Counting Whom, Though?

It’s a drizzly Saturday in New York City, and I plan to spend the day with my partner. We have a Zoom brunch scheduled with friends, one of whom is an ER doc. Maybe the sun will burn through once in the afternoon. We can hope.

Given my plans, today’s piece will be relatively short, but in this short piece, I will center the remarkable image above. Meditate on it please and take a minute or two to tease out its obvious features and key trends. As you can see, between 1800 and 1890, baseline mortality seemed to vary between 20 and 25 deaths per year per 1,000 residents with the rate often spiking closer to 30 in epidemic years, and spiking three times close to 50, in each instance, during a cholera outbreak. We see further that from the time of the creation of the Board of Health and Health Department in 1866, there is a clear, steady decline in the mortality trend until around 1930, whereafter – even with the Great Depression and World War II – mortality leveled off at around 10 deaths per year per 1,000 residents until roughly 1990.

This simple graph represents a human triumph of staggering proportions. During the life span of a single person, the death rate in New York City was cut at least in half, all – essentially – through public health interventions (note a few mentioned above) though aided, of course, by the emergence of modern pharmaceutical medicines such as antibiotics.

As is pointed out in the image, the AIDS crisis – still, today, in its pandemic form, a global tragedy of awful proportions – and the attacks on September 11th, 2001 are both barely visible, and in fact, if anything, appear as minor upward blips in the otherwise gently downward trend that persisted from 1990 until around 2010, probably owing to shifts in habits around diet, smoking, and exercise, though perhaps also attributable to the City’s renewed financial “health” (although, surprisingly, no mortality spike appears in the aftermath of the City’s mid-1970s fiscal crisis/de facto bankruptcy). It seems like there has been a renewed leveling since the Global Financial Crisis – and perhaps the impact of the opioid “epidemic” will only show in years after 2017 – but, even so, the Bureau of Vital Statistics of the New York City Department of Health and Mental Hygiene reports that the city-wide mortality rate for 2017 was 545.7 or less than 6 people per thousand, so roughly one quarter of the prevailing rate through the 19th century.

A few additional observations: We see that yellow fever, small pox, the measles, scarlet fever, typhus, diphtheria, and meningitis were all capable of exacting brutal human tolls on the pre-germ theory city, but that cholera stands out as the great scourge of 19th-century New York City. Although a much bigger killer in terms of raw number of deaths (owing to the much larger population of the City in 1917 than in the mid-1800s), the flu pandemic of 1918-1920 inflicted a slight fraction of the death toll of the worst cholera outbreaks on a percentage basis. Hard to imagine, but in the three worst years of cholera in the 1830s, ’40s, and ’50s, roughly 5% of the City’s population died. Of course, only 2-3% out of that 5% were actually attributable to cholera, but imagine if between 175,000 and 250,000 New Yorkers were to die of COVID-19 – that’s what that would mean on an equivalent basis today.

(Incidentally, it should fill our hearts with sadness and shame that – owing to a war waged in our names – this dread disease, cholera, which has been banished from our shores for more than a century is currently ravaging Yemen (and that it previously ripped through a Haiti wrought vulnerable, yes, by natural disaster, but even more so by two centuries of vengeful French and US policies of neocolonialism). Since the start of the US-backed Saudi-Emirati War on Yemen, at least 1.3 million people have contracted cholera of whom at least 2,500 have died – the latter figure, both heartbreaking and yet a clear sign that, even in the midst of conflict-driven social/infrastructural collapse, the people of Yemen are likely receiving much better healthcare than did 19th-century New Yorkers.)

We don’t have to look all the way to Yemen, though, to see the ravages of health disparities wrought by injustice; here in New York City, while wealth and access to COVID-19 testing clearly correlate, so too, likely, do dying at home from this disease and lacking proper immigration status. This interview on Democracy Now! with ER nurse and labor activist Sean Petty marked the first time I’d heard it suggested publicly that undocumented people likely make up the majority of those dying at home in New York City from COVID-19, and while we currently lack data to confirm this grim conclusion, this points to another clear reason why a proper accounting of the death toll is so crucial as we start to move forward. Undocumented New Yorkers are estimated to make up between 6 and 7% of NYC’s population. If even half of the people who have thus far died at home have been undocumented, then undocumented people are dying at a rate disproportionate to their numbers, and the true toll is probably significantly worse (as we look to how hard hit has been immigrant and service sector-heavy central Queens).

From rural meatpacking plants to the New York City public schools; from elite US universities to authoritarian governments (both seizing the opportunity of the pandemic to further persecute/criminalize dissent); from politicized pandemic response from our ignoramus-in-chief to increasingly captive regulatory bodies and cowed Federal agencies afraid (as the Good Germans must have been) to acknowledge obvious scientific truths; from Bezos’ Amazon firing workers of conscience for speaking out to the New York Times continuing to give the blowhard David Brooks a platform; from the financial press reporting credulously on our elected executives to the scientific press failing to properly scrutinize Big Pharma (note, what’s reported on in the linked piece are results of Gilead’s own clinical trials); from the insistence of much of our media and political classes on using bellicose rhetoric to characterize public health efforts that are about life-saving, not life-taking to the already present convergence of climate crisis and pandemic that menaces much of the Global South, one need not look any farther than any given day’s news to see the profound state of corruption, despair, hypocrisy, contradiction, and injustice which have been surfaced by COVID-19’s global spread, but – in perhaps slightly less egregious forms – have been with us all along.

At the same time, everywhere, we find reasons for hope: In Colorado Governor Jared Polis confronting anti-Semitism and reaffirming our interdependence; in Michael Che honoring his late grandmother (who died of COVID-19) by offering to pay rent for 160 NYC families; in the hundreds of thousands of New Yorkers who plan not to pay rent altogether as part of a massive, coordinated rent strike launching May 1st; in the work of scientists, technologists, and policy people to chart a path out of our current state of paralysis by massively ramping up speed and availability of testing; to the healthcare workers and hospital support staff putting their lives on the line everyday to care for the sick; to the heroism of MTA train operator, Garrett Goble, who died after helping to evacuate passengers from a train car that was consumed by flames in what seems to have been a shocking act of arson.

I look at the image at the top of this page, and recognize that we, in settler-colonial New York City, are at once descendants – or at least inheritors – of a grisly legacy of violence, and beneficiaries of an almost unimaginable history of progress. As the deaths of all those New Yorkers who have died at home in recent weeks – alone, afraid even to seek medical attention – lay bare, we have only progressed so far, but even should COVID-19 kill not the ~16,000 New Yorkers it has to date, but ~50,000 New Yorkers (effectively doubling the annual rate of death) that would still only make the city-wide mortality rate for 2020 roughly equal to the average rate that held throughout much of the 20th century.

We have come a long way, and yet, we have a long way to go, and rather than hand-wring on the one hand, or disingenuously celebrate all our successes (a la Steven Pinker) on the other, we should be asking ourselves – given our great fortune to be heirs to proud traditions of public health and public-minded science – what type of world can we make if we set our minds, our immense resources, and – with tongue only half in cheek – our lives, (public) fortunes, and sacred honors to building the sane, just world that, today, trembles just the other side of the possible?