The Bioeconomics of Covid-19

Both the left and the right perceive the need for data rapidly collected, centralized, analyzed, and deployed in preventing and arresting epidemics. But they diverge on how to do it. The left argues that public health, a fundamental public good, can only be accomplished by a well-funded, attentive state. The private sector cannot and does not—or should not—be interested. If health care were free and universally available, it would generate no profit.

How, exactly, do we value a human life?

Back of the 50 centime emergency note issued in 1916 by the Merksplas Local Board of the National Assistance and Food Committee © Museum of the National Bank of Belgium

Biopower and necropolitics

In Discipline & Punish Michel Foucault describes the measures taken, as per magisterial edict, in a plague-ridden French city sometime in the late seventeenth century. On the first day of quarantine, everyone is ordered to stay indoors; the doors are locked from the outside. Sentinels are posted at the city gates. Armed guards patrol the town hall.

Each street is placed under the surveillance of a syndic, who visits every house every day, speaking through a window. “Everything that may be observed during the course of the visits—deaths, illnesses, complaints, irregularities—is noted down and transmitted” to the city authorities. A resident who goes out without permission or a syndic who leaves the street may be sent to the gallows. Public health and social control go hand in hand.

The authorities recognize an obligation to the people inside the houses, who receive a kind of care, albeit compulsory: interrogations; bread, meat, fish, herbs, and wine delivered by means of “small wooden canals” and pulleys and baskets; inscription of the names of their dead. Meanwhile, circulating in the streets are those described in the edict as “people of little substance who carry the sick, bury the dead, clean and do many vile and abject offices”—colloquially, the “crows.” Their faces obscured by the iconic beaked mask, “the ‘crows,’” notes Foucault, “can be left to die.”

During the Plague of 2020, zip code disease-prevalence maps are color coded on a spectrum from a cool beige of privilege to the blood red of poverty and loss. On New York City’s map, mid-Manhattan and brownstone Brooklyn, close to the centers of finance and culture, are light, suggesting both skin color and disease burden. The outer reaches of the outer boroughs are orange and red, and black and brown.

Block to block, social segregation is vertical. The elite bodies, up in the apartment towers, are not unaffected by Covid. Their homes have become high-tech versions of preindustrial domestic workshops, where children and animals roam through spaces of production and trade, and intimate disorder—unmade beds, unwashed hair—is open to public judgment. Virtual work is more work. A study of over three million employees on three continents finds that the workday has grown by forty-eight minutes, with 13 percent more meetings. In the US, it’s three hours longer. Yet on balance, these workers are lucky. Convening with colleagues and receiving paychecks through fiber optic cable, they pause each evening to lean out the windows and bang pots in appreciation of the health-care workers whose services they probably will not need.

While the white collar workforce Zooms above, down in the pestilent streets “essential”—“front line,” in the inevitable parlance of war—workers zip around on electric bikes, pinging up to the apartment-ateliers, and leaving packages and pizza cartons on the doorsteps. Tips are typed into apps. Contact of hand or eye, breath or caste is avoided. Other essential workers toil further away, in warehouses, tomato fields, and meatpacking plants. As in wartime, politicians travel to the battlefront to commune with the grunts. In April, while governors plead with the Trump administration for ventilators and PPE, Vice President Mike Pence and Agriculture Secretary Sonny Perdue arrive by motorcade at the Walmart Distribution Center in Gordonsville, Virginia. With CEO Doug McMillon by his side, the VP thanks the workers for their patriotic contribution, “keeping food on the table for the American people.” Loaders and truckers at the center are putting in ten- and eleven-hour days. During the visit no one wears a mask or observes social distancing.

The next day, McMillon sends a long memo to the company’s million and a half US “associates.” He too praises them for “going the extra mile” in “service” to America’s families and communities. He enumerates the health and safety measures the company is purportedly taking, and signs off, “Stay safe.”

Later that week two Walmart workers die of Covid-19. Jennifer Suggs, a South Carolina cashier, tells a reporter that the company is not providing masks or gloves. Another cashier, in New Orleans, says her manager won’t let workers wear masks brought from home. Their choice is simple: Go to work and endanger themselves and their families. Stay home and risk their jobs. No one will pay the doctor bills for them. “Unemployed and [non-healthcare] essential workers are the most vulnerable [to Covid] given their lower income, lack of health insurance, and differences across household structures,” according to an analysis by the Brookings Institution of data collected between March and July. The disparities are “intensified” by race, it says. Though many are eligible for public healthcare, “Black and Hispanic essential non-health care workers report no health insurance coverage four times more often than white essential non-health care workers.”

Says Suggs: “We’re not essential. We’re sacrificial. I will be replaced if I die from this.” Indeed, as sales leap 74 percent online and 10 percent in stores, the company hires hundreds of thousands of fresh workers. Walmart pulls in total first-quarter revenues of $134.62 billion, 8.6 percent above the same period the previous year.

When spatial segregation is breached, enforcement is mobilized. In late April, the New York Daily News runs a front-page photo of a homeless man slumped in a subway seat, dwarfed by a mountain of his belongings in plastic bags. Governor Andrew Cuomo holds up the paper in a press briefing and pronounces the scene “disgusting,” as well as “disrespectful to the essential workers” who must ride the trains every day. The Metropolitan Transportation Authority decides, for the first time ever, to interrupt twenty-four-hour-a-day service, from 1 AM to 5 AM, to disinfect the cars, an effort that is later determined to be more theatrical than effective. It also means removing the trains’ overnight denizens. “It’s my job to make sure everyone who rides our system feels safe and secure,” New York City Transit interim president Sarah Feinberg says.

On the first night of the new regime, a thousand police descend into the tunnels to roust the homeless, giving them the choice of transport to a violent and virus-ridden shelter or escort to the rainy, cold street. In the name of public health, a city agency has summarily ejected the homeless—at this point almost sixty-three thousand in shelters alone, plus thousands who sleep in the streets and subways—from the ranks of the public. The city places some unhoused people in hotels to keep them marginally safer, but they are relocated again and again, and finally sent back to the shelters, as neighbors protest their presence and defend their own “quality of life.”

Feinberg also stresses that the police are treating the evictees with gentleness and respect. Skepticism is affirmed when body-cam footage recorded on May 25—the day of George Floyd’s murder—reveals two of New York’s Finest pulling Joseph Troiano, a white former hairdresser, off a near-empty subway car, allegedly for taking up two seats. They punch, pepper spray, kick, and choke him while he weeps and begs for his life. Troiano is wheeled out of the station on a gurney, cuffed.

Elsewhere, often behind closed institutional doors, the bodies of the old, the disabled, and the incarcerated—those the Nazis called “useless eaters”—are succumbing. Nearly four in ten deaths are “linked to nursing homes,” the New York Times reports; those with significant portions of African-Americans and Hispanics residents have seen coronavirus rates twice as high as largely white facilities, regardless of location, size, or government rating. More than a quarter-million inmates and employees of prisons and jails have been infected by Covid-19—at a rate more than five times higher than the US generally—and correctional facilities and their communities have led the lists of disease clusters throughout the epidemic.

 Foucault used the plague city to illustrate a historic shift in societal control from “the threat of death” to “taking care of life.” Power that had derived from a sovereign’s prerogative to kill any subject was displaced by what Foucault called biopower: the practices and institutions, such as psychiatry and public health, that prevent and treat illness and police normalcy and deviance. The Cameroonian political theorist Achilles Mbembe, however, argues that the “threat of death”— necropolitics—lives on. Far from vanishing in the seventeenth century, he says, necropolitics drove colonialism and continues to dominate the contemporary world through violence—policing, incarceration, and war. In the US, the failure of the state to protect the public during the pandemic, and the gross racial and ethnic inequities in sickness and mortality, expose the relationship between biopower and the neoliberal necropolitical state, whose economy is built on the dispossession and enslavement of brown and black bodies and whose fiscal policies presume their neglect.

“Nothing is more material, physical, corporeal than the exercise of power,” said Foucault. But the pandemic illuminates something more: nothing is more economic than the exercise of power upon the body. Even in our digitized, financialized economy, wealth, which is power, is accumulated through the use and misuse of bodies. Foucault teaches us that all politics are biopolitics. What we learn from Covid is that all biopolitics are economic.


Market values

In January and February most of the developed world establishes a plan for the pandemic: Enforce a general lockdown until the rate of infection diminishes and flattens, then gradually reopen. Because the economy will contract, replace large portions of workers’ wages, in essence paying people to stay home. Test and contact trace widely so as to reduce quarantine to those who are exposed or sick, speeding the return to normalcy. The plan does not work perfectly. European countries that conquer community spread through stringent lockdowns early on experience late-summer surges after opening and are forced to restore restrictions. Vicious inequities are discovered on the undersides of other supposedly exemplary successes: Singapore rapidly institutes what looked like universal testing and contact tracing, limiting cases to fewer than six hundred by late April. Then the numbers surge in the squalid dormitories that house hundreds of thousands of the island’s million near-indentured migrants. Still, the basic principle remains: controlling the virus is not an impediment to economy recovery but, rather, its precursor.

In the US, recognizing that the Trump administration will do little or nothing to contain the pandemic or to ease the pain of joblessness and evaporating commerce, voices rise from an anxious capitalist class to construct a picture of antagonistic policy goals: either safeguard lives or safeguard the S&P 500. And they choose the latter. “Neither mitigation nor waiting for a vaccine is acceptable given the magnitude of the problem we are facing,” writes Douglas A. Perednia, a retired dermatologist, in The Federalist in mid-March. “Economies are like a living organism—as soon as their normal functions are shut down, they begin to die.” The doctor’s choice of metaphor is striking, given that his is a brisk description of what happens to a human organism infected with the novel coronavirus. Oxygen deprivation and blood clots cause rapid damage to the organs. Normal functions shut down. The patient begins to die.

In April, with deaths approaching twenty thousand, the White House steps up its campaign to open shops, bars, and schools. Treasury Secretary Steven Mnuchin assembles a committee of corporate executives and lobbyists to give the idea a putatively informed nod. Among all but the most doctrinaire Covid deniers, noise is made resembling concern for safety. The White House even publishes guidelines for reopening. Yet like the president, Republican elected officials ignore the guidelines, flinging open the doors and making life-and-death decisions by the seat of their pants. Georgia Governor Brian Kemp initiates Phase I on April 20, when cases are still climbing in his state. He gives tattoo parlors the go-ahead to resume operations but not amusement park rides. That same day Texas Lieutenant Governor Dan Patrick, fanatical defender of the pre-born, allows that “there are more important things than living” and calls upon grandparents to martyr themselves to “get this country back up and running.” And what is Trump’s calculation? Does he cipher the ratio of hamburgers gained to meatpackers’ lives lost on a napkin, like the Laffer curve?

Under the assumption that rescuing the economy and restoring individual liberty will, sadly, require human sacrifice, Perednia proffers a modest proposal, minus the Swiftian satire. Young healthy adults should volunteer for “controlled voluntary infection,” or CVI, like kindergarteners exposed to chickenpox or measles at “pox parties.” Upon recovering (which he assumes they will do) these adults become certified Covid-immune workers, go back to their jobs, revive the economy, and in the meantime build herd immunity to the coronavirus.

Enthusiasm for the herd immunity strategy, even before an effective vaccine, remains background chatter for months, while scientists manage to dissuade anyone from trying it. In August, however, the idea gains an influential spokesman: Trump’s new pandemic advisor, Scott Atlas, a neuroradiologist, fellow at the conservative Hoover Institute, and, according to the Washington Post, the self-styled “anti-Dr. Fauci.” Since, unlike Fauci, Atlas has no expertise in disease control, it is clear he has been selected for the same reason everyone on the president’s staff is selected: he is willing to endorse the President’s stupidest ideas—in this case to give quasi-scientific cover to Trump’s insistence that the US can reopen without serious health consequences.

In October, as infections surge to unforeseen heights and Trump’s odds of reelection to unprecedented lows, Atlas touts the libertarian “Great Barrington Declaration,” which puts forth a more organic form of CVI—ending lockdowns and protecting only the vulnerable while the more resilient get sick by “natural infection”—as the “most compassionate approach” to building herd immunity. The signers—who purport to number nine thousand, though most are anonymous—estimate that herd immunity can be reached at infection rates of 20 to 25 percent. World-renowned infectious diseases expert Michael Osterholm calls the figure “the most amazing combination of pixie dust and pseudoscience I’ve ever seen.” Scientific consensus puts the percentage closer to 90 percent. Within the week, hundreds of scientists denounce the Great Barrington Declaration. On a campaign staff call, Trump grouses that “people are tired of hearing Fauci and all these idiots.”

What are the human costs of what the president has called “going herd,” a phrase bringing to mind other high-casualty depravity, like “going postal”? In the Biopolitical Times,  Pete Shanks does the math. “To achieve herd immunity in the US without a vaccine, we would need at least 200 million Americans to get sick and recover.” Given Covid-related mortality rates, that translates to one to two million deaths. At that point, “[w]e’re not so much talking about building herd immunity as culling the herd,” says Shanks. “Are we going to accept one or two million deaths?” In August a CBSNews/YouGov poll hints at an answer: a majority of Republican voters say the number of fatalities—then nearing 170,000—is “acceptable.” Of course, the unspoken question is whose deaths are acceptable.

There’s another wrinkle in the back to work plan: how to ensure that people who say they’re immune actually are immune, and keep those who are not from crossing the thresholds of offices, airplanes, states, or countries. In the US, this is a question more of lawsuits than lives, as evidenced by the Trump campaign’s requirement that Tulsa rally-goers waive their right to sue should they be infected. Not to worry: a credentialing instrument is on its way. Called an antibody or immunity passport, certificate, or license, it is a digital system combining mobile apps and centralized registries, facial recognition and QR codes, which instantaneously affirms the health status and identity of its holder.

FaceFirst, a $10.4 million facial recognition startup in Encino, California, is working on a “coronavirus-immunity registry” of medical data, which feeds into a mobile facial recognition app. Aside from immunity status, it will include information on the types and qualities of any tests the owner has undergone. The London-based tech company Onfido has raised $265 million to develop what it describes as “a system for citizens, guests and employees to have proof of immunity that is designed to help an individual prove their health status, but without them having to share any other personal information.” Apple and Google are collaborating on a Bluetooth-networked contact-tracing system into which such apps might tie.

Public health experts denounce “controlled voluntary infection” as medically, ethically, and practically ill informed and short sighted. The World Health Organization cautions that immunity and antigen tests, on which the passports are based, are untrustworthy as permanent proof of immunity, since it remains unclear how long antibodies protect a person from infection or prevent transmission of the virus. In the New Yorker Siddhartha Mukherjee notes that the passport is “a divisive, ethically fraught approach to begin with. Add in diagnostic errors, and it could be a lethal one.” Nevertheless, governments are biting. The systems have been discussed in connection with reopening plans in Chile, Germany, and Italy. A committee of the British Parliament has solicited a proposal from Onfido. Estonia has launched a trial at numerous workplaces of a passport created pro bono by engineers at the financial tech firm TransferWise.

Here in the US, according to Forbes, FaceFirst has what appear to be tentative discussions with officials at the Department of Health and Human Services and the White House. California is, as always, ahead of Washington. A bill to fund financial literacy programs, introduced in the State Assembly pre-pandemic, has morphed into a proposal to empower state agencies to issue blockchain technology–based “verifiable credentials”—aka immunity passports—of an individual’s Covid-immunity status, tests, and other medical information, which can be used to screen workers and travelers, and for other purposes yet named. Opposition from civil libertarians has forced California’s state senate to slow down, and the bill’s latest version simply empanels a working group, including privacy experts, to make recommendations. The purpose of such working groups is usually to postpone a proposal until everyone forgets about it, but that seems unlikely given that California is home to the country’s most aggressive and influential adventurists in biotechnology and electronic surveillance. In the state capital, privacy, public safety, and democracy advocates struggle to rein in their techno-gaga lapdogs. If Silicon Valley has its way, and the legislators green-light the passports, other states will feel safe to follow.

Proponents stress that participation in these schemes will be voluntary. Who, then, would volunteer to get a potentially fatal disease for the promise of what is essentially a license to work? The young, the reckless, the deluded—and the economically desperate. Imagine Jennifer Suggs’ personal CVI decision spreadsheet. On the risk side: “I get sick and recover,” “I sustain lung damage and go bankrupt because of medical bills,” “I infect Mom and she dies,” “I die.” On the reward side: a paycheck.

CVI and the immunity passport “marketize health, life, and death,” says Marcy Darnovsky, Executive Director of the Center for Genetics and Society in California and a longtime activist and public intellectual around issues of biopolitics and social justice. With such policies, “you are letting market logic force people to do something that is really bad for them and [that] they would not do if there was not the economic incentive.” The untenable choices that workers make between income and health are not unique to the coronavirus pandemic: people clean up nuclear spills, cross oceans in leaky boats, and sell their livers to wealthy patients needing transplants. “The libertarian argument is that people should have autonomy over their bodies. It’s their choice, and it might be a better choice for them than working in the salt mine,” comments Darnovsky. “Those arguments never look at the larger pictures: what the social and political conditions and the power relations are.”


Registration

The QR-coded face-recognizing immunity/identity app is not the first instance of a health-for-work credential. Earlier iterations likewise masqueraded as tickets to freedom and livelihood while inhibiting liberty and increasing employers’ control and the state’s biopower. From the 1860s to the 1880s, Britain’s Contagious Diseases Acts required prostitutes to be “registered” by undergoing intrusive fortnightly medical inspections for symptoms of syphilis and gonorrhea. If the sex worker was found to be ill, she could be confined to a “lock hospital” for treatment and then to a penitentiary to receive vocational and moral education, often in the form of forced labor.

Around the same time, the American antebellum South was being clobbered by wave after wave of yellow fever, a hideous disease that was fatal to half its victims. Those who survived became “acclimated,” or immune for life, writes historian Kathryn Olivarius in a New York Times op-ed, gaining what she calls immunocapital. Unsurprisingly, the value of this currency varied by race. For white people survival was considered proof of divine intervention—and what better reference for a worker or insurance client than God? As for enslaved black people, immunity “increased their monetary value to their owners by up to 50 percent. In essence, black people’s immunity became white people’s capital.”

How and whether to maintain a worker’s health is a business calculation. When the worker is a foreigner, that calculus is more obviously political: the trope of the toxic alien mobilizes nativist movements and justifies anti-immigrant policies. During the 1917 epidemic of typhus, a disease carried by lice, the US Public Health Service under the zealous eugenicist President Woodrow Wilson instituted a policy requiring all Mexicans crossing the border between Juárez and El Paso to strip naked and submit to full-body inspection, dousing in vinegar and gasoline, and sometimes head-shaving. Their clothing was fumigated with a new chemical called Zyklon B. Once “sanitized,” the Mexican national was issued a certificate stating that the bearer had been “deloused, bathed, vaccinated, clothing & baggage disinfected,” which had to be renewed through the same procedure every eight days.

In the twenty-first century, Republicans have revived the specter of the poisonous alien. When Trump rechristened the coronavirus the Chinese Virus, he not only exonerated himself for failing to mitigate the ravages of the pandemic, but also invoked the Yellow Peril, a phantasmagoric existential threat of Asian immigrants to Western culture, democracy, and religion—to whiteness itself. But the political needs of demagogues and the economic needs of capital do not always mesh.

At the beginning of the pandemic Trump closes the borders and almost all immigration to keep out the disease he insists came from away. Then in April, he tweets an exception: Growers may keep recruiting so-called guest workers. Do non-farmworker Central American refugees spread Covid-19 more than agricultural laborers? Do “guest workers” contract the disease less? This is not the point. The idea is “to separate immigration, which is people wanting to become citizens, [from] a temporary, legal guest-worker program,” Agriculture Secretary Perdue tells the American Farm Bureau Federation in January. “That’s what agriculture needs, and that’s what we want.”

By summer, as migrants travel north with the harvests, this priority burns like the midday sun over fruit and vegetable fields in rural towns as far from the border as New Jersey and Washington State. “People are really scared. There are a lot of unknowns,” a farmworker in southern Florida tells Politico, through a translator. On the first of September the National Center for Farmworker Health  tallies more than four thousand five hundred farmworkers and family members who have tested positive Covid-19. While these workers are considered essential, the federal government leaves it up to growers to decide what safety measures, if any, to take.

Meanwhile, by August, detained immigrants are testing positive at three times the national rate; epidemiological models suggest the real numbers could be fifteen times what ICE discloses. Advocates sue,  with little success, for the release of people at high risk, children, and families from detention facilities, where they lack not just masks or medical care, but even, in some cases, hot water. The Trump Administration continues to put deported migrants on planes to countries where they face not just poverty and violence but now galloping rates of Covid-19 as well. To leave no cruelty unrealized, when Congress enacts emergency relief payments, it excludes (over Democratic objections) families in which any member lacks a Social Security number, even if they pay taxes—affecting an estimated 16.7 million US residents, including an untold number of front-line, highly exposed workers.


Biomath

How do we value a human life—as property, as labor, as parent or patient, as citizen or migrant, alive or dead?

In late-1800s England, a prostitute bought moral redemption with workhouse labor. In the slavery-era South, a typhus-immune enslaved Black body commanded a premium for the slaver but not for the laborer him or herself. In the xenophobic, eugenicist early-twentieth century US, a Mexican worker was cheap both as political prop and agricultural hand. And in 2020? “I’m asking you: Is that what a black man is worth? Twenty dollars?” George Floyd’s brother Philonise challenges Congress on June 10. He is referring to the counterfeit bill George allegedly used to buy cigarettes at Cup Foods in Minneapolis on May 25. Across the country, police turn peaceful protests against racist police brutality into violent melees, adding injury to existential insult. Foregoing masks, pushing close to demonstrators, spraying teargas, and throwing people into crowded paddy wagons and jail cells, “the activities of the police seem to be one of the main sources of increased transmission risk at these protests,” Boston University epidemiologist Ellie Murray tells Gothamist. Protesting death can lead to more death.

How, exactly, do we value a human life? Compared with the haphazard calculations of a Governor Brian Kemp or the day-to-day odds played by a worker like Jennifer Suggs, the utilitarian economics of the pandemic look eminently logical. For instance, in late April Reason magazine sponsors a debate on the assertion “The US economy should be liberated from governments’ lockdowns right away.” Arguing the negative, economist Justin Wolfers runs the numbers. Valuing a life at the US standard rate, $10 million, one million deaths over a year without lockdown (the International Monetary Fund estimate at the time) total $10 trillion. Compare this to the predicted suppression in productivity due to lockdown lasting a year: just $500 billion. Moral questions aside, it’s a no-brainer, he concludes.

But economic questions are moral questions, perhaps nowhere more clearly than in health care. In every health-care system, whether socialized, privatized, or a hybrid of the two, market logics loom over life-and-death decisions. To determine whether a certain cancer drug or surgical procedure for a certain patient is worth the money, medical budgeters assign a value to the patient’s life and then calculate how much and for how long the intervention will improve the score. The metric they commonly use is the “quality-adjusted life year,” or QALY, which combines quantity (number of years) with quality of life (icily termed “utility level”) to arrive at a single figure. One year of perfect health equals one QALY. Death equals zero QALYs. But some circumstances are deemed “worse than death.” These can accrue negative QALYs.

What are the criteria for optimal utility—what laypeople might call a good life? The dimensions are borrowed from another metric called EuroQol, or EQ: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Such considerations help people make their own end-of-life decisions: do they want “extraordinary measures” taken and if so, under what circumstances? But the EQ factors acquire more ominous meanings when applied to people who do not want or expect to die soon. If you use a wheelchair, say, need personal help to dress and bathe, or live with physical or emotional pain, is your life of lesser quality than that of a cheerful person who can walk and dress herself? Even if your answer is no, on these dimensions you come up short on EQ anyway.

What about the other QALY variable, quantity of life? Histories of oppressive material conditions and emotional and spiritual stress have left black and brown people vulnerable to illnesses including asthma, high blood pressure, obesity, diabetes, HIV/AIDS—and to early death. Class also factors in: The economists Anne Case and Angus Deaton document how “deaths of despair from suicide, drug overdose, and alcoholism have risen dramatically” among white blue-collar Americans without college degrees, especially men, left behind by late capitalism. Membership in a demographic with a high prevalence of socially wrought premature death shaves points off your QALY.

So here we are in the emergency room at the peak of the pandemic. Ventilators are scarce. I, a white senior citizen in good health, am lying on one gurney. Beside me is a thirty-year-old triathlete with 14 percent body fat and a VO2-max of 70; she thinks she contracted Covid on a plane. Over there is a 56-year-old African-American bus driver who grew up in a moldy public housing project and has severe asthma as a result. We are all gasping for air, but the hospital must ration the ventilators, which will be critical in saving us. And, oh, there’s another patient on the phone—a young man with cystic fibrosis at home with his own oxygen tank. He is also showing symptoms of Covid-19. Which of us should get a ventilator?

To prevent massively consequential decisions being made on the fly in the midst of a crisis, most state health departments have rules and guidelines for health-care facilities in specific disaster scenarios, including running short of ventilators during a pandemic of respiratory infection. To read these policies is to appreciate the anguished decisions that medical staffs face. “Due diligence in disaster planning requires consideration of ‘measures of last resort,’” reads Alabama’s guidelines. “Some mass casualty disasters, such as a pandemic event, may necessitate that commonly accepted standards of medical care be altered to provide the maximum number of patients their best chance of survival.”

Triage is based on a patient’s likelihood of responding to a treatment, relative to another patient’s. But even if a numerical metric like QALY is not implemented, health-care policymakers weigh categorical “risk factors” that apply to “populations” and may or may not apply to the individual in the hospital bed. “If you’re eighty, you have less life ahead of you than if you’re forty,” explains Darnovsky. “But this particular eighty-year-old may have a better chance to survive on a ventilator than this forty-year-old.”

Even the most punctilious guidelines contain an unmeasured portion of culturally determined notions about which lives are worth living. The Center for Public Integrity analyzed ventilator-rationing policies in thirty states (the other twenty either had no such guidelines or did not release them for review). In twenty-five states, people with disabilities—some states name particular diagnoses—are likely to be sent to the back of the queue. In five states, doctors are advised not to give ventilators to people with chronic lung diseases, specifically cystic fibrosis, even though there’s no evidence that such a person can’t fully recover from Covid, according to a spokesperson from the Cystic Fibrosis Foundation. Thirteen states tell hospitals to give lower priority to someone who needs “assistance with activities of daily living.” CPI reports that in six states hospitals are guided to “consider taking ventilators away from patients who rely on them in daily life if others need them more.”

Utililitarian, categorically derived metrics reward the fortunate for their good health and punish the marginalized for the historic injuries inscribed on their bodies. The medicalized language in which bodies are sorted between the likely-to-succeed and the lost causes obscures the histories and policies that create health and chronic illness. “When you talk about comorbidities and underlying conditions, that makes it sound like a biological fact,” says Darnovsky. “It sounds inevitable. But those biological conditions are largely determined by social and economic conditions. Your chances of getting the infection and weathering it or not depend a lot on your zip code and your socioeconomic status.” Doctors and nurses do not cure such ills. That is the job of community organizers and policymakers.

Indeed, the #NoBodyisDisposable Coalition, which describes itself as “people targeted by triage plans during the Covid-19 crisis—people with disabilities, fat people, old people, people with HIV/AIDS and other illnesses—and our loved ones who don’t want us to die,” has circulated an extensive toolkit called “Know Your Rights Guide to Surviving Covid-19 Triage Protocols.” Disability justice organizations have brought legal action against several states, charging that their care-rationing policies discriminate on the basis of ability or age. In response to a claim filed with the US Health and Human Services’ Office of Civil Rights, for instance, Alabama deleted guidelines singling out “profound mental retardation” and “moderate to severe dementia” as reasons for denial of ventilators.

These advocates are mustering against their own annihilation. It is harder in 2020—and will be harder in 2030 or 2050—than it was in 1920 to lay blame should that come to pass. There is no well-meaning doctor in a white coat, not even a psychopathic eugenicist in a black-site abattoir overseen by Stephen Miller. Instead, the judgment will emerge from a computer programmed to cull the herd of bodies with negative QALYs.


Biodata

As summer gives way to fall and new infections mount, hospitals are learning how to treat the disease better and more patients are going home alive. But as eviction moratoria weaken or disappear, many Americans are worried they will soon have no place to go home to. The Census Bureau’s Household Pulse Survey reports that almost 30 percent of US renters say it is somewhat or very likely that they will be evicted in the next two months; about one third—more in some states—say they cannot cover all their usual household expenses.

On July 31, federal stimulus programs expire, including the CARES Act supplementing unemployment insurance and the Paycheck Protection Program extending forgivable loans to employers who keep workers on their payrolls. Democrats propose robust appropriations to continue these policies, adding aid to tenants and state governments contemplating crippling cuts as tax revenues dwindle. Trump expresses a passing interest in doing some of these things, but spending less, and tells Treasury Secretary Stephen Mnuchin to work out a deal with House Majority Leader Nancy Pelosi. The two talk for many weeks, and every once in a while the press reports that the sides are moving closer to agreement. Senate Majority Leader Mitch McConnell goes on summer vacation and returns renewed to his single-minded crusade to deliver the federal courts to the Christian God, the Republican Party, and Mammon. All the while, however, Federal Reserve Chairman Jerome Powell pleads for increased stimulus, reassuring Congress that even more money than is absolutely needed “will not go to waste”—it will speed recovery—whereas “a long period of unnecessarily slow progress could continue to exacerbate existing disparities in our economy,” which “would be tragic.” Wall Street, tempest tossed, changes its mind every other day.

But, ultimately, no calamity goes to waste. Tsunami, oil spill, war, recession—each presents an empty canvas for capital to redraw the property lines and the state to rewrite the rules; Naomi Klein calls it disaster capitalism. Some possibilities: the office-less office defeats contractual enforcement of overtime pay. Layoffs during the pandemic lead to higher productivity—more work from fewer workers—and employers find no reason to rehire and lighten the load. Capping the trend in universities and colleges, online teaching proves to be cheaper, and e-instruction tapes can be resold. Faculties shrink and students are even more frequently taught by underpaid adjuncts.

Even short of wholesale restructuring, crisis holds the promise of profit. The Boston Globe reports that “insiders at companies developing experimental vaccines and treatments to ward off Covid-19 aren’t waiting until they finish the job to collect their reward.” From March through October, Pharma execs and investment firms sell more than $1.3 billion in company stock, up from $74 million in the same period last year.

As smiling brown boxes cover the earth even more thickly than usual, Amazon’s market value rockets 86 percent, surfeiting the fortunes of its CEO. During the worst economic downturn since the Great Depression, Jeff Bezos reaches a net worth of $200 billion and becomes the richest person in human history.

Each disaster favors certain products—two-by-fours and insulation after floods, hand sanitizer and bicycles during pandemics. Covid-19 has propagated one of the only commodities you cannot buy (yet) on Amazon: biodata. In the twenty-first-century global economy, data are more valuable than oil. Biodata—the info in the FaceFirst registry, for instance—fuel a rocketing industry. Add surveillance and technology and the combination is unbeatable. “The global biotechnology market is expected to reach $727.1 billion by 2025, at a [combined annual growth rate] of 7.4 percent,” announced Grand View Research Inc., on the results of a 2017 report.  Among the key trends the report identifies: “Technological advancements pertaining to the penetration of artificial intelligence in this industry [are] expected to fuel progress with potential avenues.”

The state, scientific institutions, and private corporations (which all overlap) have long mined valuable biomatter, particularly from poor, Black, brown, and Native people. The cancer cells of Henrietta Lacks and the blood of the Havasupai Indians have enlarged scientific reputations and biomedical profits but returned little or no benefit to the bodies and communities from which they were extracted. Police routinely take and file the facial biomarkers, fingerprints, and DNA of arrestees. Even if the person is never charged, the data are fed into “risk-assessment” tools, which, complemented by surveillance camera footage, guide “predictive policing” in poor neighborhoods. And when a crime is alleged, the computer dispenses its own list of algorithmically marked usual suspects.

The pandemic has opened up new avenues for growth in what the philosopher Paul B. Preciado calls cybernetic biosurveillance. For instance, Turnstiles.us Inc., which manufactures terminals and other digitally based building-entrance security apparatus, has just introduced its newest “biometric access control” technology. This No-Contact Body Temperature Reader and Face ID Terminal (CVX021) “rapidly takes a user’s temperature with an Infrared Thermal Detection System” and its “facial recognition works even when wearing a mask.” Like the private prison industry, which lobbies for more criminal statutes and longer sentences, manufacturers like Turnstiles.us have a perverse incentive to support reopening economies before it is wise. More social intercourse and fewer restrictions translate to more Covid cases, more fear, and a greater perceived need to screen people entering buildings and workplaces. That means more CVX021 terminals, with software upgrades and new models on the horizon as the next novel virus and the ones after that roll in.

Both the left and the right understand the need for data rapidly collected, centralized, analyzed, and deployed in preventing and arresting epidemics. But they diverge on how to do it. The left argues that public health, a fundamental public good, can only be accomplished by a well-funded, attentive state. The private sector cannot and does not—or should not—be interested. If health care were free and universally available, it would generate no profit.

The right, of course, has a different idea. “The CDC should convene an intergovernmental task force, with outside experts as needed and input from states and the health care community, to develop and support a new national surveillance system and data infrastructure for tracking and analyzing Covid-19,” reads “National Coronavirus Response: A roadmap to reopening,” authored by the right-wing libertarian American Enterprise Institute. The system, AEI continues, should “be augmented through technological solutions . . . accomplished through partnerships with the private sector.” Who will own and control the biodata in the national database? What entities will have access to it? Will there be public oversight? AEI’s roadmap recommends “careful attention paid to preserving privacy and avoiding coercive means to encourage compliance” with biodata collectors. Note careful attention, not stringent enforcement. If the institute has a single raison d’être, it’s the privatization and deregulation of everything.

The digitization of biodata vastly expands the potential for corporate-state abuse of biopower. For instance, Onfido trumpets its immunity passport as the “linchpin of a new normality in a post-COVID19 society” in the EU. But the company has a grander vision. A white paper on its website proposes “a harmonized EU-wide framework that 1) supports digital identity verification and 2) allows European organizations to adopt safe and robust digital solutions.” Among the functions of this seamless system are “age verification for online gambling, verification of identities for e-pharmacies and telemedicine, as well as car rentals, home-sharing, social media verification and e-voting”—“and more.” The EU has at present only twenty-seven member countries. This “framework”—whatever that means—will not satisfy the needs of global capital. It will have to expand.

Coordinated systems like the ones imagined by the American Enterprise Institute and Onfido look like Big Data Brother, more powerful than anything we have known. But equally perilous is the devastation wrought by engineered neglect. In May, when the Trump Administration announces it will wind down the coronavirus response, even while infections and deaths mount, Gregg Gonsalves, an epidemiologist who started out in Act Up and now teaches at Yale’s public health and law schools, tweets: “How many people will die this summer, before Election Day? What proportion of the deaths will be among African Americans, Latinos, other people of color? This is getting awfully close to genocide by default. What else do you call mass death by public policy?” When, later that month, the video of George Floyd’s fatal suffocation emerges, and on its heels a dozen more, the words by default feel overgenerous.


Biopower and Necropolitics Redux

 Trumpism combines authoritarianism and libertarianism, but Trump himself is (fortunately) too lazy and undisciplined to pull off anything as complex as genocide. More salient: He doesn’t have to. The corporatocracy commits its murderous deeds and leaves no fingerprints. In a pandemic, it hypes products like the immunity passport as instruments of mutual protection and personal and economic freedom—and instead gives individuals, abandoned by the state to forces astronomically more powerful than them, “opportunities” to trade on the high-risk market of their own “immunocapital.”

The neoliberal state patiently dismantles each public good, lets the private sector scoop up the spoils, and sets up the conditions for hundreds of thousands of deaths. “It is what it is,” says Trump when reminded by Axios’s Jonathan Swan that a thousand Americans are perishing of Covid-19 every day. On Fox News, the president calls “shooting a guy in the back many times” a mistake made under pressure and compares police who commit such acts of excessive force to golfers who “choke” under the pressure of a tournament and “miss a three-foot putt.”

Neoliberalism and its political enablers have built a diffuse, elusive, laissez-faire necropolitical state. It abdicates biopower—takes no responsibility for life—and turns the imperial edict of death into a noncommittal shrug.

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