Immunity
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In the weeks and months after COVID-19 emerged as a cascading set of personal, professional, and political crises that we have all been negotiating over the past three and a half years, I received numerous invitations to contribute my thoughts on the pandemic. Even as I understood why those invitations were extended to me—my work in the history of epidemics and epidemiology made me a natural go-to—I declined most offers. The most pressing professional reason for this is that my work has taught me that the best way to sound foolish during a public health crisis is to make a definitive claim about the nature or significance of an epidemic. Where subtlety, patience, and humility are critical to the production of knowledge and to the development of diagnostic and treatment plans, the fear of death and of economic catastrophe seem to demand decisive action. Very little of what I would have liked to say about the trajectories of contagion back in 2020 or 2021 would have been useful to the people who were most in need of help in the moment. And help—care for each other—was what we all needed most.
As was the case for all of us, I learned a lot about the nature of COVID and had many thoughts on the matter. Among those were two observations that stuck with me relatively early in the pandemic. The first is trivial, but a source of optimism—that medical technology and medical knowledge are always changing; even if recommendations about mask-wearing, social distancing, and sanitation practices emerged haltingly, the development of effective vaccines occurred with a speed never seen before in history. The second observation is deeper, but also more pessimistic—that the way people behave during epidemics does not change. It is difficult to describe the heartbreak of seeing how fear of contagion led to behaviors in 2020 that were nearly identical to behaviors during the late-twentieth century HIV/AIDS pandemic, the mid-nineteenth century cholera outbreaks, late-eighteenth century yellow fever pandemics or plagues dating as far back as Athens in the fifth century BCE. Plus ça change …
But if science and medicine are now so much better at predicting immunological patterns and designing strategies for breaking chains of contagion than they have been at any time in the past, why are professionals in these fields so often treated with obvious contempt? Surely, it is not contempt for life itself. It was while I was wrestling with these questions that Sari Altschuler, Johnathan Metzl, and Priscilla Wald invited me to write about “immunity” for their Keywords for Health Humanities. What appealed to me about the invitation was that while immunity seemed to be an intuitively clear concept, so many of our public health debates since February and March 2020 arose from disagreements about just what and how “immunity” signified. As I would end up discussing in the piece, the history of “immunity”—of its appropriation and use in the field of medicine—encodes a particular tension between public and private interests precisely because it was borrowed from Roman law, where it referred to the exemption from taxation and tribute that could be conferred upon a subject by the sovereign.
It was not until the age of microbiology that immunity would become a common concept in medicine. So why would physicians turn to a still-current juridical term to describe their understanding of the internal biological interactions between a pathogen and a patient’s body? More pertinent, perhaps, is to consider that the immune-system model of disease causation replaced longstanding medico-theological models of illness rooted in divine sovereignty and punishment; by the nineteenth century, a person’s biological history became a more scientifically convincing explanation for ill health than judgment about the state of their soul had previously been. And yet—crucially—this historic immunological shift from God to Individual took place alongside the rise of Enlightenment liberalism. That is, the rise of individual sovereign rights and freedoms in the political arena (which found its U.S. apotheosis in the post-Reagan era of anti-Government liberalism) mirrored the internalizing of immunity as a highly personal (dare I say personalized) individual possession: my body, my immunity; my sovereignty, my choice.
These observations were not quite fully fleshed out when I traced the history of immunity’s linguistic shifts for the Keywords piece. I drafted the contribution during several key moments of the pandemic: the summer of 2020 prior to the approval of the vaccine; the rollout of the vaccines in winter 2021; the successive waves of SARS-CoV-2 variants that persisted through the following summer—all of which were shadowed by a national election and increasingly violent political dissent. As I have continued to think about the ways that immunity might prove to be useful for talking about COVID in the long term, it has struck me that a great barrier to conversation is that epidemics and pandemics are public crises occurring at the intersection of political and medical life: while the question of how best to treat a body or a pathogen ought to be a straightforward scientific judgment, the question of how to direct those treatments is a judgment about the nature and place of sovereignty—an ambiguity that lies at the etymological and epistemological core of immunity.
I am not arguing that the word “immunity” causes these political problems—indeed, the problems predate the word itself. Nor am I naïve enough to suggest that finding a different term for susceptibility and non-susceptibility to disease will resolve any political issue—though some physicians have begun to debate whether the concept “immune systems” is particularly accurate or helpful. Nevertheless, since I first sat down to write the piece for Keywords, I have been thinking a lot about how to have more forthright conversations about the relation between sovereignty and responsibility, about the polemic of origin stories, about the rationality of vaccine skepticism, and about the relative risks of isolation and exposure. The issue as I see it is not about convincing people that their behaviors are healthy or dangerous—those are debates that predate modern medicine and that will doubtless return during the next outbreak and the ones after that. The crisis of the pandemic is, rather, about the mutual recognition that no one is immune—I mean this in the ethical and juridical sense—from the responsibility to give care.