled in the last 15 years and is the second highest cause of death among this age group. Seventy percent of juveniles in the justice system had at least one diagnosable mental illness. Asthma rates vary as much at ten times between the poor and rich zip codes in Washington, D.C., where children miss an average of 8 days of school a year due to the disease.

The social response to COVID-19 has exacerbated the public health reality that the United States spends the most on “sick care” for the lowest outcomes. The coronavirus is killing African Americans at twice the rate of other demographic categories; 24 million Americans may spend “stimulus” checks on street drugs, tobacco and alcohol; and prescriptions for anti-anxiety medicine have increased 34% in the last month. Farmers are destroying food while hunger is more apparent in our homeless populations. We are (maybe) winning the battle with COVID to lose the war.

The prevention policy prescriptions that addressed obesity, diabetes and substance abuse (exercise, peer support, tobacco cessation, diet) were ignored in the development of COVID guidelines. As we start to end the Great Pause, it is time to implement new strategies to make our society healthier and make the tactical approach to tackling COVID far richer. This might include giving forgivable SBA loans to urban farmers to expand fresh food production; incentives to gyms to ensure infection control; and massive expansion of prevention efforts in the core funding at all levels, especially CMS.

The Vietnam War co-occurred with the War on Poverty. We need a new generational effort as an entire population to transform our sick care system through prevention efforts at all levels.

Tim Stephens has been involved in all aspects of public health and preparedness for more than 20 years. He spent ten years as the National Sheriffs Association Public Health Advisor. He was the founding executive of the Emergency Services Coalition for Medical Preparedness, which in 2013 recommended a complete overhaul of the Strategic National Stockpile to protect the first responders at the outset of any emergency. He is currently developing a coalition to launch a new Population Health Incubator.