Dr. Li is an assistant professor in the Rice University History Department. She is a historian of the body and filmmaker focusing on medicine and health in global East Asia. She received her PhD in History, Anthropology, and Science Technology and Society Studies from MIT in 2016 and served as a Presidential Scholar in Society and Neuroscience at Columbia University.
This interview was conducted in April of this year.
Victoria Saeki Serna: Could you contextualize COVID-19 within the history of pandemics and medicine? Is COVID-19 comparable to other pandemics in history - such as the Sars outbreak of 2003 - in terms of the global reaction or medical challenges?
Dr. Li: What’s different about COVID is how it's impacted us profoundly day to day – we’ve never had schools close like this. Even with Sars, there wasn’t a big public health reaction where schools and museums closed, where both private and public institutions held themselves responsible for the spread of the virus and for each other’s safety. However no pandemic affects everyone equally despite it being called a pandemic. This is not a surprise and this is not unique to COVID. A lot of people who work on disaster politics and the ethics of how to respond to disasters and catastrophes know that these affect people differently based on their socioeconomic position. New York is a classic example where depending on your zip code, where you work and what kind of job you have are directly linked to your chances of getting COVID and dying of COVID. This has a lot to do with the medical treatment that is available - COVID is poking holes in our already overwhelmed healthcare system. When you see stories of women who are pregnant getting COVID because they’re at the Brooklyn hospital and they have a child or have to have labor induced early – those are typical of all these complications the healthcare systems are facing. There is also a language that is blocking us from seeing the bigger picture. We talk about physicians fighting at the front lines – I have friends who are still going to work at hospitals and they do feel unsafe, and they are scared – but they still nonetheless have faith in the mundaneness of going to work. This is distracting us from the bigger problems: how are the resources being distributed, how is the system actually broken and can we find ways to make it more efficient, what are the hierarchies of power in play. It shouldn’t be that difficult and yet why is it so expensive and impossible to get face masks to people? That is the bigger scheme of things. So that’s nothing new, that’s definitely obvious from the start. There’s something else that is not totally new about COVID which is the economic confusion – what policies you implement to mitigate the economic consequences of a pandemic and how they are passed. A lot of people are worried about the economic crisis and the inequities it is exposing.
COVID is still very current – we’re in week five of quarantine in Houston – no one knows how long it will last because you’re dealing with an invisible infectious disease and the only way you can avoid getting hit is by not touching anyone. So there are different things that make this feel new – the fact that we are still in it, and that we don’t know how it will end. We also don’t know how it will look like if the numbers will change. But there are things that are familiar – the patterns of how it’s affecting groups of people based on where they live, what their jobs are and what their financial security looks like – that is not a surprise at all.
Victoria: You’ve discussed a lot about the socioeconomic effects of the pandemic. Could you tell us your thoughts on the response of the United States – how the policies so far have or have not addressed these issues?
Dr. Li: Inequality of data is another reflection of economic disparities. If you have the money to test, the numbers of those infected will get bigger and bigger and they will make themselves visible. In places and countries where testing is impossible, we just don't have the data. If you can have a testing center it's because you can afford it, but again these tests don't have to be that expensive. There are DIY home kits for testing for COVID or other types of chronic and acute diseases, yet those aren't as readily available. Part of the issue is that these distribution chains are based off of a capitalistic model, and so they can get very expensive really quickly. Patents are also very tricky to handle and legal issues are complicated, so if you see more numbers of infection statistics it's also a reflection of the fact that people can afford these tests. This is kind of the “catch-22” where the more visible the pandemic is it almost feels more dire, whereas places where there aren't enough testing facilities there might be less visible so it goes both ways. One of my students lives on a military base and they have a drive-thru center with doctors standing around so no one at this military base is at risk – although we've seen US military personnel be dismissed because of COVID related issues so that's not to say that everyone is the same – but this is to say there are some communities that are more readily served. Again, the distribution of testing reflects socioeconomic inequalities. Not to be super critical, but everyone is recognizing that now and it can still be scary, but it's also become this everyday thing, it's become a mundane thing that can prevent you from taking action.
Victoria: Could you compare the response of the United States to that of China or the international community as a whole?
Dr. Li: In China staying home is almost easier to socially engineer because of the political system. For such a long time, until 1978, China was effectively under a dictatorship – and it's not to say that it still isn’t, as there are a lot of similarities to a true dictatorship today. This social pressure of confirming, of behaving a certain way – the biopolitics are really strong in China which is why you see so much literature on biopolitics from China. At the same time, it's hard to generalize because each precinct is different, each province is different, and each city is different. In Beijing for instance you have a lot of migrant workers, so if you are trying to measure the success of coverage in China, Beijing is going to be different from the countryside.
Another thing – in the United States a lot of people are blaming Mayor DeBlasio for not reacting sooner. The first reaction of the New York people on Mayor DeBlasio’s response was, “New Yorkers don't behave this way.” There was a cultural response because of this social expectation of what New Yorkers behave like. It’s hard to compare responses between countries because of these local differences in economics and cultural expectations, which is why most ethnographers and historians like to talk about trans-local comparisons – compare cities rather than countries to see things play out in a much more interesting series of patterns that people don't expect.
A lot of the differences in responses to public health crises are also in basic education – in elementary school we were taught to duck and cover so we have these safety regulations to a point where it controls your behavior. Similarly in China in the 70s, when my parents were in school, they had the campaign to get rid of the four pests – mosquitoes for malaria, rodents for plague, airborne flies, and sparrows so there would be these campaigns of people shooting down sparrows with homemade BB guns. Maybe, if we had a more publicized health campaign that is a usual part of life, our behaviors would be different.
Victoria: Earlier in the interview you mentioned at-home testing kits – what medical developments of the past will help us develop tests and cures? How long do you think it will take to find a cure?
Dr. Li: The very idea of a cure is complicated. There is a long history of discourse in medicine that debates the idea of a simple cure – many people think if you have a vaccine that will solve all of your problems, but most people working in the healthcare industry know that this is not the case at all. Vaccines take a long time to develop and distribute. Making a vaccine involves millions of chicken eggs which have to be stored in military bases, the techniques of creating a vaccine are very difficult. Most people fall into this magic bullet myth where if you just have the pill, if you just have the injection, you will be safe. That never quite happens in reality – if you look at the history of diabetes there is a book called Bittersweet, it talks about the transmutation of disease. When you introduce a new treatment it involves this whole infrastructure of technology where that disease changes, so getting insulin injections doesn't cure diabetes it only makes a child with diabetes look healthier, and once it's replaced there are symptoms of a lifetime of dialysis or having to withstand a ton of insulin injections. So there are these kinds of chronic issues in which there really isn’t ever a cure that fully solves the problem – the “cure” just turns the disease into something else. So it’s hard to think of the idea of a full cure for COVID.
Even if you had a vaccine, it doesn't solve the socioeconomic problems that worsen this kind of crisis. People are sick and people are still dying – that's never going to go away – but there is a way to distribute resources and preventative measures more equitably. It’s not sexy at all – no one wants to be told how to take care of yourself, be told“here is something to wear on your face,” we want to be taken care of. The history of the medical field is such that it has made itself paternalistic – when we enter the clinic we want to be cared for, we want to be told what is wrong with us, but that is not what the medical field was like a hundred years ago. But sometimes not getting sick is as easy as preventing it by yourself or having the resources to find ways to prevent it.
Victoria: I didn’t know cures were so complicated, and I think we should all take a step back and think about this misinterpretation of cures more often in the public sphere.
Dr. Li: What I want to say again about cures is that for a lot of chronic issues, including lung cancer, things that we assume can be preventable, it's hard to even find the cause.
If you have a complicated situation, again, say for instance, a woman living in Brooklyn and she is giving birth and she has COVID, you can't give her the vaccine. You have to deliver her baby, take care of her, and maybe the kid is in the NICU. Then, even if you give her the vaccine she might go home to an environment that is not conducive for long-term care. So there are temporal questions, it never just solves itself and the goal is not a sexy answer – it's not just to make sure that they can have facemasks and that they can have hand sanitizer, it’s about long term solutions.
Rice has a really good program – Rice 360 – where they are trying to teach engineers to work with local groups. They try to get students to think about if you go to a different city, or a different country, or a racially tense community for example in Johannesburg, and try to introduce a lot of medical technologies by saying, “here are a bunch of x-rays and here are all the pads you can have so you can give young girls menstrual aid,” – can they afford to make it themselves? What resources do they have to sustain that long-term? Rice is trying to make students think about these questions in these terms rather than giving out free handouts. How do you work with the existing economic infrastructure so that people can be self-sustaining? That's where the real change happens; it takes time and it takes some thought. Even if you can hand someone a free MRI machine, are they going to have the electricity grid to sustain it or is it just going to sit there? Technologies and inventions don't travel well, or at least medical technologies don't travel well unless or until there is what we call a homogeneity, a homogeneous infrastructure to sustain it. It's important to be thoughtful about what are the material limits to finding these cures as we can't just throw food at someone, it has to be a more thoughtful process that goes into sustaining the system in the long-term.
Victoria: I would hope that doctors and scientists are able to come up with a medical advancement that mitigates the effects of COVID-19 even if it’s not a “cure” or “vaccine” as people like to think of it in the public eye. Could you speak as to what this “cure” would mean for medical advancements and the socioeconomic implications it might have?
In terms of looking ahead, sure it would be great to have a vaccine, but what would also be great in addition to that is to learn more about immune systems. We don't know that much about our own immunity – we've seen different patterns, some people who are really young and get really severe symptoms, some people who are middle-aged who have mild or medium symptoms, and then it relapses. We don't know the pattern this virus actually has on people. Immune systems are pretty complicated; there are people who never have any symptoms. One thing that has always been a concern for immunobiologists is immunosyncrisy – there's so many things about the physiology of the human body that we can try to learn more about rather than just fixating on one virus. I was working in an HIV/AIDS lab for a long time for the summer, and we tried studying the virus and viral vectors for a whole month, and the lab is still studying the same kinds of vectors. You look at the care side and you look at how the body responds to it. How do you tie your diet with your immunity and ability to recover, for instance? That is basically an economic question – what kind of foods do you have access to? Can someone afford turmeric if their immune system calls for it? Food is such a huge aspect of how long we can live.
One of my favorite articles is a takedown of the common theory that European colonists came to North America and that a lot of Native Americans died because they were exposed to smallpox for the first time through biological warfare. That is an easy narrative but it's one that misunderstands immune systems – there are groups of Cherokees that already had smallpox, that already had cholera, there are groups that already had tuberculosis. It wasn't just that you had these Native American bodies that were physically unable and genetically weaker, that's not the case at all. Whether you have acquired immunity is something that's pretty complicated. What was more the case is that a lot of these Native American groups were malnourished and because they were malnourished that made them more susceptible to really deadly forms of diarrhea and infection and STDs, and so all of these taken together show that if we had a less racialized understanding of immune systems that would reveal these political issues that can cause violence.
Victoria: Any closing remarks?
Dr. Li: We'll just have to wait and see. We're lucky that we're in Texas, we're lucky that the space is so big. Cities are often what struggle the most: we saw this with Hurricane Katrina, we saw this with the 1995 Chicago heat wave where certain communities were hit the worst. The biggest thing now is really having people in the humanities look at infrastructure and also talk a lot about the science. I'm not saying that there isn't a solid solution that we can try to find, it's just that so many people have to make mistakes for some big catastrophe to happen. In most situations, you can have small mistakes happening with lots of people that make these issues cascade into large crises, so it's hard to find a single cause or factor. It's a lot of things and a lot of people making decisions that lead to a crisis. A long time ago a book called the Checklist basically divided a list of 10 things doctors could do, really simple things they could do to prevent infant mortality or to prevent unwanted infections in the hospital. These really simple things just weren't on the radar because again you can get 9 out of 10 and still be fine you can get 8 out of 10 and still be fine as long as you don't do all 10. But then problems happen so there has to be some kind of sense of mapping out where all the holes are because there has to be a lot of them, not just one that causes this to happen.
We should also think about patterns of infection. Google and Apple, more recently, are trying to find ways to have your phone tracked to see how and when you come into contact with someone that is positive with COVID, but there are so many privacy issues around that. People are trying to come up with solutions where the information would not be all revealed, and all that is shown is just whether you're positive or in proximity to someone that is positive. Again those technologies would be useful if we all had phones and it's possible that by the time it's useful all of this will have passed and that technology can be used for something else, so you see these inventions bring thrown out now and a lot of the grants that are opening to study COVID on a smaller scale. But what will be the next thing that will actually take advantage of these new studies, as it's clear that COVID is not going to last forever. While it won’t last forever, it has set in motion lots of projects that are very targeted so a lot of what we can do now is just to wait and see. I have faith in people so as long as we're asking the right questions, there can be some kind of meaningful steps taken to try and mitigate something like this in the future.